Parshin V D, Avdeev S N, Rusakov M A, Parshin A V, Ursov M A, Parshin V V, Merzhoeva Z M
National Medical Research Center of Phthisiopulmonology and Infectious Diseases, Moscow, Russia.
Sechenov First Moscow State Medical University, Moscow, Russia.
Khirurgiia (Mosk). 2023(1):13-22. doi: 10.17116/hirurgia202301113.
To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia.
There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period.
Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device.
Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone», immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.
描述新型冠状病毒肺炎（COVID-19肺炎）患者瘢痕性气管狭窄和气管食管瘘的治疗情况。
2020年8月至2022年4月（21个月）期间有91例瘢痕性气管狭窄患者。其中，32例（35.2%）患者存在瘢痕性气管狭窄、气管食管瘘且既往有严重急性呼吸综合征冠状病毒感染史。大流行期间病毒性肺炎通气后医源性气管损伤的发生率相比其他病因的肺炎增加了5倍。大多数患者肺炎CT分级为4级（12例）和3级（8例）。其他患者有肺实质病变2 - 3级或混合性病毒 - 细菌性肺炎。4例患者诊断为孤立性气管食管瘘，无严重的气管或食管瘢痕性狭窄。另外2例患者，气管狭窄合并气管食管瘘。8例（25%）患者首次入院时行气管切开术。该比例几乎是大流行前瘢痕性气管狭窄治疗患者的一半。
COVID医院出院后1 - 7个月发生呼吸窘迫综合征。所有患者均接受了手术。7例患者，我们首选扩张和支架置入的姑息治疗直至完全康复。5例患者在6 - 9个月后取出支架并接受了手术。进行了3例气管切除吻合术，2例患者接受了气管成形术。3例患者因无法置入支架而进行了切除术。这些患者的术后病程是标准的，与无病毒性肺炎的患者无异。对于气管食管瘘，姑息性干预很少能使气管隔离。4例患者通过颈部入路进行了手术。2例气管食管瘘合并瘢痕性气管狭窄的患者手术困难。其中1例在首次入院时通过颈部入路进行了瘘管分离和气管切除。另1例有胸段瘘管的患者，我们最初尝试置入封堵器。然而，后来由于装置移位需要进行开放手术。
与大流行前相比，有气管狭窄、气管食管瘘且既往感染过COVID-19的患者绝对数量增加了数倍。这是由于需要通气的患者数量增加，存在气管损伤风险，未遵守气管损伤预防方案，包括机械通气期间的抗缺血措施。最后一个因素因“红区”经验不足的联合医生参与、这些患者的免疫缺陷加剧气管壁的化脓性炎症过程而恶化。气管切开术患者数量减少了一半，这与SARS-CoV-2机械通气的特殊性有关。事实上，气管切开术是一个不良预后指标，医生试图避免该操作。这些患者气管食管瘘的发生率相比大流行前增加了1倍。在COVID相关肺炎的亚急性期，瘢痕性气管狭窄和气管食管瘘应首选姑息性措施。根治性治疗应在3 - 6个月后进行。环形气管切除吻合术的绝对指征是无法进行气管支架置入且无法通过内镜方法确保安全呼吸，以及瘢痕性气管狭窄合并气管食管瘘和难治性误吸综合征。瘢痕性气管狭窄且既往因COVID-19肺炎接受机械通气的患者与大流行前患者术后并发症的发生率相似。
