key: cord-0843370-p52r1nxa authors: Lucchi, Marco; Ambrogi, Marcello; Aprile, Vittorio; Ribechini, Alessandro; Fontanini, Gabriella title: LARYNGO-TRACHEAL RESECTION FOR A POST-TRACHEOTOMY STENOSIS IN A COVID-19 PATIENT date: 2020-08-13 journal: JTCVS Tech DOI: 10.1016/j.xjtc.2020.08.023 sha: d2e95611e5c8590547d65a764cc6f89794814859 doc_id: 843370 cord_uid: p52r1nxa ABSTRACT The current COVID-19 pandemic has shown a relevant rate of patients developing an acute respiratory distress syndrome that requires hospitalization. Approximately 3-17% of hospitalized patients require Intensive Care Unit (ICU) and invasive mechanical ventilation. Initial recommendations advocated for early intubation, while early tracheotomy should not be routinely performed in COVID-19 patients. We report the case of a COVID-19 patient developing laryngo-tracheal stenosis secondary to an open surgical tracheotomy in the ICU. A conservative endoscopic management was not successful and we performed a laryngo-tracheal resection. The specimen was negative for COVID-19 but the pathological examination revealed how the virus damaged the trachea. This case is, as far as we are aware, the first case of laryngo-tracheal surgery in a COVID-19 patient and provides an insight to justify the higher rate of tracheal injuries occurring in intubated COVID-19 patients. COVID-19 has quickly spread worldwide since the first reported case [1] [2] [3] in Wuhan, China. Patients who need hospitalization for respiratory support require, in about 10% of cases, oro-tracheal intubation (OTI) for invasive ventilation, and a tracheotomy whenever the patient is intubated for a long time and the prognosis is good 4 . If a tracheotomy is deemed necessary in a COVID-19 patient, an open surgical tracheotomy is recommended over a percutaneous dilatation tracheotomy (PDT) in order to minimize aerosol generation 5 . Recently physicians at NYU Langone Health have developed newer and perhaps safer approach to tracheotomy that especially in COVID-19 patients may reduce the risks of healthcare workers 6 . The procedure should be performed at bedside, in a negative pressure room, in order to minimize the risk of transmission during patient transport 5 . However, the best strategy for tracheotomy in COVID-19 patients is far to be written in recommendations and we continue to learn and evolve through experience. We present a case of a 53-year-old man, who was admitted to a tertiary hospital complaining fever (38.5°C), cough and dyspnoea. In his medical history, the patient reported systemic hypertension and 2 family members with COVID-19 infection. At the time of admission, oxygen saturation was 88% and laboratory tests showed an enhanced Creactive protein (4,58 mg/dL) and lymphopenia (740 cells per μL). Chest X-Ray showed multiple bilateral opacities and signs of interstitial pneumonia. A computed tomography (CT) scan was performed, showing multiple ground glass opacity extensively involving the lungs bilaterally, especially at the basis. The nasopharyngeal swab PCR-test confirmed the infection by SARS-CoV-2. The patient was immediately isolated in a dedicated COVID-19 ward and was given supplemental oxygen and c-PAP by helmet, antiviral (lopinavir/ritonavir), hydroxychloroquine, azithromycin, dexamethasone. Ten hours later the patient deteriorated as well as arterial oxygenation (pO2 44mmHg and pCO2 37mmHg)). He was intubated (OTI) and transferred to a dedicated COVID-19 intensive care unit. The patient slowly improved, and 15 days after OTI underwent bedside open surgical tracheotomy. It was described as a difficult operation because of a bleeding thyroid gland. The patient was progressively weaned from sedation and ventilation, four Broncho Alveolar Lavages (BAL) in progressive days were negative for SARS-CoV-2, and 16 days later the tracheotomy was surgically closed. At that moment bronchoscopy and/or laryngoscopy of the airway had not been performed. When the patient was alert, collaborating, with a normal relaxed breathing, feeding with a free diet, he was transferred to a rehabilitation center. The recurrent nerves having not been exposed, the distal resection begun by transection of the airway obliquely at the superior edge of the third tracheal ring. The distal trachea was intubated from the surgical field with a cuffed tracheal tube Bivona N°6 and the oral tracheal tube was retracted. We then resected the anterior cricoid arch leaving a segment of the posterior plate of the cricoid above the postero-lateral aspects of the mucous membrane in the subglottic region. The membranous posterior part of the anastomosis was performed using a 4/0 absorbable running suture. The cartilaginous anterior part of the anastomosis was performed using a 3/0 absorbable single stiches suture. All the maneuvers of intubation from the field and then again through the oral tube have been rapidly performed in apnoea to reduce the aerosol contamination, with the anesthetist constantly monitoring the vital signs. The post-operative course was characterized by a small dehiscence of a stich on the cartilaginous part of the anastomosis, which was treated conservatively, and healed in 7 days. We obtained informed consent of the patient for publication of his medical records The sample of trachea showed small bleeding areas in the thickness of the mucosa of the cartilaginous portion. On microscopic examination the mucosa sample displayed large areas of disepithelization and microfoci of coagulative necrosis. Close to the pars membranacea a rich vascular proliferation was present, with small and medium caliber vessels surrounded by a mix of lympho-monocytic and plasmacellular infiltrate. Some foci of granulocytic inflammation were also detected together with some occasional giant cell granulomas. Immunohistochemistry using CD3, CD4, CD8, CD20 PGM1 plasma cells, and CD31 and CD34 monoclonal antibodies was performed to evidence and characterize lympho-monocytic and plasma cellular infiltrate and to visualize the vessels wall (Fig.3) . Unfortunately, such injuries have become more frequent and present a more challenging technical problem as far as repair is concerned 9 . The reasons for this increasing number of high airway lesions is uncertain but we can assume that the placement of a tracheotomy in difficult scenario (such as a COVID ICU) or inflammation of the mayor airways (as it happens in COVID patients and it was confirmed in this case) may contribute to its further increase 9 . It is reasonable to predict that the positive-pressure ventilation required in COVID-19 patients with consequent intubation and later tracheotomy together with the inflammation of the airway for vasculitis phenomena may increase the rate of tracheal injuries and stenosis we may face in the near future 10 . It appears that the COVID-19 pandemic presents an amazing challenge for surgical management of laryngotracheal stenosis because open airway access during laryngotracheal surgery create a highrisk situation for surgeons, anaesthesiologists, and operating room personnel 11 . While some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway obstruction or progressing symptoms often require urgent surgical intervention 11 . Consequently, appropriate measures should be taken to prevent them and a discussion about their appropriate treatment and timing would be recommended. In Italy 12 , and worldwide, a high rate of patients, affected by COVID-19, required, and are still requiring, tracheal intubation and tracheotomy for mechanical ventilation. The presence of platelet-fibrin thrombi in small arterial vessels caused by a coagulopathy, appeared to be common in patients with COVID-19, as detected in a series of autopsies in northern Italy 13 . Inflammation, vasculitis and coagulative necrosis of the major airways, induced by the virus, have been documented by this case. The fragility of the tracheal tissue, as well as difficult operative conditions, may be responsible of a high rate of tracheal injuries in the short term and will produce a high rate of tracheal sequelae in the long term. Our case report emphasizes that: 1. meticulous surgical tracheostomy, either open or percutaneous, should be performed to mitigate the risk of post tracheostomy stenosis, especially in COVID-19 patients. 2. 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