Predictors for Postoperative Complications After
Tracheal Resection
Benoit Jacques Bibas, MD, Ricardo Mingarini Terra, MD, PhD,
Antonio Lopes Oliveira Junior, MD, Mauro Federico Luis Tamagno, MD,
Helio Minamoto, MD, PhD, Paulo Francisco Guerreiro Cardoso, MD, PhD, and
ˇ
Paulo Manuel Pego-Fernandes, MD, PhD
Thoracic Surgery Department, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de S~ao Paulo,
S~
ao Paulo, Brazil
Background. Tracheal resection and anastomosis is the
gold standard for the treatment of tracheal stenosis. The
objective of this study is to evaluate the complications
after tracheal resection for benign stenosis and the pre-
dicting factors for such complications.
Methods. A retrospective study was made involving
patients with benign tracheal or laryngotracheal stenosis
who underwent surgical resection and reconstruction
between February 2002 and January 2009. Complications
related and unrelated to the anastomosis were studied.
Categorical variables were presented as percentage and
continuous variables as mean and standard deviation.
Predicting factors were determined by univariate anal-
ysis. Factors with p less than 0.05 were used for multi-
variate regression. Logistic regression models were also
employed for dependent variables. Statistical significance
was set for p less than 0.05.
Results. Ninety-four patients (18 female, 76 male) were
included. Complications occurred in 42 (44.6%). Twenty-
one percent had anastomotic complications. The most
T racheal resection and primary anastomosis remain
the standard of care for the definitive treatment of
tracheal stenosis. In spite of being very effective, with
success rates greater than 90%, complications are an
issue. Not only might these complications be life-
threatening once they compromise the airway, but also
they are quite frequent. Some studies have already
addressed this issue and observed complications rates as
high as 50%; consequently, adequate patient selection is
paramount [1].
To improve tracheal resection outcomes, some re-
searchers tried to identify predictors for the occurrence of
postoperative complications [1, 2]. Laryngeal involvement
is frequently cited as a relevant factor for anastomotic
complications [3]. Other commonly mentioned factors are
the need for suprahyoid release, redo tracheoplasty,
diabetes mellitus, and long-segment stenosis [3, 4].
Accepted for publication March 20, 2014.
Address correspondence to Dr Bibas, Secretaria do Serviço de Cirurgia
Tor
acica, Av Dr En
eas de Carvalho Aguiar 44, Bloco II, 2o Andar, Sala 9,
S~
ao Paulo, SP 05403-900, Brazil; e-mail: benoitbibas@hotmail.com.
Ó 2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
GENERAL THORACIC
common complication was restenosis (16%). Non-
anastomotic complications occurred in 23.2%. Wound
infection occurred in 10.6%. Clinical comorbidities, pre-
vious tracheal resection, and the length of tracheal
resection were statistically significant factors for compli-
cations. Previous tracheal resection was the most signifi-
cant factor and was highly associated with anastomotic
complications (odds ratio 49.965, p [ 0.012). The greatest
number of complications was found in the laryngo-
tracheal reconstruction group, and in resections more
than 4 cm. Mean follow-up was 19 ± 14 months. At the
end of the study, 86 patients (91.4%) were breathing
normally. There was no mortality in this series.
Conclusions. Comorbidities, previous tracheal resec-
tion, and the length of tracheal resection more than 4 cm
were statistically significant factors for the onset of
complications.
(Ann Thorac Surg 2014;98:277–82)
Ó 2014 by The Society of Thoracic Surgeons
Nevertheless, only a few of these studies have a signifi-
cant number of patients to allow an adequate multivariate
analysis to identify predictors.
Therefore, more information regarding the most
frequent complications after tracheoplasty as well as their
predictors is still necessary. The objective of the present
study was to evaluate the complications after tracheal
resection for benign stenosis and the predictive factors for
such complications.
Material and Methods
This retrospective study included patients who under-
went tracheal or laryngotracheal resection with primary
reconstruction at our division of thoracic surgery between
February 2002 and January 2009. Our institution is a ter-
tiary teaching hospital and a national referral center for
tracheal diseases. Data were collected from medical re-
cords, and all patients were assigned a code number to
ascertain confidentiality of information. This project was
submitted and approved by the hospital’s Ethics
Committee.
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2014.03.019
 278 BIBAS ET AL
TRACHEAL RESECTION COMPLICATIONS
We included all patients diagnosed with postintubation
tracheal or laryngotracheal stenosis who underwent sur-
gical resection and reconstruction during the study
period. The exclusion criteria were patients who under-
went laryngeal split and cartilaginous grafting; patients
who underwent carinal resection; patients with incom-
plete records; and resection due to conditions other than
postintubation tracheal stenosis (eg, airway tumors,
idiopathic stenosis, infectious diseases, trauma, Wege-
ner’s granulomatosis, chronic relapsing polychondritis).
Preoperative workup of all patients selected for surgical
treatment included a computed tomography scan of the
GENERAL THORACIC
larynx and trachea and a flexible bronchoscopy to classify
the severity of the stenosis. All surgical procedures began
with an endoscopic assessment of the airway, using rigid
bronchoscopy or suspension laryngoscopy, as it allows
the surgeon to identify and measure the segment to be
resected, and if necessary, dilate the airway [5].
Airway resection and reconstruction followed the
standard procedures published previously by Grillo and
associates [3] and Pearson and colleagues [6]. Operations
were performed by one of the three surgeons with
experience in tracheal diseases (B.J.B, H.M, P.F.G.C). The
anastomosis was performed with a continuous running
suture of polydioxanone 4-0 (PDS II; Ethicon, Bridge-
water, NJ) in the membranous wall and separated sutures
of polyglactin 3-0 (Vicryl, Ethicon) in the cartilaginous
wall. The technique used was similar for both laryngo-
tracheal reconstruction and tracheal reconstruction.
Suprahyoid laryngeal release maneuvers were used
judiciously according to the surgeon’s preference to
reduce anastomosis tension in addition to mediastinal
dissection and neck flexion during the procedure. Pa-
tients were instructed to avoid neck hyperextension in the
postoperative period, and we did not routinely use the
“guardian stitch.”
Patients were seen at the outpatient thoracic surgery
clinic at 1, 3, and 6 months after hospital discharge and
twice yearly thereafter. In the event of any complaints
related to the operation or clinical signs or symptoms of
complications, imaging studies and flexible bronchoscopy
were performed.
We defined complications as those related (anasto-
motic) or unrelated to the anastomosis (nonanastomotic).
Overall complication was a binary (yes/no) variable. By
definition, anastomotic and nonanastomotic complica-
tions comprised overall complications. Complications
related to the anastomosis were anastomosis dehiscence
and restenosis or granulation tissue in the anastomotic
line. Only events that required reintervention or led to
prolonged admission were counted as complication for
the current study analysis purposes.
Complications unrelated to the anastomosis were
wound infection requiring intravenous antibiotics, hema-
tomas requiring drainage, tracheoinnominate fistula,
dysphagia, dysphonia, and tracheoesophageal fistula. Both
dysphagia and dysphonia were not analyzed quantitatively
because we do not perform these tests routinely in the
postoperative period. These complications were analyzed
on a clinical basis, through a binary variable (yes/no).
Ann Thorac Surg
2014;98:277–82
Other variables were also analyzed: sex, age, body mass
index, comorbidities, intubation time, interval between
intubation and surgery, previous treatments (such as
tracheal stenting and dilation), operative technique,
postoperative complications, reoperation, follow-up
length, mortality, and cause of death.
Telephone contact was made with patients to retrieve
information that was unavailable in the medical records.
If the patient had any difficulty answering the questions
by phone, a return visit was scheduled in the outpatient
clinic. Likewise, patients with less than 6 months of
follow-up were contacted by phone, and a return visit to
the clinic was scheduled. To ensure data quality, all the
data inserted were checked for every 20 new patients
included in the database, and the auditing was performed
by at least two different investigators.
Data were collected and inserted in the software Epi-
Data version 3.0 (EpiData Association, Odense,
Denmark). Statistical analysis was performed with the
Statistical Package for Social Sciences, version 13.0 for
Windows (SPSS, Chicago, IL). Categorical variables were
presented as percentage and continuous variables as
mean and standard deviation. To determine the predict-
ing factors, we used univariate analysis for all variables
collected. Factors that had a p less than 0.05 were used for
the multivariate regression model. Logistic regression
models were also employed for dependent variables.
Statistical significance was set for p less than 0.05.
Results
The flow of the patients is depicted in Figure 1. During
the study period, 138 patients with laryngotracheal ste-
nosis underwent operation. Forty-four patients were
excluded from the study (10 patients had incomplete
medical records; 28 underwent laryngeal split and carti-
laginous grafting; and 6 had miscellaneous etiologies).
Ninety-four patients (18 women and 76 men) were
eventually included in the study. Patient demographics
and the characteristics of the study group are depicted in
Table 1.
Of the 94 patients who underwent surgery during the
study period, 42 (44.6%) had some sort of complication.
Twenty patients (21%) had anastomotic complications.
The most common complication was restenosis, which
occurred in 16% of the patients. Those patients were
treated endoscopically (n ¼ 12), with tracheal T tube
(n ¼ 6), or tracheostomy (n ¼ 2). One patient had an
anastomosis dehiscence that required reoperation. A
tracheostomy was initially performed, and the patient
was later treated with a T tube. Four patients had gran-
ulation tissue at the anastomosis site, and were treated
with laser therapy.
Nonanastomotic complications occurred in 23.2%, with
superficial wound infection occurring in 10.6% of the
patients. All infections were treated with local debride-
ment or intravenous broad-spectrum antibiotics or both.
No reoperation was needed. The complications related
and unrelated to the anastomosis are described in
Table 2. Dysphonia was clinically evaluated and treated
Ann Thorac Surg BIBAS ET AL 279
2014;98:277–82 TRACHEAL RESECTION COMPLICATIONS

Fig 1. Flowchart of the study.

GENERAL THORACIC
with phonoaudiology, but no invasive tests were per- analysis are shown in Table 4. The presence of comor-
formed. One patient had a postoperative trache- bidities, previous tracheal resection, and the length of
oesophageal fistula. He was initially treated with a tracheal resection were the statistically significant factors
tracheostomy and a T tube; 6 months later the fistula was for the onset of anastomotic complications. Previous
surgically closed. tracheal resection was the most significant factor, and was
Data from univariate analysis for overall complications highly associated with the development of anastomotic
are presented in Table 3, and the data from multivariate complications (odds ratio [OR] 49.965, p ¼ 0.012). The
greatest number of complications was found in the lar-
Table 1. Demographics yngotracheal reconstruction group, and in resections
more than 4 cm in length.
Sex The mean follow-up was 19  14 months. At the end of
Male 76 (81) data collection, 86 patients (91.4%) were breathing nor-
Female 18 (19) mally without stridor. There was no mortality in this
Age, years 31.2  14 series.
Body mass index, mean 24.01  3.13
Tracheostomy 68 (72.3)
Comorbidities Comment
Diabetes mellitus 05 (5.32) In the present study, the overall complication rate was
Epilepsy 03 (3.20) 44.6%, with no mortality. Restenosis was the most
Heart failure 02 (2.13) frequent complication, occurring in 16% of the patients.
Rheumatic fever 02 (2.13) The factors associated with anastomotic complications
Amyloidosis 01 (1.06) were the presence of comorbidities, previous tracheal
Scleroderma 01 (1.06) resection, and the extent of the resection.
Asthma 01 (1.06) The overall morbidity after tracheal resection varies
Type of surgery from 17% to 45% [3, 7–11], and mortality ranges from 0%
End-to-end tracheal anastomosis 52 (55.32) to 2.4% [3, 7–10]. The high variability rates of complica-
Cricotracheal anastomosis 24 (25.53) tions after airway resection are probably multifactorial,
Laryngotracheal anastomosis 18 (19.15) but some issues should be discussed. The definition of
Length of resection, cm 2.9  0.83 complication is certainly a key point. Some researchers
Follow-up, months 19  14
define complications as early or late [8], others describe
simply overall complications [4, 10], and some choose to
Values are n (%) or mean  SD. divide complications into major or minor [9]. We defined
 280 BIBAS ET AL Ann Thorac Surg
TRACHEAL RESECTION COMPLICATIONS 2014;98:277–82

Table 2. Complications Unrelated and Related to the In the present study, we had 21% anastomotic problems.
Anastomosis Those included restenosis in 16%, granulation tissue at
Complications n (%) the anastomosis in 4%, and dehiscence in 1%. This per-
centage, although higher than the rate reported by
Unrelated to the anastomosis Wright and colleagues [7], is still similar to the reports of
Infection 10 (10.6) other groups [8–11].
Dysphonia 5 (5.3) Macchiarini and colleagues [8] reported 41% early
Dysphagia 4 (4.2) complications (<30 days), with 15 patients (34%) having
Hematoma 2 (2.1) some sort of anastomotic complication (air leaks,
Tracheoesophageal fistula 1 (1.0) granuloma, or restenosis). Marulli and colleagues [9]
Total 22 (23.2) reported 37.8% of anastomotic complications after
Related to the anastomosis laryngotracheal resections in 37 patients, with 2
GENERAL THORACIC

Restenosis 15 (16) dehiscences. Mutrie and colleagues [10] reported

Granulation tissue at the anastomosis
Dehiscence
Total
complications as anastomotic or nonanastomotic, in the
same manner as Wright and colleagues [7]. The events
that meant complications were very specific and clearly
defined, and only events that required hospital admission
or led to prolonged admission were counted as a
complication. That led to a clear definition of outcomes,
with all anastomotic and nonanastomotic complications
included in the review charts.
Anastomotic complications are not uncommon after
tracheal resection [7–11]. Nevertheless, major anasto-
motic complications such as dehiscence of the anasto-
mosis are less common [3, 7–10]. Wright and colleagues
[7] had 9% of anastomotic complications in more than
900 patients who underwent surgery, and demonstrated
that mortality among patients with anastomotic compli-
cations was 7.4%, whereas it was 0.01% among patients
without anastomotic complications (OR 13.0, p ¼ 0.0001).
4 (4) complications in 18 patients (17%). Of those, 7 (7%)
1 (1) required a tracheostomy in the postoperative period,
20 (21) and 2 (2%) are tracheostomy dependent. Still, post-
operative dilation was required in 18 patients (17%).
The investigators do not specify whether those were the
same patients who were included in the overall
complication rates. Our study had a high percentage of
restenosis (16%). We had a very strict policy on defining
anastomotic complications. Any dilation performed in
the postoperative period was considered restenosis,
regardless of the final outcome. Confirmed restenosis
was treated with dilation or tracheal stents, or both,
according to the institution’s experience [12–14].
Figure 1 shows that of the 20 patients who underwent
postoperative procedures, 6 ended up needing a T tube
and 2 were tracheostomy dependent at the end of data
collection. If we considered only these 8 patients as
failures, our restenosis rate would be 8.5%.
In our series, the most prominent risk factor for com-
plications by multivariate analysis was the previous his-
tory of tracheal resection (OR 49.9, 95% CI: 2.4 to 1.038;
p ¼ 0.012), which occurred in 3 patients. All of them were

Table 3. Univariate Analysis

No Complications Complications
Variable n ¼ 76 (80.9%) n ¼ 18 (19.1%) OR 95% CI p Value

Anastomosis . . 0.017a
Tracheal-tracheal 47 (61.8) 5 (27.7)
Cricotracheal 18 (23.6) 6 (33.3)
Tyrotracheal 11 (14.4) 7 (38.8)
Extent of resection 2.76  0.74 3.63  0.83 4.366 1.922–9.917 <0.001
Resection >4 cm length 7 (9.2) 7 (38.8) 6.273 1.841–21.369 0.005
Perioperative tracheostomy 7 (9.2) 6 (33.3) 4.929 1.411–17.218 0.016
Body mass index >30 3 (3.9) 4 (22.2) 6.952 1.400–34.520 0.024
Comorbidities 9 (11.8) 6 (33.3) 3.722 1.119–12.382 0.036
Previous tracheostomy 51 (67.1) 17 (94.4) 8.333 1.049–66.224 0.020
Previous T tube 10 (13.1) 7 (38.8) 4.200 1.320–13.367 0.018
Previous resection 1 (1.3) 2 (11.1) 9.375 0.801–109.775 0.093
Time until surgeryb 506.05  475.32 861.50  779.85 1.001 1.000–1.002 0.030
a
c2; all other analysis are univariate logistic regression. Perioperative tracheostomy is tracheostomy performed during tracheal resection, mainly owing to
b
tension in the anastomosis. Comorbidities include chronic diseases and diabetes mellitus; they are listed in Table 1. Time from intubation until
definite surgery (days.)
Values are n (%) or mean  SD. Outcome variable is overall complications.
CI ¼ confidence interval; OR ¼ odds ratio.
Ann Thorac Surg
2014;98:277–82
Table 4. Multivariate Analysis
Variable OR 95% CI
Comorbidities 7.041 1.510–32.840
Previous resection 49.965 2.403–1038.985
Extent of resection, >4 cm 5.162 1.935–13.772
Outcome variable is overall complications.
CI ¼ confidence interval; OR ¼ odds ratio.
referred to us from other institutions. One of them had a
failed 1-cm tracheal resection and was using a tracheos-
tomy. A 3-cm resection was performed, with no compli-
cations. The other 2 patients had failed tracheal resections
that further required a laryngotracheal anastomosis and a
cricotracheal anastomosis. Both resections measured 5
cm. Tracheostomy was done in both patients, and they
are both still using T tubes. The patient who underwent
a laryngotracheal anastomosis is using a supraglottic
T tube.
Donahue and associates [4] reported a 39% complication
rate in patients with a previous resection and a 15%
complication in patients without it. Wright and associates
[7] reported that, for patients undergoing reoperation, not
only did the rate of complications increase with length of
resection but also the failure rate at all lengths except for
the smallest was more than double that for primary re-
sections. The increased morbidity after reoperation can be
explained by the dense surrounding peritracheal fibrosis
from previous operation; it impairs tracheal mobility and
thus may increase tension in the anastomosis, leading to
restenosis and failure [4, 7]. However, despite the elevated
risk, reoperation may still be successful if patients are well
selected [7].
The greatest number of complications in this study
was found in the laryngotracheal reconstruction group,
and in resections more than 4 cm in length (OR 5.1, 95%
CI: 1.9 to 13.7; p ¼ 0.001). Indeed, when analyzing pa-
tients who had a resection more than 4 cm, 9.2% had no
complications, whereas the majority, 38%, had some
sort of complication (OR 6.2, 95% CI: 1.8 to 21.3; p ¼
0.005). This finding has been reported by several other
groups [2–4, 7, 11], and it is clear that resections greater
than 4 cm are associated with a dramatic increase in the
rate of failure [7]. Therefore, prudence dictates that
patients undergoing resections longer than 4 cm should
be considered for a release procedure or stent treat-
ment [7, 8].
Clinical comorbidities were an important risk factor in
multivariate analysis, in our study (OR 7.04, CI: 1.5 to
32.84, p ¼ 0.013). Among our patients, 45% were diabetic.
This finding echoes other reports and can be explained by
the poor circulation of the tracheal mucosa in such pa-
tients [7]. Diabetes is notorious for damaging the micro-
circulation, resulting in deleterious effects on wound
healing.
The main weakness of this study is its retrospective
nature; nevertheless, we selected very objective end-
points, and we had few missing data, making our
BIBAS ET AL 281
TRACHEAL RESECTION COMPLICATIONS
conclusions stronger. Still, our population was very
homogeneous, as we included only patients with
p Value
benign postintubation tracheal stenosis. Tracheal tumors
0.013 and tracheoesophageal fistulas were not taken into
0.012 consideration.
0.001 Another important weakness of the study was our
definition of success. Like most series [2, 4, 7–10], we
defined success as a condition in which patients
require no further treatment, but does not specify
laryngeal function or quality of life . We believe that
this simple outcome is not sufficient. Gonfiotti and
associates [15] proposed a new disease-specific
GENERAL THORACIC
outcome measure, in which endoscopy, laryngeal
function, and voice were evaluated. The main goal for
the treatment of benign stenosis should be not only
anatomic but must also take into consideration the
quality of life of the patients, including all laryngeal
functions.
In conclusion, tracheal resection for benign tracheal
stenosis has a high success rate. Nevertheless, it may have
morbidity rates as high as 45%. The presence of comor-
bidities, previous tracheal resection, and the length of
tracheal resection greater than 4 cm were the statistically
significant factors for the onset of complications in this
study.
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