A segment of trachea may rarely and inexplicably become malacic rather than stenotic from the effect of a cuff injury. Such a lesion is best treated by resection and anastomosis. A small number of patients with a well defined cuff stenosis may also have a malacic segment between the site of the original tracheal stoma (or an existing stoma) and the stenosis. When the distance between the stoma and the stenosis is short, and removal will not result in too extensive a resection, it is preferable to resect the entire area of damaged
trachea. External cartilage grafts have not been very successful in malacia. The grafts survive, but most often are not incorporated into the tracheal wall to provide stability.
A small number of patients, in whom complete resection of both lesions would have been impossible, were managed by resecting the stenosis and by external splinting the malacic segment with specially designed polypropylene rings.16 Splinting was limited to the use of one or two rings. These rings were developed originally for construction of cervical cutaneous tubes. Their use in tracheal splinting is described in more detail in Chapter 32, "Surgery for Tracheomalacia, Tracheopathia Osteoplastica, Tracheal Compression, and Staged Reconstruction of the Trachea." Splinting a malacic segment of the trachea in this way may be hazardous. Care must be taken not to free up such a thin and altered segment circumferentially throughout its entire length or it is likely to necrose, as occurred in one patient. Tracheomalacia resulting from softening or loss only of cartilages differs from malacia due to what is essentially total loss of the tracheal wall and scar replacement. The latter necroses easily when freed from its connection to surrounding tissue from which blood supply derives. It is necessary to create an individual tunnel for each ring around softened trachea, so that the blood supply will remain. A ring must not be in contact with either a stoma or the anastomosis to avoid infection. Rings must be thoroughly imbedded in tissues using strap muscles. These foreign bodies figure 24-22 A, A stoma sufficiently remote from a lesion so that anastomosis can be made in the healthy trachea above and below the stenosis. The stoma is left in place, replanted, or surgically closed, depending upon circumstances. B, The stoma and stenosis may be excised in continuity here since the total length is not great enough to produce excessive anasto-motic tension.
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