Modern management of penetrating tracheal injuries

Complications after tracheal repair in the past have included wound infections, tracheal stenosis, "spitting" of sutures, and tracheoesophageal fistulas. Modern operative approaches have significantly decreased the incidence of these complications. We conducted retrospective data collection using the TRACS database. Changes that preceded the time interval of the study included the following: 1) an emphasis on clinical (rather than endoscopic) recognition of injury; 2) minimal peritracheal dissection and repair with absorbable sutures; 3) limited use of "protective" tracheostomies; and 4) use of muscle buttresses to cover tracheal repairs, especially in patients with combined injuries. From 1997 to 2010, 22 patients were treated for wounds to the trachea (cervical 20, thoracic 2). The mechanism of injury was a gunshot wound in 15 patients and a stab wound in seven. A clinical diagnosis of the need for cervical operation or of a tracheal injury was made in 19 patients (86%), whereas three patients had positive diagnostic studies. Direct tracheal repair (No. 19) or evaluation of a superficial injury (No. 1) was performed in 20 patients, and three (15%) had a tracheostomy performed. Combined injuries were present in 12 patients (55%), most commonly to the esophagus (10 of 12 [83%]), and 10 of these 12 patients had vascularized buttresses applied to the tracheal repair. There were seven significant complications in patients with combined injuries to the esophagus or carotid artery. One patient (4.5%) died. Patients with penetrating tracheal injuries most commonly present with overt findings. Modern techniques of repair have eliminated many of the complications noted in the past.