Tracheal surgery is associated with low mortality but substantial morbidity. Major complications after tracheal and laryngotracheal resection and reconstruction may affect a significant percentage of patients. Anastomotic complications include granulations, dehiscence, and recurrent stenoses. Breakdown of the airway anastomosis may lead to catastrophic complications such as tracheoinnominate and tracheoesophageal fistulas. Nonanastomotic complications include recurrent laryngeal nerve injury, glottic dysfunction, and respiratory infections. This article discusses complications occurring after tracheal surgery and offers strategies for optimizing patient outcomes based on current evidence. The final sections provide a summary of best practices for redo tracheal surgery and current challenges.

Tracheobronchomalacia (TBM) is a frequently under-recognized condition that often coexists with other chronic respiratory diseases. The diagnosis of excessive central airway collapse requires consideration by the physician. Dynamic computed tomography scan of the chest and awake dynamic bronchoscopy are critical to establishing a diagnosis of TBM. Patients with severe TBM are candidates for tracheobronchoplasty. Multidisciplinary evaluation of patients with TBM has the potential benefit derived from shared decision-making to ensure patient optimization, prehabilitation, periprocedural care and posttreatment recovery, rehabilitation, and follow-up. Robotic tracheobronchoplasty is safe and improves pulmonary function tests and quality of life in patients with severe TBM.

Tracheal resection and reconstruction (TRR) surgery presents unique challenges to the anesthesiologist. These challenges include the induction of anesthesia and establishment of an airway in a patient with tracheal stenosis; airway management during the open tracheal phase of the operation; and emergence from anesthesia and extubation at the end of the case. A number of approaches to the safe conduct of these anesthetics have been described in the literature. Ultimately the successful anesthetic management of TRR hinges on an understanding of the surgical procedure, as well as close communication with the surgeon.

Nonintubated airway surgery is an innovative procedure for tracheal tumors or stenosis. It avoids intubation and the interference of cross-field intubation, reducing airway trauma and postoperative complications. Utilizing supraglottic devices and short-acting anesthetics, it maintains spontaneous ventilation, facilitates surgery, and enhances recovery after surgery. Various surgical approaches are tailored to the airway lesion's location, and surveillance bronchoscopy, computed tomography (CT), MRI, and PET/CT are crucial for postoperative monitoring and outcome evaluation.

A surgeon managing complex airway disease benefits from knowledge of laryngeal physiology and pathology. The Larynx provides phonation and protection for the lower airway via closure and cough reflex. Disruption of these functions or development of paralysis or stenosis can lead to respiratory failure. Management includes a variety of endoscopic and open management techniques. Understanding of laryngeal physiology can also limit laryngeal functional impairment through careful preservation of motor nerves and early recognition of injuries.

Laryngotracheal stenosis (LTS) encompasses a spectrum of conditions characterized by the luminal narrowing of the supraglottis, glottis, subglottis, and/or trachea. However, endoscopic treatment methods are associated with significantly higher rates of restenosis compared to open techniques. The number of endoscopic modalities continues to expand without a clear consensus on the most appropriate treatment choice. The purpose of this article is to review these options along with their functional outcomes. The article herein reviews the common causes, descriptors, and endoscopic options to address LTS along with their functional outcomes.

Post-intubation and post-tracheostomy tracheal stenoses are relatively uncommon common complications of prolonged intubation. Patients with tracheal stenosis usually present with stridor and dyspnea once a significant portion of their airway is compromised. Tracheal resection and reconstruction offer durable treatment options for these patients with minimal risk once initial endoscopic treatment has failed.

Idiopathic subglottic stenosis (ISS) is a rare disorder resulting in cicatricial narrowing of the airway centered at the cricoid cartilage. It almost exclusively affects Caucasian women. Endoscopic treatments such as dilatation, laser, or local injection of agents that can decrease the inflammatory and fibrotic reaction can be effective at palliating symptoms. However, definitive treatment involves surgical correction with a laryngotracheal resection with primary reconstruction, which is associated with low recurrence rates. This article discusses the evaluation and treatment of patients with ISS, discusses surgical technical details, and brings attention to issues that might arise in the postoperative period.

Fistulization between the tracheobronchial tree and gastrointestinal tract is a challenging clinical situation that leads to life-threatening pulmonary contamination and inadequate nutrition. Operative management requires repair of both airway and esophageal defects with or without tracheal resection and reconstruction to restore a functional airway and maintain gastrointestinal continuity. Tracheoinnominate fistula is a rare communication between the airway and innominate artery that can result in fatal hemorrhage. Prompt operative intervention is lifesaving and can be performed by division of the innominate artery and interposition of a vascularized tissue flap between the trachea and divided artery.

The diagnosis and treatment of patients with tracheal tumors is challenging due to the low incidence of these tumors. A precise diagnostic work-up and experience is necessary to distinguish between patients amenable to surgery and nonsurgical patients. An individualized treatment concept should be established for each patient in a multidisciplinary team and ranges from interventional removal of benign lesions to multimodal strategies in patients with extended malignant tumors. Early diagnosis despite unspecific symptoms and complete resection are crucially important to achieve long-term survival.

Carinal resection is defined as the resection of tracheal-bronchial bifurcation with or without associated lung resection. It is usually indicated in case of primary tumors with limited involvement of the carina. The reported mortality ranges from 3% to 20% in high-volume centers. The surgical approach depends on the location of the lesion. Surgery for carinal pathology is technically difficult and the development of anastomotic complications such as devascularization, separation, and stenosis may be directly related to surgical technique.

The trachea serves as a conduit for inspiration and expiration of air; apparatus for phonation; mucociliary escalator for airway clearance and pulmonary defense; and allows for the more distal exchange of oxygen and carbon dioxide. Each of these functions is a result of the embryologic development and resultant structural anatomy of the trachea. The purpose of this article is to provide a review of tracheal embryology and anatomy, including endoscopic anatomy and airway imaging techniques.

Airway stenosis and malignant tumors are the 2 main reasons to perform a surgical resection of part of the trachea. Tracheal lesions with a length shorter than 5 cm can be resected and primary reconstruction can be safely effected. Excessive anastomotic tension should be avoided because it may lead to restenosis or dehiscence at the anastomosis. Reconstruction of a longer defect may be attempted with a tracheal allotransplant or with autologous tissue.

Aorto-esophageal fistula is a rare but life-threatening source of massive upper gastrointestinal bleeding. Prompt diagnosis and intervention are key for patient survival. Treatments consist of aortic resection, thoracic endovascular aortic repair, esophagectomy with diversion, and primary esophageal repair. The appropriate treatment is dependent on patient hemodynamics and fitness and familiarity with operative approaches by the treating team.

Fistulae between the esophagus and the pericardium or the left atrium are rare but feared complications of transcatheter ablations and esophageal procedures and pathologies. Patients may present variably with cardiopulmonary, gastrointestinal, infectious, and/or neurologic symptoms; a high index of suspicion is paramount. The presence of atrial involvement will dictate the approach and extent of the necessary intervention. While mortality is high overall, surgical repair confers the highest likelihood of survival.

Acquired tracheoesophageal fistulas (TEFs) are rare pathologic connections between the trachea and esophagus. Esophageal and tracheal stenting have been increasingly and safely utilized in management of TEFs, but surgical repair remains the most definitive treatment. Surgical approach to treating TEFs depends on its location, but principles include division and closure of the fistula tracts and insertion of a muscle flap in between the repairs to buttress and prevent recurrence. Advances in diagnostic tools, endoscopic and surgical methods, and intensive care have led to significantly improved outcomes in the management of acquired TEFs.

This article outlines the anatomic and physiologic basis for gastric conduit ischemia and the range of its possible manifestations, from superficial mucosal ischemia to gross conduit necrosis. Methods by which these complications are suspected and ultimately diagnosed are discussed, focusing on clinical and laboratory signs as the harbingers and the use of imaging and endoscopy for confirmation. From there, management options are detailed based on the Esophagectomy Complications Consensus Group classification of esophageal leak and gastric necrosis. Finally, the short- and long-term implications of these complications are reviewed.