Abstract

Background: This study aims to evaluate the clinical characteristics, interventions performed, and follow-up outcomes of patients undergoing bronchoscopy or surgical intervention for tracheobronchial diseases.

Methods: A total of 47 patients (28 males, 19 females; mean age: 49±19 years; range, 4 to 78 years) who underwent bronchoscopy or surgical interventions for tracheobronchial diseases between 2018 and 2023 were included in the retrospective study. Patients who underwent stent placement, tracheal resection, or bronchoscopic interventions due to tracheobronchial disease were included in the study.

Results: The most common presenting symptom was dyspnea, with 76.6%. The most frequent lesion location was the trachea (74.5%). Malignant etiologies were found in 29.8% of the patients, while benign causes were observed in 70.2%. Stent placement was performed in 57.4% of patients. The mean followup period was 13.51±1.65 months, and five (10.6%) patients died during follow-up. A significant correlation was found between stent placement and longer survival (p<0.05). The survival time was positively correlated with the diagnosis, need for stent placement, and control bronchoscopy.

Conclusion: Bronchoscopy and surgical interventions for tracheobronchial diseases are effective and safe treatment options. Stent placement, particularly in malignant or severe benign airway obstructions, significantly improves survival. Regular follow-up and early intervention are crucial for improving patient prognosis.

Tracheobronchial diseases are potentially life-threatening conditions that compromise the structural integrity and function of the airway, which may result in significant respiratory compromise. These disorders may arise from a variety of etiologies, including benign stenosis, malignant tumors, traumatic injuries, infections, and congenital anomalies. Clinical manifestations of airway obstruction include dyspnea, stridor, recurrent respiratory infections, and reduced quality of life. In many cases, clinical deterioration may be rapid, depending on the severity of the underlying pathology, and the absence of timely intervention can markedly increase mortality risk.[1]

Before the 1960s, the treatment of airway disorders was limited to rudimentary techniques with modest clinical outcomes. However, over the past few decades, significant advances in bronchoscopic techniques, airway stent technologies, and surgical interventions have led to marked improvements in success rates and reductions in complication rates.[2,3] Despite these developments, large-scale studies that simultaneously evaluate both bronchoscopic and surgical approaches in the management of tracheobronchial diseases remain limited in the literature.

In this retrospective study, we aimed to contribute to the existing knowledge by analyzing the clinical characteristics, treatment modalities, and follow-up outcomes of patients who underwent bronchoscopic or surgical interventions for tracheobronchial diseases at a single center.

Methods

This retrospective study was conducted with 47 patients (28 males, 19 females; mean age: 49±19 years; range, 4 to 78 years) who underwent bronchoscopic or surgical interventions for tracheobronchial diseases at the Kayseri City Training and Research Hospital between 2018 and 2024. Patients diagnosed with tracheobronchial stenosis or obstruction and treated with either bronchoscopic or surgical procedures were included. Those with incomplete medical records or lacking follow-up data were excluded. Written informed consent was obtained from all participants. The study protocol was approved by the Kayseri City Training and Research Hospital Clinical Research Ethics Committee (Date: 12.12.2023, No: 967). The study was conducted in accordance with the principles of the Declaration of Helsinki.

All patients underwent airway evaluation using both flexible and rigid bronchoscopy, along with thin-section three-dimensional computed tomography. Flexible bronchoscopy (BF Type 1T260; Olympus Corporation; Tokyo, Japan) was performed under sedation, while rigid bronchoscopy (Karl Storz, Tuttlingen, Germany) was conducted under general anesthesia with appropriate ventilatory support.

Interventions such as mechanical dilatation, cauterization, laser application, and stent placement were carried out under rigid bronchoscopy. In patients for whom surgery might be appropriate in the future, no bronchoscopic interventions other than mechanical dilatation were planned to avoid increasing the risk of surgical complications. In patients deemed inoperable due to medical or surgical reasons, energy-based therapies or stent placement were selected during the procedure based on the bronchoscopic appearance of the lesion, the underlying primary disease, and the patient's clinical characteristics.

Cauterization procedures were performed under general anesthesia. To minimize the risk of airway fire, the fraction of inspired oxygen (FiO₂) was intermittently reduced to <40% while maintaining an oxygen saturation above 90%. The airway was humidified throughout the procedure, and continuous aspiration was applied to prevent gas accumulation. No complications, including airway burns, related to cautery use were observed.

Laser procedures were also performed under general anesthesia using a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser system. A sterile flexible fiberoptic probe was inserted through the bronchoscope channel to deliver laser energy directly to the lesion. Laser power was set at 20 to 40 W to avoid excessive carbonization and collateral thermal injury. Energy was applied in short, perpendicular pulses to prevent perforation. Similar to cautery, FiO2 was kept below 40% to prevent mucosal burns. No airway burns or perforations were observed in any case.

Stenosis severity was classified using standard protocols.[4] Stents were inserted under general anesthesia and rigid bronchoscopy. Patients with severe stenosis (>70%) received Dumon silicone stents (Tracheobronxane®, Novatech, La Ciotat, France) or customized self-expanding metallic stents in selected malignant cases. Stent selection was based on etiology (benign vs. malignant), stenosis length, and anatomical localization.

Metallic stents were placed under fluoroscopic guidance or direct visualization by measuring the proximal and distal margins of the stenotic area. Dumon stents were implanted via a size 14 Storz rigid bronchoscope, with prior mechanical dilatation. If necessary, stents were secured with sutures to prevent migration.

For lesions involving the trachea-carina or bilateral main bronchi, Y-shaped (T-type) stents were used. These stents were trimmed to fit bifurcation anatomy and inserted under rigid bronchoscopy.

Surgical technique
Candidates for surgical treatment were discussed in a multidisciplinary council. All patients underwent detailed airway evaluation with thoracic CT, and three-dimensional reconstruction was used as needed. Preoperative assessments included cardiac risk evaluation, anesthesia consultation, infection prophylaxis, and dietary optimization for wound healing.

All surgeries were performed under general anesthesia in the supine position. Orotracheal intubation was used for induction, and fiberoptic bronchoscopy was employed when necessary for atraumatic intubation. During resection, the existing tube was advanced above the tracheal incision without full extubation, and a second endotracheal tube was inserted through the incision for ventilation maintenance.

For tracheal resection, a transverse cervical incision was used in all patients. The trachea was mobilized inferiorly down to the carina and superiorly up to the cricoid cartilage with careful preservation of surrounding tissues and recurrent laryngeal nerves. The stenotic segment of the trachea with distorted lumen was resected. Neck flexion was maintained with cricotracheal release if necessary to reduce anastomotic tension. End-toend anastomosis was completed using full-thickness 3-0 or 4-0 nonabsorbable polypropylene sutures. Continuous sutures were used on the membranous wall, whereas interrupted sutures were used on the cartilaginous wall, ensuring mucosal alignment and equal spacing. A positive-pressure test was performed for air leakage, and additional sutures were applied if needed.

For patients undergoing surgical repair for tracheoesophageal fistula (TEF), following singlelumen endotracheal intubation under general anesthesia with bronchoscopic guidance, a collar incision was made. The skin, subcutaneous tissue, and strap muscles were dissected to expose the trachea. Blunt dissection was performed between the trachea and the esophagus to separate the two structures. Primary repair was carried out by suturing the anterior esophageal wall and the posterior tracheal wall. A muscle flap (sternohyoid or sternocleidomastoid) was interposed between the two lumens to reinforce the repair. After confirming the absence of leakage with nasal administration of methylene blue, the procedure was concluded.

Postoperatively, a guardian stitch (sternumjaw suture) was placed to maintain neck flexion and reduce anastomotic tension. Extubation was performed as early as clinically feasible. Early postoperative flexible bronchoscopy was performed to assess airway patency and anastomotic healing.

Statistical analysis
Data were analyzed using IBM SPSS version 26.0 software (IBM Corp., Armonk, NY, USA). Collected data included demographics, clinical symptoms, lesion localization, diagnosis, treatment modalities, bronchoscopic and surgical procedures, requirement for chemoradiotherapy, and follow-up outcomes. Normality was tested using the Kolmogorov-Smirnov test. For group comparisons, Student's t-test was applied for parametric variables, and the Mann-Whitney U test was used for nonparametric variables. Categorical data were compared using Pearson's chisquare or Fisher exact test. Pearson correlation was used for normally distributed variables, and Spearman correlation was used for nonnormally distributed variables. Logistic regression was employed to assess intergroup associations. A p-value <0.05 was considered statistically significant.

Results

The most common presenting symptom was dyspnea (76.6%, n=36), and the most frequent lesion location was the trachea (74.5%, n=35). Of all patients, 14 (29.8%) were diagnosed with malignant disease and 33 (70.2%) with benign disease. Interventional stenting was performed in 27 (57.4%) patients. Chemoradiotherapy was required in 14 (29.8%) patients. While 39 (83.0%) patients did not require any surgical intervention, three (6.4%) patients underwent TEF repair, and five (10.6%) underwent tracheal resection. In five patients with tracheal stenosis, only mechanical dilatation was performed prior to surgery. None of these patients underwent advanced bronchoscopic interventions such as cautery, laser, or stent placement. The most frequently applied bronchoscopic procedure was mechanical dilatation (44.7%, n=21), followed by energy device use (25.5%, n=12), and combined methods (21.3%, n=10). Four (8.5%) patients did not undergo any bronchoscopic intervention. Control bronchoscopy was performed in 27 (57.4%) patients. The mean follow-up period was 13.51±1.65 months (median: 14 months; range, 8 to 16 months). During the follow-up, five (10.6%) patients died (Tables 1, 2).

Table 1. Clinical characteristics of the patients (n=47)

Table 2. Procedures performed on the patients (n=47)

According to logistic regression analysis (Nagelkerke R²=0.55), stenting (p=0.042), chemoradiotherapy requirement (p=0.009), and diagnosis type (benign vs. malignant, p=0.009) were significantly associated with survival. In contrast, the need for surgical intervention and lesion localization (trachea vs. main bronchus) did not show a statistically significant effect on survival (p>0.05; Table 3).

Table 3. Factors affecting survival

When evaluating the relationship between diagnosis type and lesion localization, malignant lesions were more frequently observed in main bronchial localizations (58.3%) compared to tracheal ones (20.0%), with a statistically significant difference (p=0.02). However, the primary diagnosis had no impact on the need for surgical intervention (p=0.55). Malignancy was present in 29.6% of patients with stents and in 30% of those without stents, with no statistically significant difference (p=0.97; Table 4).

Table 4. Distribution of benign and malignant patients

There was a significant difference in clinical outcomes between patients who underwent stenting and those who did not (p<0.05). Survival was significantly associated with diagnosis type, the need for chemoradiotherapy, stent placement, and whether control bronchoscopy was performed (p<0.05). In addition, significant correlations were found between diagnosis and lesion localization, chemoradiotherapy application, and follow-up period (p<0.05).

Discussion

Tracheobronchial diseases may lead to severe clinical symptoms due to airway obstruction. Flexible and rigid bronchoscopy, along with thoracic CT, play crucial roles in diagnosis. The choice of intervention should be guided by lesion characteristics and the overall clinical condition of the patient. Both bronchoscopic and surgical approaches are appropriate in selected benign and malignant cases.[3-5]

Bronchoscopic techniques, including mechanical dilatation, thermal ablation, and stent placement are particularly effective in the symptomatic treatment of obstructive airway lesions.[3,5,6] However, in certain cases, particularly with malignant lesions or severe tracheal stenosis, surgical intervention may be necessary for a definitive cure.[3,6]

In this study, we retrospectively evaluated the clinical features, interventions, and follow-up outcomes of 47 patients who underwent bronchoscopic or surgical treatment for tracheobronchial diseases. Dyspnea was the predominant presenting symptom, and most lesions were located in the trachea. Although the majority of cases involved benign pathology, survival was notably shorter in patients with malignant disease.

Mechanical dilatation was the most frequently performed bronchoscopic intervention, applied in 44.7% (n=21) of cases. This method provided rapid symptomatic relief and improved airway patency in benign tracheal strictures. However, a higher frequency of follow-up bronchoscopies was needed in these patients due to restenosis, aligning with the findings of Ernst et al.,[7] who noted that mechanical methods offer short-term benefit but often require repeat procedures.

Stenting was performed in more than half of the patients, and a significant survival benefit was observed in this group. The literature similarly supports that stenting improves both airway patency and quality of life.[1,2] In our cohort, survival was positively associated with benign diagnosis, stent placement, the need for chemoradiotherapy, and follow-up bronchoscopies. These findings are consistent with prior studies showing that bronchoscopic interventions, when paired with systemic therapies, can yield palliative and sometimes survival benefits in malignant airway obstruction.[3,4]

Murgu et al.[3] highlighted the utility of stenting for symptom control and short-term survival in malignant airway obstruction. Similarly, Routila et al.[8] reported significantly improved survival among patients receiving chemoradiotherapy following stent placement (hazard ratio=0.29, 95% confidence interval 0.15-0.56, p<0.001), as well as benefits from adjunct interventions such as laser therapy or dilatation (hazard ratio=0.36, 95% confidence interval 0.23-0.58, p<0.001). Wood et al.[4] also emphasized that combining endoscopic techniques with chemoradiotherapy can enhance survival outcomes. Consistent with these findings, patients in our study who initially could not undergo chemoradiotherapy due to respiratory or infectious complications were later able to complete their treatment after interventional bronchoscopy and stenting, resulting in significant survival benefits.

The importance of routine follow-up bronchoscopy to detect and manage stent-related complications has also been emphasized in the literature. A 2017 study showed that performing follow-up bronchoscopy in 70% of stented patients enabled early identification and management of complications.[9] Our findings support that a multidisciplinary approach, along with regular monitoring and timely interventions, contributes to improved survival in tracheobronchial diseases.

Neither the need for surgery nor the anatomical location of the lesion (trachea vs. main bronchus) had a statistically significant impact on survival (p>0.05), which is consistent with the findings of Liu et al.,[10] indicating that lesion location does not independently influence prognosis in advanced malignant airway disease. Instead, factors such as age, tumor histology, and treatment modality appear to be more relevant prognostic indicators.[10,11]

Tracheal resection and reconstruction, while potentially curative, are technically demanding and carry significant perioperative risks, including anastomotic dehiscence, infection, and respiratory compromise.[2] Successful outcomes depend on proper patient selection, multidisciplinary evaluation, surgical expertise, and meticulous postoperative care.[11,12]

In our study, five patients underwent tracheal resection and three underwent TEF repair. The low number of surgical interventions is likely due to the invasive nature of these procedures and concerns over complications, particularly in elderly patients or those with poor performance status or systemic comorbidities. Wright et al.[13] previously noted that while anastomotic complications are rare, risk factors such as reoperation, diabetes, and extended resection lengths must be considered during preoperative evaluation. Moreover, an analysis from the Society of Thoracic Surgeons General Thoracic Surgery Database involving 1,617 cases of tracheal resection between 2002 and 2016 reported a 30-day mortality rate of 1%, with lower complication rates in high-volume centers.[14]

In our experience, both tracheal resection and TEF repair were performed according to the patient selection criteria defined in the literature, and all procedures were successfully completed without major complications. These results affirm the safety and efficacy of surgery when proper patient selection and a multidisciplinary team approach are applied. Our low complication rate supports findings from other studies.[3,13,15]

One of the main limitations of this study was its retrospective and single-center design, which restricted generalizability. Furthermore, only eight of the 47 patients underwent surgery (five resections, three TEF repairs), limiting subgroup analyses. This likely reflects real-world clinical considerations, including inoperability in advanced malignant cases and the growing preference for minimally invasive bronchoscopic methods. Additionally, the relatively short mean follow-up period (13.5 months) hindered long-term survival and recurrence analyses. Therefore, future prospective multicenter studies with larger cohorts are needed to validate these findings.

In conclusion, bronchoscopic and surgical interventions play a pivotal role in the management of tracheobronchial diseases by maintaining airway patency and improving patients" quality of life. Among these, stenting is particularly effective in prolonging survival in patients with malignant lesions or severe benign airway stenosis. Regular follow-up bronchoscopies and timely reinterventions are crucial in optimizing clinical outcomes and sustaining symptom relief throughout the treatment process. Moreover, a multidisciplinary approach and individualized treatment planning contribute significantly to therapeutic success. The involvement of a highly skilled thoracic surgery team, proficient in both advanced bronchoscopic techniques and surgical resection, ensures comprehensive care and minimizes the risk of complications. Managing complex tracheobronchial cases with such a holistic strategy not only enhances procedural success rates but also facilitates early complication control, ultimately leading to improved survival and quality of life.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea: B.M., O.T.; Design: B.M., M.A.E., I.E.O.; Control: M.A.T., I.E.O.; Data collection and proceccing: O.F.D., O.T.; Analysis and interpretation: O.F.D., M.A.E.; Literature review: Z.O.S.; Writing the article: B.M.; Critival review: M.A.E.; References and funding: B.M.; Materials: B.M., O.T., M.A.E.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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