For a long time, surgeries for challenging tracheal diseases have been associated with high levels of difficulty and mortality, presenting a significant challenge in thoracic surgery. Due to the unique anatomical and physiological characteristics of the trachea, the reconstruction and repair of the trachea face numerous clinical difficulties, such as recurrent infections, poor vascularization, and challenges in achieving satisfactory anastomosis, stenosis, and epithelialization. To overcome these treatment challenges, the Department of Thoracic Surgery at Shanghai Pulmonary Hospital has been one of the pioneering teams in China to conduct complex tracheal surgeries. Over the course of more than 40 years, the team has been dedicated to the clinical diagnosis and treatment of complex and challenging tracheal diseases. They have made significant progress by jointly innovating surgical techniques, inventing instruments, and developing critical technologies for artificial tracheal construction.

Over the years, the project team has been involved in various international collaborative projects based on research related to complex tracheal diseases. They have secured and initiated several national-level projects, including six grants from the National Natural Science Foundation for Young Scientists and General Programs (in 2017, 2019, 2020, and 2022; details are provided in Table 1), with total funding exceeding 3 million RMB.

Table 1: List of National-Level Projects Obtained by the Project Team in Recent Years (Arranged in Chronological Order):

With the support of organizations such as the Ministry of Science and Technology and the National Natural Science Foundation, the project team has pioneered several novel surgical techniques for the treatment of challenging tracheal diseases on an international scale. These innovations have addressed treatment gaps and have given rise to an entirely new treatment system in the field of tracheal surgery. These advancements are being promoted both domestically and internationally, and they primarily encompass the following aspects:

1. Establishing a Novel Technical System for the Resection and Reconstruction of Tracheal Elevation Tumors

The project team has pioneered two new techniques for the resection and reconstruction of elevation tumors, introducing the “lowered elevation” and “autologous bronchial flap turnover” reconstruction procedures. These innovations simplify the complex elevation tumor surgeries and have significantly reduced postoperative mortality rates by 20%. This has resulted in the complete establishment of an innovative technical system for the resection and reconstruction of tracheal elevation tumors, which has gained broad international recognition and application, making it a global leader in the field (Figure 1A). Resection of long-segment tracheal tumors (>6 cm) poses a significant challenge in tracheal surgery. The team has introduced novel defect repair techniques, “pedicled pectoralis major muscle skin flaps” and “asymmetric circular turnover reconstruction”, which have broken through the limitations of traditional tracheal tumor resection methods. These techniques increase the resection length by 25% and have successfully made challenging surgeries minimally invasive, improving the resection rates for some patients (Figure 1B). Among these advancements, the “Clinical and Basic Research on Challenging Tracheal Elevation Diseases” conducted by the team received the Second Prize of the Chinese Medical Science and Technology Award in 2017 (Figure 1C).

Figure 1: A - Schematic representation of the “autologous bronchial flap turnover” reconstruction procedure. B - Schematic illustrations of the defect repair techniques “pedicled pectoralis major muscle skin flaps” and “asymmetric circular turnover reconstruction”. C - The “Clinical and Basic Research on Challenging Tracheal Elevation Diseases” conducted by the project team received the Second Prize of the Chinese Medical Science and Technology Award in 2017.

2. Reconstruction Surgery for Benign Tracheal Stenosis in the Neck Region

In clinical practice, tracheostomy or endotracheal/nasotracheal intubation for mechanical ventilation is a crucial intervention for managing critically ill patients with acute or chronic respiratory failure. With the advancement of critical care medicine, mechanical ventilation has become widely used in clinical settings, but it also brings a series of complications. For instance, it can disrupt the stability of tracheal structures, leading to the proliferation of surrounding granulation tissue and resulting in airway stenosis. Currently, laryngeal intubation and tracheostomy injuries are the most common causes of benign tracheal stenosis. After the outbreak of the novel coronavirus pneumonia, the number of patients with benign tracheal stenosis has significantly increased, severely affecting their quality of life. The goal of treating benign central airway stenosis should focus on relieving patient symptoms, maintaining their survival, and improving their quality of life. Existing airway stents are still the primary means of treating refractory benign scar-related airway stenosis. For patients with subglottic and high-level tracheal stenosis, T-tube insertion is the gold standard treatment. However, for patients with refractory benign scar-related airway stenosis that is unresponsive to endoscopic treatment, surgical tracheal reconstruction is the last resort. The team focuses on surgical neck tracheal reconstruction for patients with intractable neck tracheal stenosis, especially those with stenosis involving the larynx. This approach systematically establishes innovative treatment strategies for refractory benign airway diseases (Figure 2).

Figure 2: For patients with high-level tracheal stenosis in the neck region, individualized designs for tracheal segment resection or laryngotracheal joint resection surgeries are performed.

3. Tracheoesophageal Fistula Reconstruction and Repair Surgery

Tracheoesophageal fistula (TEF) refers to a pathological communication between the trachea or bronchus and the esophagus. TEF is most commonly seen in patients who have undergone surgery for trauma, thyroid and esophageal tumors, as well as those treated with tracheal intubation. After tracheal intubation, the pressure and friction of the tube can cause necrosis in the tracheal wall, resulting in the formation of an abnormal channel that penetrates the posterior tracheal wall, creating an abnormal passage between the posterior tracheal wall and the anterior esophageal wall. In patients who have undergone esophageal tumor surgery, poor anastomotic healing can lead to the development of tracheoesophageal fistulas. Most patients with tracheoesophageal fistulas experience symptoms such as coughing, vomiting after eating, recurrent lower respiratory tract infections, and even respiratory distress syndrome, significantly impacting their quality of life. In terms of treatment, surgery is the preferred approach. The team has developed a unique surgical technique for large tracheoesophageal fistulas, introducing an innovative “oblique circular resection and reconstruction” approach to broaden clinical indications. They have also pioneered the use of the “pectoralis major muscle skin flap transposition” to repair membrane defects, addressing the challenging issue of large tracheoesophageal fistula surgery. This has filled a significant treatment gap and is considered a leading approach on the international stage (Figure 3).

Figure 3: For patients with tracheoesophageal fistulas with different clinical conditions, innovative personalized surgical approaches are designed to maximize the treatment benefits for the patients. (A) Direct resection of the tracheoesophageal fistula and closure of the fistula ends separately. (B) Innovative “oblique circular resection and reconstruction” technique to achieve tracheal segment resection and closure of the esophageal end of the fistula. (C) Original “pectoralis major muscle skin flap transposition” to repair membrane defects and address the challenge of massive tracheoesophageal fistula surgery.

Based on the clinical challenges posed by the aforementioned complex tracheal diseases, strengthening basic research efforts and enhancing the translation of achievements have been an extension and expansion of the project team's clinical work. Functional tracheal reconstruction has consistently been a major clinical challenge, with a key technical obstacle being the lack of ideal tracheal grafts. Tissue engineering techniques offer a feasible strategy for constructing functional tracheal grafts. The project team has pioneered the circular strategy for constructing biomimetic tracheas, making significant advancements in the field of biomimetic trachea construction and long-segment tracheal defect regeneration and repair. Clinical validation has been achieved as a pioneering effort in this area. Currently, in the field of tracheal tissue engineering, the team has published seven articles with an impact factor exceeding 10 in prominent international journals, including "Advanced Healthcare Materials," "Advanced Functional Materials," and "Advanced Materials" (see Table 2 for details). One of the articles was published in the prestigious materials science journal "Advanced Materials" (Figure 5), with the highest impact factor reaching 29.4 (Figure 4).

List of High-Impact and Representative SCI Publications by the Project Team in Recent Years (Sorted by Publication Date):

Figure 5: The project team has internationally pioneered the innovative use of a ring-shaped strategy in combination with mesenchymal stem cells to construct a highly biomimetic trachea, achieving significant progress in the fields of biomimetic tracheal construction and regeneration for long-segment tracheal defects. The results of this work have been published in the renowned materials science journal “Advanced Materials”.

These achievements have elevated the project team to the level of internationally recognized tracheal disease diagnosis and treatment centers, significantly enhancing the global influence of Chinese tracheal surgery. The project team remains dedicated to their original mission and will continue to work tirelessly in the clinical field of challenging tracheal diseases, bringing hope and improved outcomes to a growing number of patients with such conditions.