Background <p>Tracheal resection with end-to-end anastomosis remains the standard surgical treatment for acquired high-grade laryngotracheal stenosis. Slide tracheoplasty has emerged as an alternative reconstructive technique that enlarges airway caliber while preserving tracheal length and vascularity, yet direct comparative evidence in acquired stenosis is limited.</p> Objective <p>To compare the clinical, surgical, and functional outcomes of slide tracheoplasty versus tracheal resection with end-to-end anastomosis in patients with acquired laryngotracheal stenosis.</p> Methods <p>In this prospective pilot randomized controlled trial, 30 patients with grade II–IV acquired tracheal stenosis were allocated 1:1 to slide tracheoplasty (n = 15) or tracheal resection with end-to-end anastomosis (n = 15). Randomization was performed using a computer-generated sequence with variable block sizes, and baseline characteristics were assessed for group comparability. The primary outcome was surgery-specific success, defined as successful decannulation without need for revision open surgery within 6 months. Secondary outcomes included operative time, decannulation time, complications, restenosis, postoperative interventions, hospital stay, dyspnea (MRC scale), voice quality (VHI-10), and swallowing function (GUSS, PAS). Analyses followed the intention-to-treat principle.</p> Results <p>A total of 30 patients were randomized and completed follow-up. Baseline characteristics were comparable between groups. Surgery-specific success was high in both arms (slide 93.3% vs resection 86.7%; RR 1.08, 95% CI 0.85–1.37; p &gt; 0.99). Slide tracheoplasty required longer operative time (152.3 ± 15.7 vs 134.0 ± 17.5 min; p = 0.005) but resulted in earlier decannulation (12.3 ± 3.2 vs 16.3 ± 5.0 days; p = 0.013) and fewer postoperative balloon dilatations (13.3% vs 40%). Hospital stay and overall complication rates were similar. Both procedures significantly improved dyspnea and voice outcomes; however, postoperative MRC and VHI-10 scores favored slide tracheoplasty (p &lt; 0.05). Early postoperative swallowing impairment occurred more frequently after resection, with full recovery in both groups by one month. No mortality occurred.</p> Conclusions <p>In this pilot randomized controlled trial, both slide tracheoplasty and tracheal resection with end-to-end anastomosis were associated with high success rates and acceptable safety profiles in acquired laryngotracheal stenosis. Slide tracheoplasty demonstrated comparable success and was associated with earlier decannulation and a trend toward improved short-term functional recovery; however, findings should be interpreted cautiously given the exploratory nature of the study. Larger multicenter trials are required to confirm these preliminary observations.</p> Trial registration <p>Clinical Trials.gov (NCT06917222).</p>