By: Beny Rilianto

Jessieca LiusenMarni SianturiMitha Pradini

Wawan KurniawanP. Ingen Setiasih

Journal Reading

25 July 2012Int J Gen Med. 2012; 5: 93–98. Published online 2012 January

25

*Background

*The most common indication for tracheal surgery postintubation tracheal stenosis. Surgical approaches was primary resection and anastomosis and other method tracheoplasty.

*This report was about Iranian experience with surgical management for postintubation tracheal stenosis moderate-severe

*Comparation between with and without previous tracheostomy

*5 year period Jun 2005-Jul 2010

*Subject were 50 patients aged 14-64 years with moderate (50-70% lumen) to severe (>70%) resection and primary anastomosis

*Follow up the outcomes after surgery

*Groups divided into with tracheostomy (group A = 27) and without (group B n=23)

*Resection and primary anastomosis cervical incision (45 patients) and right thoracotomy (5 patients)

*2 with subglotic stenosis complete resection of lesion in trachea and anterior part of cricoid cartilage, remaining trachea was anastomosed to thyroid cartilage using Montgomery T-Tube

*1 perioperative death fistula tracheo-innominate

*Tracheostomy group segmen resected, number resected ring, duration surgery were longer (p<0,05)

*6 months after surgery excellent outcome 47 patients 95,9%

*Surgical approach highly successful result to treat moderate to severe postintubation trachea stenosis

*Previous tracheostomy prolong duration of surgery, increased number and length resected segmen of trachea

*Recommendation postintubation trachea stenosis tracheostomy tube must be inserted close to the stenotic segmen

*Keywords: trachea, tracheostomy, tracheal stenosis, intubation, tracheal resection

*Postintubation tracheal stenosis caused by pressure airway necrosis and most common cause for tracheal surgery

*Incidence decreased because *Modification in management with endotracheal tube and

tracheostomy

*Non surgical approaches: high recurrence rate*Stenting

*Percutaneus dilation

*Fiberoptic assisted balloon dilation

*Argon plassma coagulation

*Laser therapy

*Definitive theraphy rapid progressive stenosis : surgical approach : primary resection and anastomosis tracheoplasty

*If lack of surgical expertise tracheostomy 1st

*This report was about Iranian experience in moderate to severe postintubation tracheal stenosis over 5 years period on 50 patients

*Variables to compare were with or without tracheostomy before definitive surgical treatment

*Patients and study protocol

*This study was held over 5 years period : Jun 2005 – Jul 2010

*Involved 50 patients aged 14-64 years old

*Moderate (50-70% lumen) to severe (>70%) postintubation tracheal stenosis

*Mild degree : treated with bronchoscopic dilatation asymtomatic after 6 months excluded

*Diagnostic evaluation methods were pulmonary function test, CT, fiberoptic and rigid bronchoscopic examination

*Patients and study protocol

*Follow up after surgery

*Surgical variables to study the effect of previous tracheostomy were

*Length of resected segmen

*Number of resected rings

*Duration of surgery

*Total ICU stay

*Duration hospitalization

*With tracheostomy group A n=27; without : group B n=23

*Standard general anesthesia

*Rigid broncoscope used to induce intubation

*Complete resection of the stenosis segmen

*Insertion of T-spiral tracheal tube in distal segment to perform ventilation

*Anastomosis was done using 4-0 polyglactin (Vicryl) absorbable sutures with tie outside of the lumen

*Previous tracheostomy stoma site as the stenosis segmen resection

*Subglottic stenosis complete resection of lesion and anterior portion of cricoid cartilage

*If cricoid cartilage was intact tracheal anastomosis and resection

*To reduce tension of anastomosis

*Suprahyoid laryngeal release

*Pericardial incision

*Mobilization of right lung hilus

*Laryngeal release and

*Hilus mobilization

*Chin was sutured with silk to presternal skin in neck flexion prevent sudden hyperextension of neck and tension to anastomosis

*Removal of suture 1 week after procedure

*Extubation was done in Operating room

*The 1st 24 hours after surgery low dose hydrocortisone and antibiotic intravenous for prophylactic

*Outcome*6 months after surgery classified the outcome to:

*Excellent : normal voice and respiration

*Good: slight lessening of maximum voice volume, hoarseness, weakness of voice, but breathing was adequate for daily living

*Satisfactory: hoarse voice, slight wheezing, shortness breathing on exercise, but no impairment to daily living

*Not satisfactory: more complications and need numerous postoperative bronchoscopic dilatation

*Statistic analysis:*SPSS v.13 using Chi Squared test, Fisher test or t-

independent sample test

*P< 0,05 significant value

32 men64%

32 men64%

18 women

36%

18 women

36% 5 moderate5 moderate 45 severe45 severe

39 had 1-5 times bronchoscopic dilatation before but stenosis still

recurred after 1-5 months

39 had 1-5 times bronchoscopic dilatation before but stenosis still

recurred after 1-5 months

6 had previous emergency

bronchoscopic dilatation

6 had previous emergency

bronchoscopic dilatation

*12 patients underwent tracheostomy due to lack surgical expertise

*5 patients with bad general condition and inflammation on the trachea

27 had previous tracheostomy

10 with prolong

intubation

10 with prolong

intubation

45 had cervical incision

5 underwent right thoracotomy

-3 thoracic stenosis-2 supracarinal stenosis

3 with cervicothoracic

stenosis underwent partial sternal split

3 with cervicothoracic

stenosis underwent partial sternal split

*2 had subglottic stenosis underwent complete resection of lesion and anterior part of cricoid anastomosis made to thyroid using Montgomery T-tube

*Removal T-tube 3 months after surgery

*4 had subglottic stenosis but cricoid was intact resection of trachea and cricotracheal anastomosis

*Mean length of resected segmen 3,66±1,01 (2-6cm)

*Mean of number resected segmen 5,46±1,43 (3-10)

*Mean duration of surgery, ICU stay, and hospitalization 3,61±0,64 hours, 3,42±1,52 days, and 9,3±2,28 days

*Minor complications :

*Superficial wound infection (n=4),

*Temporary vocal cord disfunction (n=4),

*Pneumonia (n=2)

*1 inhospital death due to previous brain tumor surgery developed postoperative mediastinitis and severe bleeding to tracheoinnominate fistula

Due to need for numerous bronchoscopis

dilatation

*The excellent and satisfactory rate for this study was 95,9%

*Abbasidezfouli et al 61,5% success rate due to complexity therapeutic approaches toward multisegmental stenosis

*Grillo et al failure rate was similar to this study about 4%

*Rea et al no not satisfactory result from benign trachea and laryngotracheal stenosis

*Other study no individuals had previous tracheostomy lack surgical failure cases

*Both case with not satisfactory result subglottic stenosis due to previous tracheostomy

*Perioperative mortality rate was similar to this study

*Previous tracheostomy significantly increased duration of surgery, length and the number segmen resection

*No significant to ICU stay and hospitalization

*It happened because who had previous tracheostomy surgical approach must be done by sacrifice the normal site between stoma and lesion increase length resected segmen and duration of surgery

*Postintubation stenosis iatrogenic sequele after intubation incidence reported was 0,6%-21% and 6%-21%

*Main cause of stenosis was pressure exerted to tracheal mucosa by the cuff (>30 mmHg) ischemia mucosa ulcer stenosis as sequele

*Tracheostomy most common complication were damaging cartilage, wound sepsis at stoma*But it can reduce postintubation injury

*High pressure from cuff and tube

*Subglottic stenosis due to proximal erosion of cricoid from tracheostomy tube

*Current treatment strategies:

*Bronchoscopic dilatation maintained safe airway

*Laser therapy to repaired the cicatrized lesion due to stenosis indicated to patients who had contraindication to surgery

*The best was still tracheal surgery

*Main principle to the surgery was to maintain blood supply of trachea, reduced tension, dissection, and anastomosis

*Extensive lesion of tracheal stenosis remains unsolved problem

*Recent study investigated alternative treatment for this problem

*Tissued engineered airway

*Revascularized allograft

*Cryopreserved aortic allograft

*Surgical approach had highly successful rate to treat moderate –severe postintubation tracheal stenosis

*Previous tracheostomy prolonged duration of surgery, increased need for postoperative intervention due to number and length of resected segmen

*Recommendation: emergency tracheostomy to patients had postintubation tracheal stenosis must be held by insert the tube closely to stenotic segmen

*Treatment of subglottic stenosis required used of Montgomery T-tube to support anastomosis