13. Link TM, Schuierer G, Hufendiek A, et al. Substantial head trauma: value ofroutine CT examination of the cervicocranium. Radiology. 1995;196:741-745.

14. Ajani AE, Cooper DJ, Scheinkestel CD, et al. Optimal assessment of cervicalspine trauma in critically ill patients: a prospective evaluation. Anaesth IntensiveCare. 1998;26:487-491.

15. Davis JW, Parks SN, Detlefs CL, et al. Clearing the cervical spine in obtundedpatients: the use of dynamic fluoroscopy. J Trauma. 1998;45:768-771.

16. Sees DW, Rodriguez CL, Flaherty SF, et al. The use of bedside fluoroscopy toevaluate the cervical spine in obtunded trauma patients. J Trauma. 1998;45:768-771.

17. Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous inju-ries of the cervical spine in unreliable blunt trauma patients: incidence, evalua-tion, and outcome. J Trauma. 2001;50:457-463.

Trauma

Percutaneous TracheostomyGuest Reviewers: Claire Morgan, MD, and George Machiedo, MD,Department of Surgery, University of Medicine and Dentistry ofNew Jersey, East Orange, New Jersey

PERCUTANEOUS OR SURGICAL TRACHEOSTOMY: A META-ANALYSIS.Dulguerov P, Gysin C, Perneger T, Chevrolet J. Crit Care Med 1999;27:1617-1625.

Objective: To compare percutaneous with surgical tracheostomy using a meta-anal-ysis of studies published from 1960 to 1996.

Design: Meta-analysis of studies culled from a Medline data base search with aBoolean combination of tracheostomy or tracheotomy and complications, taking onlythose studies addressing all perioperative and postoperative complications. Complica-tions were divided into perioperative and postoperative groups and further subclassi-fied into severe, intermediate, and minor groups. Because most studies of percutaneoustracheostomy were published after 1985, surgical tracheostomy studies were dividedinto 2 periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed indepen-dently by 3 investigators.

Participants: Medline data base search with a Boolean combination (tracheostomyor tracheotomy) and complications, with human studies and the English language aslimits. Publications addressing all perioperative and postoperative complications wereincluded. Studies limited to specific complications or containing insufficient detailswere excluded.

Results: Earlier surgical tracheostomy studies (n � 17; patients, 4185) have thehighest rates of both perioperative (8.5%) and postoperative (33%) complications.Comparison of recent surgical (n � 21; patients, 3512) and percutaneous (n � 27;patients, 1817) tracheostomy trials shows that perioperative complications are morefrequent with the percutaneous technique (10% vs 3%), whereas postoperative com-plications occur more often with surgical tracheotomy (10% vs 7%). The bulk of thedifferences is in minor complications, except perioperative death (0.44% vs 0.03%)and serious cardiorespiratory events (0.33% vs 0.06%), which were higher with the

REVIEWER COMMENTS

This is a vast review, with well-detailedbreakdowns of complications based onseverity. In fact, one of the few com-plaints readers may make about this pa-per is that it presents so much informa-tion that it can be somewhatoverwhelming. However, their conclu-sions are clear. The risk of either proce-dure is so small and the differences be-tween the two are so slight (if oneconsiders those surgical tracheostomiesdone since 1985) that no compelling rea-sons exist to choose one or the other. Onesmall disappointment is that althoughthey do break down the differences be-tween different types of Pct (PDT withor without endoscopic control, and othermethods of Pct), they do not comparethese subsets to the SgT group. As statis-tically significant differences exist be-tween these subsets, one may in fact havean advantage over Sgt. Also, it should benoted that although they are careful todivide the SgT group into 2 groups toaccount for the differences in intensivecare medicine, anesthesia, and other de-velopments over the past 50 years, the

388 CURRENT SURGERY • Volume 59/Number 4 • July/August 2002

percutaneous technique. Heterogeneity analysis of complication rates shows higherheterogeneity in older and surgical trials. Percutaneous tracheostomy (PcT) was fur-ther subdivided into progressive dilation technique (PDT), PDT-PcT with endoscopiccontrol, and other methods, which showed a statistically significant decrease in peri-operative complications in the PDT-PcT with endoscopic control group.

Conclusions: Percutaneous tracheostomy is associated with a higher prevalence ofperioperative complications and, especially, perioperative deaths and cardiorespiratoryarrests. Postoperative complication rates are higher with surgical tracheostomy. Con-sidering the heterogeneity of the studies used and the low prevalence of complicationsin either group, the choice of tracheostomy should remain with the surgeon untilcompelling evidence favoring 1 technique becomes available.

PREFERRED ROUTE OF TRACHEOSTOMY—PERCUTANEOUS VERSUSOPEN AT THE BEDSIDE: A RANDOMIZED, PROSPECTIVE STUDY IN THESURGICAL INTENSIVE CARE UNIT. Porter J, Ivatury R. Am Surg 1999;65:142-146.

Objective: To compare percutaneous versus open tracheostomy at the bedside.

Design: Prospective, randomized study.

Setting: Surgical intensive care unit at University of California at Davis-East Bay,Oakland, and Medical College of Virginia, Richmond.

Participants: Twenty-four patients (12 in each group) were randomized to receiveeither bedside open (BO) or percutaneous (BP) tracheostomy over an 11-month pe-riod. All BP tracheostomies were done with endoscopic guidance. Over the same timeperiod, 46 medical intensive care unit patients received standard open tracheostomy inthe operating room. The number of ventilator days before tracheostomy and theclinical indications for tracheostomy were similar between the BO and BP groups.Variables compared were procedure time, blood loss, perioperative and postoperativecomplications, and cost. The operating room tracheostomies were performed by thesame surgeons and used as contemporaneous controls for the BO tracheostomies.

Results: Between the BP and BO groups, the only statistically significant differencenoted was the procedure time (15.4 vs 25.2 minutes, respectively). No postoperativecomplications occurred in either the BP or the BO group, 6 occurred in the operatingroom group, including 1 death. One perioperative complication occurred in the BOgroup and 5 in the BP group (1 death, 3 episodes of transient hypoxia, and 1 failedinsertion; the failed insertion and death occurred in the same patient). Patients werefollowed to the end of their hospital stay.

Conclusions: Although BP has been shown to have an advantage over standardoperating room tracheostomy in terms of safety, speed, and cost, most of these differ-ences disappear when BP is compared with an open procedure at the bedside. Theauthors do not believe that the advantages of speed outweigh the increased risk ofperioperative complications, and they recommend BO as the procedure of choice.

REVIEWER COMMENTS (Con’t)

time span covering the PcT papers origi-nates with the Ciaglia paper, when thePcT technique was just beginning to takehold. A learning curve exists that is gen-erally acknowledged in any new surgicalprocedure, and it is impossible to tellwhether a decreasing trend has occurredin the number of PcT-related complica-tions. In the authors’ defense, they admitthis difficulty and make an attempt tograph the trends in perioperative andpostoperative death rates in both proce-dures, but its significance in unclear.With these minor complaints, this is anexcellent review that calls for further eval-uation of PcT.

REVIEWER COMMENTS

Although the authors maintain that BP isa significantly more dangerous procedurethan is BO, the small numbers and lackof statistical analysis make their conclu-sions unconvincing. Their study doesshow a trend toward increased complica-tion rates in the percutaneous procedure,but as they were willing to show statisticalanalysis of the differences in time of pro-cedure, one can only assume that a simi-lar analysis of the complications was in-determinate. They offer no analysis ornumerical evidence of the cost compari-sons, although they do say in the discus-sion section that the cost of BO is lessthan BP. Although it is a prospectivestudy, this paper does not offer any evi-dence that should sway the reader towardeither procedure.

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TRACHEOSTOMY IN CARDIOSURGICAL PATIENTS: SURGICAL TRACHE-OSTOMY VERSUS CIAGLIA AND FANTONI METHODS. Westphal K, Byha-han C, Rinne T, Wilke H, Wimmer-Greinecker G, Lischke V. Ann Thorac Surg1999;68:486-492.

Objective: To compare the different techniques of tracheostomy.

Design: Prospective, randomized study.

Setting: Cardiosurgical intensive care unti of the J.W. Goethe University Hospital,Frankfurt, Germany.

Participants: One hundred twenty patients who required elective tracheostomybecause of the need for long-term ventilation. Forty patients each received an opentracheostomy in the operating room, a bedside percutaneous tracheostomy using theCiaglia technique, or one using the method of Fantoni and Ripamente. Infection of theproposed tracheostomy site and severe coagulopathy were considered contraindica-tions for tracheostomy. All percutaneous tracheostomies were done under endoscopicguidance. All open tracheostomies were performed in the operating room. Variablesinvestigated included preoperative diagnoses, preoperative coagulation profiles, oper-ative times, change in oxygenation indices perioperatively, difficulty of the procedure,postoperative site infections, tracheal trauma, and cost.

Results: Oxygenation indices (PaO2:FiO2) decreased using all methods, but theywere significantly worse in the open tracheostomy group. Overall complication ratewas 12.5% in the open and percutaneous dilatational groups, with no complicationsseen in the translaryngeal group. Bacterial contamination of the tracheostomy site wasfound in 35% of the open tracheostomies, with no infection seen in either of thepercutaneous groups. Cost of either percutaneous procedure was significantly less thanthat of the conventional open group.

Conclusions: Percutaneous dilatational and translaryngeal tracheostomies are safeand cost-effective procedures that can be done easily at the patient’s bedside and, thus,are attractive alternatives to conventional surgical tracheostomy in long-term airwayaccess in a cardiosurgical intensive care unit.

PERCUTANEOUS VERSUS SURGICAL TRACHEOSTOMY, A DOUBLE-BLINDRANDOMIZED TRIAL. Gysin C, Dulguerov P, Guyot J, Perneger T, Abajo B,Chevrolet J. Ann Surg 1999;230:708-714.

Objective: To compare surgical (SgT) and percutaneous (PcT) tracheostomies.

Design: Prospective, randomized trial with a double-blind evaluation.

Setting: Intensive care unit at Geneva University Hospital, Geneva, Switzerland.

Participants: Seventy patients were equally randomized into either the PcT or SgTgroups, which were performed either at the bedside or in the operating room. Intra-operative variables such as patient morphology, duration of the procedure, difficulty ofthe procedure, and any intraoperative complications were recorded. Perioperative andpostoperative complications were recorded and classified as serious, intermediate, orminor. Blinded postoperative evaluation was performed daily for the first week, on the14th day, and then 3 months after decannulation. At the last evaluation, patients wereasked about subjective dyspnea, dysphonia, and unaesthetic scar, and the patient wasexamined with a nasofibroscope to evaluate the vocal cords and trachea.

Results: No major complications occurred in either group. The only variables toreach statistical significance were the size of the incision (smaller with PcT, p �0.0001), minor perioperative complications (greater with PcT, p � 0.02), and difficultcannula changes within the first week postoperatively (greater with PcT, p � 0.05).

REVIEWER COMMENTS

In this study, the authors clearly showthat the differences between PcT andSgT are minimal, although a statisticallysignificant increase occurs in minor peri-operative complications in the PcTgroup. When those minor complicationswere broken down further, it turns outthat virtually the entire increase is causedby difficult tube placement, which theauthors attribute to the “blind” nature ofthe procedure. The authors, who arefrom the Department of Otolaryngologyand presumably have a significant pro-portion of patients who have undergonehead and neck surgery, note that chang-ing the cannula within the first postoper-ative week is significantly more difficultafter PcT than after SgT, which makesPcT a less desirable procedure in thosepatients who are difficult to intubate orhave limited motility of the head and

REVIEWER COMMENTS

The authors clearly demonstrate that ei-ther method of percutaneous tracheos-tomy is at least as safe as open tracheos-tomy in the operating room, althoughthey do not give statistical analyses toshow any superiority of the percutaneousmethods over open, except in the periop-erative oxygenation index and operativetimes.

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Among nonsignificant differences, difficult procedures and false passages were morefrequent with PcT, whereas long-term unaesthetic scars were more frequent with SgT.

Conclusions: Although both techniques have a low rate of intermediate or seriouscomplications, more minor perioperative complications occurred with PcT and moreminor long-term complications occurred with SgT.

REVIEWER SUMMARY

Over the past 15 years, percutaneous tracheostomy has become increasingly popularfor those patients requiring elective tracheostomy, especially those in the intensive careunit who are at increased risk during transportation to and from the operating room.Its advantages have been reported as lower rates of perioperative and postoperativecomplications, lower cost than open tracheostomy, and improved cosmesis after de-cannulation. The need for tracheostomies among the critically ill population is notlikely to decrease any time in the near future, and increasing pressures because of tightoperating room schedules and restrictive budgets push toward more use of cheaperbedside techniques that can be performed at the surgeon’s convenience.

At this point in time, no distinct advantage exists between the 2 methods in terms ofrisk to the patient. In particular, the risk of serious perioperative and postoperativecomplications (including death, cardiopulmonary arrest, pneumothorax, tracheo-esophageal (TE) fistula, intratracheal hemorrhage, and tracheal stenosis) ranges from3% to 5% in either procedure (see the reviewed article by Dulguerov et al). The newerprospective studies support the findings of Dulguerov et al’s meta-analysis; the totalrisk of either procedure is so low that it is almost impossible to find any major differ-ences between the 2 (see the reviewed article by Westphal et al and Gysin et al). Thisdoes not mean we should rest on our surgical laurels, however. Ciaglia et al’s procedure(progressive dilation) in particular does not require endoscopic control,1 but most ofthe papers reviewed in this article used endoscopy during all forms of percutaneoustracheostomy. Although not all surgeons agree that endoscopic control during PcT isnecessary, strong indications exist that it can prevent some of the more serious, if rare,complications, such as posterior tracheal wall perforation, as well as identify falsepassages and the cause of difficult tube placements.2 Also, patient selection is impor-tant. Little to no information exists on pediatric percutaneous tracheostomy, and thosepatients with head and neck trauma who may be difficult to intubate emergently are athigher risk of losing their airway catastrophically if the cannula should come out,especially within the first 7 days postoperatively.3,4

This leaves us with the question of cost. It is definitely cheaper to do a bedside,percutaneous tracheostomy than to do an open procedure in the operating room. Onesmall paper notes that the cost of SgT at the bedside is less than the cost of PcT (see thereviewed article by Porter and Ivatury), but in most articles, surgeons felt that therestricted space and inadequate lighting made an open procedure at the bedside aless-than-optimal choice.

Percutaneous tracheostomy is definitely a viable option in today’s intensive careunit. It can be performed with no increased risk to the properly selected patient, and itmay result in improved long-term patient satisfaction. As the procedure gains inpopularity and its practitioners gain in experience, hope exists that the complicationrate will continue to decrease. Certainly, endoscopic control is an option that should beseriously considered, especially as most of the data reviewed in this article are based onprocedures performed with this aid. It is presently an efficient, safe, cost-effectivemethod for performing one of the most commonly needed procedures in the intensivecare unit.

PII S0149-7944(00)00480-3

REVIEWER COMMENTS (Con’t)

neck. Although this study is small, it isvery thorough and the authors appear tohave been extremely diligent in reportingtheir complications, (a fact that theynoted as well). One limitation is that theyare not clear about how many of eachtype of procedure was performed at thebedside or in the operating room; theyonly note that 30% of the procedureswere performed at the bedside. They alsonoted that although the increased num-ber of false passages in the PcT group didnot reach statistical significance (p �0.67), they were able to recognize all ofthese events immediately because of tra-cheoscopic control and, therefore, rec-ommend that all PcTs be done with en-doscopy. All in all, either Pct or Sgt is arelatively safe procedure, and the authorsshow that the surgeon can be comfortablewith either choice.

CURRENT SURGERY • Volume 59/Number 4 • July/August 2002 391

REFERENCES

1. Ciaglia P, Firsching R, Syniec C. Elective percutaneous diatational tracheostomy:a new simple bedside procedure. Preliminary report. Chest. 1985;87:715-719.

2. Powell DM, Price, PD, Forrest, LA. Review of percutaneous tracheostomy. Laryn-goscope. 1998;108:170-177.

3. Trottier SJ, Hazard PB, Sakabu SA, et al. Posterior tracheal wall perforation duringpercutaneous dilational tracheostomy: an investigation into its mechanism andprevention. Chest. 1999;115:1383-1389.

4. Cook PD, Callanan VI. Percutaneous dilational tracheostomy technique and ex-perience. Anaesth Intensive Care. 1989;17:456-457.

Trauma

So You’ve Had a Minor HeadInjury. . .Now What?Guest Reviewer: John B. Fortune, MD, Department of Surgery,Southern Illinois University, Springfield, IL

A PROSPECTIVE POPULATION-BASED STUDY OF PEDIATRIC TRAUMA PA-TIENTS WITH MILD ALTERATIONS IN CONSCIOUSNESS (GLASGOWCOMA SCORE OF 13-14). Wang MY, Griffith P, Sterling J, McComb JG, Levy,ML. Neurosurgery 2000;46:1093-1099.

Objective: To define the incidence of intracranial lesions in pediatric patients with amild head injury and a field Glasgow Coma Score (GCS) of 13 to 14 after closed headtrauma.

Design: A retrospective review of the treatment of all children with a closed headinjury resulting in a GCS of 13 to 14 in a large metropolitan area, over a 12-monthperiod.

Setting: Urban Los Angeles County, including the 13 designated trauma centers.

Participants: All children under the age of 15 years with a field GCS of 13 to 14 whosustained a traumatic brain injury in urban Los Angeles County. Over a 12-monthperiod, this encompassed 157 patients who were treated in trauma centers.

Methods: The emergency medical services serving Los Angeles County transport allpediatric patients with head injuries to regional trauma centers. The Los AngelesCounty Trauma Database was searched to determine the mechanism of injury, field,and emergency department GCS, loss of consciousness, and other injuries of thesepatients. In addition, the emergency department and hospital records were reviewed todetermine the results of computed tomography (CT) scans, the treatment of otherinjuries, the need for neurosurgical intervention, and the length of stay.

Results: A total of 5822 patients were felt to have sustained a possible head injury aspart of their constellation of injuries. Over 93% of these patients had a GCS of 15,whereas 3.6% had GCS of 13 or 14 (mild head injury). In this latter group, nopredominant age group existed, although less children with an age of less than 2 yearswere included in this group. For the entire cohort, 27.4% had abnormal CT scans and19.1% had intracranial hemorrhage. Only 3.2% of the entire population required

REVIEWER COMMENTS

This article establishes the problem of“mild head injury” as common (180 of100,000 children) and associated with amultitude of physical findings that arevery poor predictors of the ultimate pres-ence intracranial injury. In this very com-prehensive study in Los Angeles County,which described the fate of over 8000 pe-diatric patients who sustained traumaticinjury, those with “mild head injury”comprised a very small number. On theother hand, nearly 50% of these patientshad abnormal CT scans with absolutelyno consistent clinical predictor of intra-cranial abnormality. The authors con-clude that because the presentation ofthese patients is so diverse and inconsis-tent that all should undergo CT scan-ning. This certainly represents the mostconservative approach, but it may be ap-propriate considering the potential disas-trous consequences of any missed inju-ries.

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