surgical treatment of postintubation tracheal stenosis
TRANSCRIPT
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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
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*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
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*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)
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*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%
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*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
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*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
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*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
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*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
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*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
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*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
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*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
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*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
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*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
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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
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*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
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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
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*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
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*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
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*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
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Due to need for numerous bronchoscopis
dilatation
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*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
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*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
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*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
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*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
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*High pressure from cuff and tube
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*Subglottic stenosis due to proximal erosion of cricoid from tracheostomy tube
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*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
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*Extensive lesion of tracheal stenosis remains unsolved problem
*Recent study investigated alternative treatment for this problem
*Tissued engineered airway
*Revascularized allograft
*Cryopreserved aortic allograft
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*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
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