Abstract
Purpose
The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6 months post-operatively.
Materials and methods
Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6 months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables.
Results
Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6 months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46–17.3; p = 0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6 months (HR 4.15, 95% CI 1.56–10.86; p = 0.004).
Conclusions
Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.
1
Introduction
Adult tracheal stenosis represents a significant treatment challenge in the field of otolaryngology, as re-stenosis occurs in as many as 50% of cases in spite of sound surgical management . The most common causes of tracheal stenosis are traumatic or prolonged intubation, history of tracheostomy, and idiopathic stenosis—tracheal stenosis with no identifiable condition or inciting event. In intubated patients, a cuff pressure greater than 30 cm H 2 O has been shown to cause mucosal damage and decrease capillary blood flow, thus increasing the risk of scar and stenosis . Use of endotracheal tube sizes larger than 7.5 has also been associated with a higher percentage of patients developing tracheal stenosis, particularly in obese and male patients . Other conditions and factors associated with tracheal stenosis include: congenital defects, malignancy, autoimmune conditions, infection, and radiation.
Except in rare cases of autoimmune conditions and some malignancies, treatment of tracheal stenosis is surgical. The goal of surgery is to secure an airway of sufficient caliber. Endoscopic surgery is appealing as it allows for shorter hospital stays, decreased surgery time, and decreased patient morbidity. Indeed, in carefully selected subgroups of patients with airway stenosis, endoscopic treatment can achieve an adequate caliber airway with good long-term results . However, re-stenosis can be a problem for this group of patients, and adjuvant therapies have been proposed to help reduce the incidence of re-stenosis. Mitomycin C and corticosteroid injections have been utilized as adjuncts for endoscopic airway surgery to decrease the likelihood of re-stenosis, and these have been shown to be beneficial in some series .
For a variety of reasons, many patients are not good candidates for endoscopic surgery. Patients with long stenotic segments or with significant comorbidities – such as neurologic injury, debilitating obstructive sleep apnea, or severe laryngeal or pulmonary dysfunction – may require permanent tracheostomy and derive more benefit from this than endoscopic treatment or airway reconstruction. On the other hand, a patient with more severe airway stenosis and lacking significant comorbidities should be considered a candidate for open airway reconstructive surgery. This is particularly true if the patient has circumferential scarring, tracheomalacia with loss of cartilage, stenosis greater than 1 cm in length, posterior scarring, or history of bacterial tracheitis . Open airway reconstructive surgery has been shown to be most successful if the resection is less than 4 cm and if the reconstruction leads to tracheotracheal rather than laryngotracheal anastamosis .
A recent European publication reviewed a series of open airway reconstructive surgeries and noted successful outcomes in 88.5% of patients . However, there are very few reports on open airway reconstruction outcomes from North American institutions in the otolaryngology literature. Thus, in the present study, we identified and reviewed our patients with tracheal stenosis who underwent open resection with re-anastomosis. We aimed to identify which demographic, historical, physical exam, and intraoperative findings were associated with better outcomes following resection and re-anastomosis. Our primary outcome measure for successful resection of tracheal stenosis was independence from tracheostomy or T-tube at 6 months post-resection.
2
Methods
2.1
Study characteristics
This is a retrospective review of patients with tracheal stenosis who underwent open airway reconstructive surgery at a single tertiary care institution between the years 2008 and 2013. Institutional review board approval was obtained prior to beginning data collection. Patients were excluded if they had tracheal stenosis due to malignancy or did not undergo an open tracheal resection. Patients included are those who underwent an open tracheal resection with re-anastomosis.
Each patient was assigned an identification number during the data collection to maintain confidentiality. Demographic information, medical comorbidities, initial airway evaluation, imaging findings, treatments prior to tracheal resection, open tracheal resection surgical details, and post-operative course were noted. Two airway surgeons performed the open airway reconstruction procedures (authors DR and ZS). A successful outcome was defined as T-tube or tracheostomy-free at 6 months post-surgery without breathing difficulties. Potential prognostic factors were assessed, including: age, gender, body mass index (BMI), diabetes mellitus (DM), laryngopharyngeal reflux (LPR), smoking status, history of tracheostomy prior to open resection, pre-operative vocal fold function, cricoid involvement in the surgical resection, and length of stenosis. Obesity was defined as a BMI greater than 30. DM and LPR were confirmed if noted in a patient’s past medical history or by noting their current medication list.
2.2
Operative technique
The patient is positioned with a shoulder roll and the neck extended. A nasogastric tube is placed to facilitate intraoperative identification of the esophagus. Preoperative antibiotics and steroids are given. The patient’s neck is prepped and draped, and a horizontal incision is made in a skin crease overlying the proximal trachea, extending to the borders of the sternocleidomastoid muscles. If the patient has a tracheostomy, an ellipse is used to incorporate the stoma into the incision. Subplatysmal flaps are elevated to enable access superiorly to the thyroid notch and inferiorly to the distal trachea. Care is taken not to undermine excessively in lateral directions, as this tends to promote subcutaneous emphysema.
The laryngotracheal framework is skeletonized, and any existing tracheocutaneous fistula is excised. The tracheal perichondrium is sharply incised and dissected free from the tracheal cartilage. Subsequent dissection takes place in the subperichondrial plane, which obviates the need to identify the recurrent laryngeal nerves. The trachea is dissected free from the surrounding fascial attachments to allow greater mobility. If more than 3 cm of length is needed to mobilize the distal trachea, a limited mediastinal release is performed, using a combination of bipolar cautery and Kittner dissection to lyse the substernal fascial attachments. Great care must be taken not to dissect blindly during this step, and to take into consideration the position of the innominate artery. A high-riding innominate artery is a contraindication to this technique. If more than 6 cm of length is needed, suprahyoid release can be performed, but the authors prefer to avoid this due to significant postoperative dysphagia that can result.
Once the trachea has been adequately mobilized, it is incised in the midline, in sagittal fashion, at the level of the stenosis. This allows identification of the exact length of the scar, and it helps prevent over-resection of normal trachea. Once the superior and inferior boundaries are known, the stenosis is removed circumferentially. Stay sutures are placed on each side of the distal trachea to facilitate mobilization and to prevent retraction into the thorax. The stenotic segment is then freed from the esophagus with cautery.
The two cut ends of the airway are freshened with a knife and prepared for anastomosis. If the ends are an excellent size match, primary anastomosis is performed with interrupted 3-0 Vicryl or 3-0 Prolene sutures in circumferential, airtight fashion, taking great care to make sure that all knots are extraluminal. If there is size mismatch, the posterior wall is closed, and the remainder of the trachea is closed around a T-tube. This is more commonly seen when the cricoid cartilage is resected, requiring a cricotracheal anastomosis. A 5-0 endotracheal tube is introduced through the external limb and used for ventilation for the remainder of the procedure. The wound is irrigated and closed in layers, with Penrose drains left in place. Patients with limited vocal fold mobility and with a T-tube placed are brought back to the operating room approximately 6 to 8 weeks after initial surgery to assess airway patency. At this time, the decision for decannulation is made.
2.3
Data and statistical analysis
Descriptive statistics were reported as a median for quantitative variables and as a percentage for qualitative variables. Contingency tables were used to explore the relationship between surgical success and all clinical and demographic variables. Continuous variables were analyzed by Wilcoxon rank sum tests. Categorical variables were analyzed using Fisher exact tests. Variables were further assessed using a univariate logistical regression model to determine the risk of decannulation failure. T-tube or tracheostomy-free survival curves were estimated by the Kaplan–Meier method using the log-rank test to assess significant differences. All statistical analyses were performed using SAS 9.3 (SAS Institute, Cary, NC), assuming a type I error rate of 0.05.
2
Methods
2.1
Study characteristics
This is a retrospective review of patients with tracheal stenosis who underwent open airway reconstructive surgery at a single tertiary care institution between the years 2008 and 2013. Institutional review board approval was obtained prior to beginning data collection. Patients were excluded if they had tracheal stenosis due to malignancy or did not undergo an open tracheal resection. Patients included are those who underwent an open tracheal resection with re-anastomosis.
Each patient was assigned an identification number during the data collection to maintain confidentiality. Demographic information, medical comorbidities, initial airway evaluation, imaging findings, treatments prior to tracheal resection, open tracheal resection surgical details, and post-operative course were noted. Two airway surgeons performed the open airway reconstruction procedures (authors DR and ZS). A successful outcome was defined as T-tube or tracheostomy-free at 6 months post-surgery without breathing difficulties. Potential prognostic factors were assessed, including: age, gender, body mass index (BMI), diabetes mellitus (DM), laryngopharyngeal reflux (LPR), smoking status, history of tracheostomy prior to open resection, pre-operative vocal fold function, cricoid involvement in the surgical resection, and length of stenosis. Obesity was defined as a BMI greater than 30. DM and LPR were confirmed if noted in a patient’s past medical history or by noting their current medication list.
2.2
Operative technique
The patient is positioned with a shoulder roll and the neck extended. A nasogastric tube is placed to facilitate intraoperative identification of the esophagus. Preoperative antibiotics and steroids are given. The patient’s neck is prepped and draped, and a horizontal incision is made in a skin crease overlying the proximal trachea, extending to the borders of the sternocleidomastoid muscles. If the patient has a tracheostomy, an ellipse is used to incorporate the stoma into the incision. Subplatysmal flaps are elevated to enable access superiorly to the thyroid notch and inferiorly to the distal trachea. Care is taken not to undermine excessively in lateral directions, as this tends to promote subcutaneous emphysema.
The laryngotracheal framework is skeletonized, and any existing tracheocutaneous fistula is excised. The tracheal perichondrium is sharply incised and dissected free from the tracheal cartilage. Subsequent dissection takes place in the subperichondrial plane, which obviates the need to identify the recurrent laryngeal nerves. The trachea is dissected free from the surrounding fascial attachments to allow greater mobility. If more than 3 cm of length is needed to mobilize the distal trachea, a limited mediastinal release is performed, using a combination of bipolar cautery and Kittner dissection to lyse the substernal fascial attachments. Great care must be taken not to dissect blindly during this step, and to take into consideration the position of the innominate artery. A high-riding innominate artery is a contraindication to this technique. If more than 6 cm of length is needed, suprahyoid release can be performed, but the authors prefer to avoid this due to significant postoperative dysphagia that can result.
Once the trachea has been adequately mobilized, it is incised in the midline, in sagittal fashion, at the level of the stenosis. This allows identification of the exact length of the scar, and it helps prevent over-resection of normal trachea. Once the superior and inferior boundaries are known, the stenosis is removed circumferentially. Stay sutures are placed on each side of the distal trachea to facilitate mobilization and to prevent retraction into the thorax. The stenotic segment is then freed from the esophagus with cautery.
The two cut ends of the airway are freshened with a knife and prepared for anastomosis. If the ends are an excellent size match, primary anastomosis is performed with interrupted 3-0 Vicryl or 3-0 Prolene sutures in circumferential, airtight fashion, taking great care to make sure that all knots are extraluminal. If there is size mismatch, the posterior wall is closed, and the remainder of the trachea is closed around a T-tube. This is more commonly seen when the cricoid cartilage is resected, requiring a cricotracheal anastomosis. A 5-0 endotracheal tube is introduced through the external limb and used for ventilation for the remainder of the procedure. The wound is irrigated and closed in layers, with Penrose drains left in place. Patients with limited vocal fold mobility and with a T-tube placed are brought back to the operating room approximately 6 to 8 weeks after initial surgery to assess airway patency. At this time, the decision for decannulation is made.
2.3
Data and statistical analysis
Descriptive statistics were reported as a median for quantitative variables and as a percentage for qualitative variables. Contingency tables were used to explore the relationship between surgical success and all clinical and demographic variables. Continuous variables were analyzed by Wilcoxon rank sum tests. Categorical variables were analyzed using Fisher exact tests. Variables were further assessed using a univariate logistical regression model to determine the risk of decannulation failure. T-tube or tracheostomy-free survival curves were estimated by the Kaplan–Meier method using the log-rank test to assess significant differences. All statistical analyses were performed using SAS 9.3 (SAS Institute, Cary, NC), assuming a type I error rate of 0.05.
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