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      Endoscopic and Surgical Treatment of Benign Tracheal Stenosis: A Multidisciplinary Team Approach

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          Abstract

          Purpose: Surgical resection and reconstruction are considered the most appropriate approaches to treat post-intubation tracheal stenosis (PITS). Bronchoscopic methods can be utilized as palliative therapy in patients who are ineligible for surgical treatment or who develop post-surgical re-stenosis. We investigated treatment outcomes in patients with benign tracheal stenosis.

          Methods: A retrospective review was performed in patients who were diagnosed with PITS. Tracheal resection was performed for operable cases, whereas endoscopic interventions were preferred for inoperable cases with a complex or simple stenosis.

          Results: In total, 42 patients (23 treated by bronchoscopic methods, 19 treated by surgery) took part in this study. No significant differences were observed in segment length, the proportion of obstructed airways, or vocal cord distance between the two groups. In all, 15 patients in the bronchoscopic treatment group received a stent. Following the intervention, the cure rates in the bronchoscopic and surgical treatment groups were 43.47% and 94.7%, respectively. A multidisciplinary approach resulted in a cure or satisfactory outcome in 90.5% of the patients while failure was noted in 9.5% of the patients.

          Conclusion: Bronchoscopic methods are associated with a lower cure rate compared to surgery. A multidisciplinary approach was helpful for treatment planning in patients with PITS.

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          Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients.

          J Stauffer, Eric Olson, Rafe Petty (1980)
          A prospective study of the complications and consequences of translaryngeal endotracheal intubation and tracheotomy was conducted on 150 critically ill adult patients. Adverse consequences occurred in 62 percent of all endotracheal intubations and in 66 percent of all tracheotomies during placement and use of the artificial airways. The most frequent problems during endotracheal intubation were excessive cuff pressure requirements (19 percent), self-extubation (13 percent) and inability to seal the airway (11 percent). Patient discomfort and difficulty in suctioning tracheobronchial secretions were very uncommon. Problems with tracheotomy included stomal infection (36 percent), stomal hemorrhage (36 percent), excessive cuff pressure requirements (23 percent) and subcutaneous emphysema or pneumomediastinum (13 percent). Complications of tracheotomy were judged to be more severe than those of endotracheal intubation. Follow-up studies of survivors revealed a high prevalence of tracheal stenosis after tracheotomy (65 percent) and significantly less after endotracheal intubation (19 percent)(p < 0.01). Thirty-nine of 41 (95 percent) patients with endotracheal intubation and 20 of 22 (91 percent) patients with tracheotomy had laryngotracheal injury at autopsy. Ulcers on the posterior aspect of the true vocal cords were found at autopsy in 51 percent of the patients who died after endotracheal intubation. There was no significant relationship between the duration of endotracheal intubation or tracheotomy and the over-all amount of laryngotracheal injury at autopsy, although patients with prolonged endotracheal intubation followed by tracheotomy had more laryngeal injury at autopsy (P = 0.06) and more frequent tracheal stenosis (P = 0.05) than patients with short-term endotracheal intubation followed by tracheotomy. Adverse effects of both endotracheal intubation and tracheotomy are common. The value of tracheotomy when an artificial airway is required for periods as long as three weeks is not supported by data obtained in this study.
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            Postintubation tracheal stenosis. Treatment and results.

            D. Wright, H Grillo, J C Wain … (1995)
            A total of 503 patients underwent 521 tracheal resections and reconstructions for postintubation stenosis from 1965 through 1992. Fifty-three had had prior attempts at surgical resection, 51 others had undergone various forms of tracheal or laryngeal repair, and 45 had had laser treatment. There were 251 cuff lesions, 178 stomal lesions, 38 at both levels, and 36 of indeterminate origin. Sixty-two patients with major laryngeal injuries required complete resection of anterior cricoid cartilage and anastomosis of trachea to thyroid cartilage, and 117 had tracheal anastomosis to the cricoid. A cervical approach was used in 350, cervicomediastinal in 145, and transthoracic in 8. Length of resection was 1.0 to 7.5 cm. Forty-nine had laryngeal release to reduce anastomotic tension. A total of 471 patients (93.7%) had good (87.5%) or satisfactory (6.2%) results. Eighteen of 37 whose operation failed underwent a second reconstruction. Eighteen required postoperative tracheostomy or T-tube insertion for extensive or multilevel disease. Twelve died (2.4%). The most common complication, suture line granulations (9.7%), has almost vanished with the use of absorbable sutures. Wound infection occurred in 15 (3%) and glottic dysfunction in 11 (2.2%). Five had postoperative innominate artery hemorrhage. Resection and reconstruction offer optimal treatment for postintubation tracheal stenosis.
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              Multidisciplinary approach to management of postintubation tracheal stenoses.

              C A Marquette, C Verkindre, J Darras … (1999)
              The optimal management of postintubation tracheal stenosis is not well defined. A therapeutic algorithm was designed by thoracic surgeons, ear, nose and throat (ENT) surgeons, anaesthetists and pulmonologists. Rigid bronchoscopy with neodymium-yttrium aluminium garnet (Nd-YAG) laser resection or stent implantation (removable stent) was proposed as first-line treatment, depending on the type of stenosis (web-like versus complex stenosis). In patients with web-like stenoses, sleeve resection was proposed when laser treatment (up to three sessions) failed. In patients with complex stenoses, operability was assessed 6 months after stent implantation. If the patient was judged operable, the stent was removed and the patient underwent surgery if the stenosis recurred. This algorithm was validated prospectively in a series of 32 consecutive patients. Three patients died from severe coexistent illness shortly after the first bronchoscopy. Of the 15 patients with web-like stenosis, laser resection was curative in 10 (66%). Among the 17 patients with complex stenoses, three remained symptom-free after stent removal. Bronchoscopy alone was thus curative in more than one-third of the patients. Six patients underwent surgery, two after failure of laser resection and four after failure of temporary stenting. Surgery was always performed with the patient in good operative condition. Palliative stenting was the definitive treatment in nine cases. Tracheostomy was the definitive solution in two cases. This approach, including an initial conservative treatment, depending on the type of the stenosis, appears to be applicable to almost all patients and allows secondary surgery to be performed with the patient in good condition.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Thorac Cardiovasc Surg
                Journal ID (iso-abbrev): Ann Thorac Cardiovasc Surg
                Journal ID (pmc): atcs
                Title: Annals of Thoracic and Cardiovascular Surgery
                Publisher: The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery
                ISSN (Print): 1341-1098
                ISSN (Electronic): 2186-1005
                Publication date (Electronic): 7 June 2018
                Publication date (Print): 2018
                Volume: 24
                Issue: 6
                Pages: 288-295
                Affiliations
                [1]Department of Pulmonology, Yedikule Chest Diseases and Surgery Training and Research Hospital, Istanbul, Turkey
                [2]Department of Chest Surgery, Yedikule Chest Diseases and Surgery Training and Research Hospital, Istanbul, Turkey
                [3]Department of Pulmonology, Istanbul Bilim University, Istanbul, Turkey
                Author notes
                Corresponding author: Cengiz Özdemir, MD. Department of Pulmonology, Chest Disease and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey

                E-mail: cengizoz78@ 123456yahoo.com

                Article
                Publisher ID: atcs.oa.18-00073
                DOI: 10.5761/atcs.oa.18-00073
                PMC ID: 6300420
                PubMed ID: 29877219
                SO-VID: 6cb04ddf-83f0-4d27-bce2-67f6b55a5ab7
                Copyright © ©2018 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery
                License:

                This work is licensed under a Creative Commons Attribution-NonCommercial-NonDerivatives International License

                History
                Date received : 20 March 2018
                Date accepted : 6 May 2018
                Categories
                Subject: Original Article

                Keywords: post-intubation tracheal stenosis,bronchoscopy,tracheal resection
                Data availability:
                Keywords: post-intubation tracheal stenosis, bronchoscopy, tracheal resection

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