Journal Reading

By: Beny Rilianto Jessieca Liusen Marni Sianturi Mitha Pradini Wawan Kurniawan P. Ingen Setiasih
25 July 2012 Int J Gen Med. 2012; 5: 9398. 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. report was about Iranian experience with surgical management for postintubation tracheal stenosis moderatesevere

* This

* Comparation between with and without previous tracheostomy

*
* 5 year period Jun 2005-Jul 2010 * Subject were 50 patients aged 14-64 years with moderate * Follow up the outcomes after surgery * Groups divided into with tracheostomy (group A = 27) and
without (group B n=23)
(50-70% lumen) to severe (>70%) resection and primary anastomosis

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* Resection *2
and primary anastomosis cervical incision (45 patients) and right thoracotomy (5 patients) 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 postintubation trachea stenosis tracheostomy tube must be inserted close to the stenotic segmen

* Recommendation

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

tracheal resection

*
* Postintubation
* Modification
tracheal stenosis caused by pressure airway necrosis and most common cause for tracheal surgery * Incidence decreased because
tracheostomy in management with endotracheal tube and

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

* Variables

*
* 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

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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
antibiotic intravenous for prophylactic

and

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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

32 men 64%

18 women 36%

5 moderate

45 severe

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

6 had previous emergency bronchoscopic dilatation

27 had previous tracheostomy

10 with prolong intubation

17 with postintubation stenosis

* 12 patients underwent tracheostomy due to lack surgical

expertise

* 5 patients with bad general condition and inflammation on

the trachea

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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

*2

had subglottic stenosis underwent complete resection of lesion and anterior part of cricoid anastomosis made to thyroid using Montgomery Ttube

* 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 3,661,01 (2-6cm)

* Mean of number resected segmen 5,461,43

(3-10)

* Mean

duration of surgery, ICU stay, and hospitalization 3,610,64 hours, 3,421,52 days, and 9,32,28 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% et al 61,5% success rate due to complexity therapeutic approaches toward multisegmental stenosis et al failure rate was similar to this study about 4% et al no not satisfactory result from benign trachea and laryngotracheal stenosis

* Abbasidezfouli

* Grillo * Rea

* 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 tracheostomy surgical approach done by sacrifice the normal site stoma and lesion increase length segmen and duration of surgery

previous must be between resected

* 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 emergency tracheostomy to patients had postintubation tracheal stenosis must be held by insert the tube closely to stenotic segmen of subglottic stenosis required used of Montgomery T-tube to support anastomosis

* Recommendation:

* Treatment