Surgery in Post-Intubation Tracheal Stenosis: Management and Results

Sudhan, Nagarajan (2006) Surgery in Post-Intubation Tracheal Stenosis: Management and Results. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION : Tracheal surgery has been one of the last specialties mastered by thoracic surgeons. The 1960s saw the rapid development of the surgical techniques in treating tracheal disorders. Surgery of the trachea and bronchi still remains a challenging subdivision and is done routinely only in experienced centres. Post-intubation tracheal stenosis remains the most common indication all over the world for surgery on the trachea. Despite the wide research done on the issue of prolonged mechanical ventilation and the advantages of large volume, low pressure cuffs, tracheal stenosis still persists as a major consequence in patients on endotracheal tube or tracheostomy tube, though the incidence has decreased considerably over the decades. The management of patients presenting with post-intubation tracheal stenosis can be urgent or elective, depending on the clinical picture and investigations. The principles of surgical management have been clearly established through several studies in the past. We have encountered patients with post-intubation tracheal stenosis referred to us on a regular basis. Hence we decided to analyse the haracteristics and surgical management of such patients in our hospital. AIMS AND OBJECTIVES : To analyse the characteristics and results of tracheal resection and reconstruction in patients presenting with post-intubation tracheal stenosis. PATIENTS AND METHODS: This was a single institution, retrospective review of 82 patients who underwent tracheal resection and reconstruction for post-intubation tracheal stenosis from January 2000 to December 2004. Patient Selection: Patients who were diagnosed to have tracheal stenosis following intubation and prolonged mechanical ventilation and underwent tracheal resection and reconstruction in our department were included in the retrospective analysis. The records of the patients operated from January 2000 to December 2004 were procured from the Medical Records Department and the details noted. Parameters Studied: The parameters evaluated in each patient were:- 1. Patient characteristics: The age and gender of each patient was noted. 2. Etiology: The cause of tracheal stenosis was ascertained as to whether due to the balloon cuff of endotracheal tube, balloon cuff of tracheostomy tube or the tracheostomy site itself. 3. Characteristics of the stenosis: The exact site of the stenosis, the involvement of the laryngeal apparatus, the multiplicity of the lesions, the presence of tracheo-oesophageal fistula or tracheomalacia and the details of any mode of treatment prior to the surgery were noted. 4. Surgical treatment: The type and technique of anaesthesia carried out in patients with and without stoma were noted. The surgical approach, the type of anastomosis, the anastamotic technique, the suture materials used, the presence of any need for reinforcement of anastomosis or laryngeal release, details of concomitant oesophageal fistula repair if any, resection of malacic segments, the need for cardio-pulmonary bypass and the amount of the trachea resected in each patient were also noted. 5. Postoperative care: The duration of Intensive Care Unit stay, the total duration of the postoperative hospital stay and the presence of the need for ventilatory support were recorded. 6. Follow-up: The follow-up was mainly by Out-Patient Department visits. The details of the follow-up visits were carefully assessed. The results in each patient were assessed using a selfdesigned grading scale. The grading of the results: Good - (i) Able to perform normal daily activities and (ii) Bronchoscopy reveals a normal airway. Moderate - (i) Has difficulty on exertion or (ii) Bronchoscopy reveals significant narrowing or vocal cord abnormalities Poor - (i) Unable to perform even the basic daily activities (ii) Bronchoscopy reveals significant narrowing and other complications which warrant re-operation. 7. Complications: A careful note of the complications was made and the details of their management were included. The mortality rate was also calculated. 8. Other interventions: Reoperation, creation of tracheostomy, temporary and permanent T-tube insertions and dilatations were included in the data collected. RESULTS: The average length of follow-up of the patients was two years. The results were good in 66 patients (78.6%), moderate in 11 patients (13.1%) and poor (failure) in 6 patients (7.1%) (Table III). The failure rate for the tracheo-tracheal anastamotic group was 6.5% and that for the cricotracheal and thyrotracheal anastamotic groups were 5.5% and 25% respectively (Table IV). The rate of overall good results in the tracheo-tracheal anastamotic group was higher than that of the other groups (Table IV). CONCLUSION: Tracheal surgery is undoubtedly one of the challenging subspecialties of Cardiothoracic Surgery. Non-neoplastic tracheal stenosis, most commonly post-intubation, is the most frequent indication for tracheal resection and reconstruction. Surgery may be required either on an elective or emergency basis. Careful patient selection is of great importance and good anaesthetic backup is mandatory for a combined team effort. Meticulous surgical technique and adherence to strict surgical principles leads to lesser morbidity and mortality. Resection and reconstruction still remains the best option for postintubation tracheal stenosis and it offers good results in majority of the patients.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Post-Intubation Tracheal Stenosis ; Management ; Results.
Subjects: MEDICAL > Cardio Vascular and Thoracic Surgery
Depositing User: Kambaraman B
Date Deposited: 10 Nov 2017 16:57
Last Modified: 10 Nov 2017 16:57

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