Pradheep, K (2010) Case series of Tracheal Surgery for Nontumoral Tracheal Stenosis : A single institutional experience. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION : Tracheal stenosis represents an emerging surgical problem seen with improvements in the understanding of airway management and respiratory mechanics. The most frequent type of large airway stenosis is due to iatrogenic events after or during tracheostomy or after orotracheal intubation and may be life threatening. The large airway stenosis usually results from prolonged ventilation from various causes like trauma, acute attacks of chronic respiratory disease, severe metabolic disorders, neurological disorders, cardiopulmonary disorders and postoperative ventilation. Since the 1960s, the steadily increasing use of endotracheal, tracheostomy, and cricothyroidostomy tubes for the management of secretions, prevention of aspiration and, most importantly, delivery of mechanical ventilatory support for respiratory failure have produced a spectrum of upper airway lesions that range in location from the nostril to the lower trachea, and in severity from pharyngitis to complete obstruction of the airway or asphyxiating hemorrhage. Endotracheal tubes cause pressure injury to the glottis, which can result in severe commissural scarring that is difficult to treat. Tracheotomy tubes can cause severe stomal stenosis in the trachea or infraglottic region. Both methods of airway intubation can result in pressure necrosis caused by the tube’s cuff, which is a preventable problem. The management of this disease is controversial, still not standardized or unified around the world because the role and efficacy of surgical techniques vs. endoscopic procedures strongly depend on the experience of the various centers and on referral pattern. We reviewed non-tumoral tracheal stenosis in 22 patients with special regard to the cause and various modalities of treatment of the stenoses in our institution. AIMS AND OBJECTIVES : 1. To study the epidemiology of post intubation tracheal stenosis. 2 To study the mode of presentation, method of diagnosis and pre-operative preparation. 3. To analyze the treatment options, surgical procedures, outcomes and results in patients with post intubation tracheal stenosis. PATIENTS AND METHODS : Setting. Department of Cardiothoracic Surgery, Government General Hospital,Chennai – 600 003. Design of The Study : Retrospective case Study. Period of The Study : January 2007 to April 2010. Ethical Clearance: Obtained from institute ethical committee. Inclusion Criteria: All patients diagnosed to have tracheal stenosis due to non-tumoral causes. Exclusion Criteria: - Patient with neoplastic lesions of upper airway and trachea. - Patients with poor respiratory reserve or marginal cardiac status. Investigations : CT NECK AND CHEST, Fiber Optic Bronchoscopy, Routine Pre-operative work up. All patients with tracheal stenosis admitted between Jan 2007 and April 2010 were retrospectively analysed and data collected. All patients’ clinical records and physical findings were reviewed for causal factors, diagnostic methods, surgical therapies, and outcomes. The initial diagnostic evaluation had included plain radiography, computed tomography, or both. The severity of the stenosis was classified as mild if less than 50% of the tracheal lumen was obstructed, moderate if the obstruction was 50% to 90%, or severe if 90% or more of the lumen was obstructed. Data including age of the patient, duration of ventilation, duration of onset of symptoms after ventilation, pre-operative investigations, intraoperative procedure, the site and nature of lesion, number of tracheal rings or length of tracheal segment excised, cause of stenosis and other epidemiological data were collected in the respective proforma and analysed. SUMMARY : Tracheal stenosis represents an emerging surgical problem seen with the steadily increasing use of endotracheal, tracheostomy, and cricothyroidostomy tubes for the management of secretions, prevention of aspiration and, most importantly, delivery of mechanical ventilatory support for respiratory failure. Cases of non-tumoral tracheal stenosis admitted between Jan 2007 and April 2010 in twenty-two patients at our institution were observed and data collected with special regard to the cause and various modalities of treatment of the stenoses and retrospectively analyzed. Over a 3-year period, 22 patients that included 19 male and 3 female patients, with an age range of 14–45 years (average 25.3 years) who had postintubation tracheal stenosis were admitted to the department of Cardiothoracic surgery at our hospital. The patients were treated with tracheal resection and primary anastomosis. The length of resected segment ranged from 1.5 to 4 cm. In 15 patients, the treatment result was good (68.2%). In 5 patients, the result was classified as satisfactory (22.7%). Trachea-to-trachea anastomosis was performed in 14 patients, trachea-to-cricoid anastomosis was performed in 5 patients, and laryngotracheal anastomosis in 1 patient. Laryngeal release was used in one patient with trachea-to-trachea anastomosis as the length of resected segment was long. The use of laryngeal release was dictated by the extent of resection and tracheal mobility in each patient. There were no operative or post operative deaths. There were no major life threatening complications observed. The principal complication observed in the patients was formation of granulation tissue to various extent at the anastomotic site. These patients were managed with laser vaporization of granulation tissue. Higher success rates can be obtained when patients are managed at a centre which routinely performs tracheal surgeries. The more complex the prior treatment, the more likely the eventual failure, even after reoperation. Early recognition and prompt referral to tertiary centers is vital for successful surgical outcomes. CONCLUSION : The good and satisfactory results of surgical treatment of postintubation stenosis (91%), even when it involves the subglottic larynx or in the presence of the rare TEF justify resection and reconstruction as treatments of choice. First operation is most likely to succeed and should ideally be performed by experienced hands in a specialized centre due to lower surgical success rate in patients who had prior failure of reconstruction. Higher success rates can be obtained when patients are managed at a centre which routinely performs tracheal surgeries. The more complex the prior treatment, the more likely the eventual failure, even after reoperation. Early recognition and prompt referral to tertiary centers is vital rather than repeated attempts at tracheostomy involving a normal tracheal segment. T tubes, inlying stents, and laser treatment may be applicable in a limited spectrum of lesions and at a much lower level of long term success. The complication rate is generally low for tracheal lesions. Serious sequelae more often follow laryngotracheal resections. The most common late complication is the formation of granulations at the suture line and can usually be managed with bronchoscopic removal or LASER vaporization.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Case series ; tracheal surgery ; nontumoral tracheal stenosis ; single institutional experience. |
| Subjects: | MEDICAL > Cardio Vascular and Thoracic Surgery |
| Depositing User: | Kambaraman B |
| Date Deposited: | 10 Nov 2017 18:06 |
| Last Modified: | 11 Nov 2017 02:57 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/3887 |
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