Surgical management of laryngotracheal stenosis in adults

Airway management during unusual tracheal stenosis: A clinical feasibility trial

Objectives

Prolonged intubation is a known risk factor of LTS. LTS related to COVID-19 may result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in these patients may carry unique challenges for both anesthesiologists and surgeons.This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow-controlled ventilation (FCV) in the management of patients with COVID-19-related LTS undergoing laryngeal surgery.

Methods

20 patients suffering from COVID-19-related LTS, as diagnosed by CT, requiring endolaryngeal surgery, with or without CO2 laser, were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency, and surgical exposure were evaluated.

Results

Median duration of mechanical ventilation during their ICU stay was 17 days, (range, 7-27), and all patients had been pronated. In 18/20 patients, endoscopic diagnosis confirmed the initial CT diagnosis: posterior subglottic stenosis. Surgeons' satisfaction on the view was rated 9 out of 10 (range 7-10), where 0 was the worst view and 10 was the best view. Hemodynamic and respiratory variables were within the normal clinical range during the surgical procedure. One patient that had a SpO2 of 90% before induction of anesthesia, a temporal drop to 89%, caused meeting the predefined requirement of "respiratory complication."

Conclusion

This study demonstrates the feasibility of using Tritube with FCV in patients with relatively unusual subglottic posterior location tracheal stenosis, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provides highly adequate ventilation especially in patients with compromised lung mechanics.

Level of Evidence

IV, non-comparitive prospective clinical trial with 20 patients.

A computational analysis on the impact of multilevel laryngotracheal stenosis on airflow and drug particle dynamics in the upper airway

Laryngotracheal stenosis (LTS) is a type of airway narrowing that is frequently caused by intubation-related trauma. LTS can occur at one or multiple locations in the larynx and/or trachea. This study characterizes airflow dynamics and drug delivery in patients with multilevel stenosis. Two subjects with multilevel stenosis (S1 = glottis + trachea, S2 = glottis + subglottis) and one normal subject were retrospectively selected. Computed tomography scans were used to create subject-specific upper airway models. Computational fluid dynamics modeling was used to simulate airflow at inhalation pressures of 10, 25, and 40 Pa, and orally inhaled drug transport with particle velocities of 1, 5, and 10 m/s, and particle size range of 100 nm-40 µm. Subjects had increased airflow velocity and resistance at stenosis with decreased cross-sectional area (CSA): S1 had the smallest CSA at trachea (0.23 cm2) and resistance = 0.3 Pa·s/mL; S2 had the smallest CSA at glottis (0.44 cm2), and resistance = 0.16 Pa·s/mL. S1 maximal stenotic deposition was 4.15% at trachea; S2 maximal deposition was 2.28% at glottis. Particles of 11-20 µm had the greatest deposition, 13.25% (S1-trachea) and 7.81% (S2-subglottis). Results showed differences in airway resistance and drug delivery between subjects with LTS. Less than 4.2% of orally inhaled particles deposited at stenosis. Particle sizes with most stenotic deposition were 11-20 µm and may not represent typical particle sizes emitted by current-use inhalers.

Comparison of Inhaled Drug Delivery in Patients With One- and Two-level Laryngotracheal Stenosis

OBJECTIVES/HYPOTHESIS

Laryngotracheal stenosis (LTS) is a functionally devastating condition with high respiratory morbidity and mortality. This preliminary study investigates airflow dynamics and stenotic drug delivery in patients with one- and two-level LTS.

STUDY DESIGN

A Computational Modeling Restropective Cohort Study.

METHODS

Computed tomography scans from seven LTS patients, five with one-level (three subglottic, two tracheal), and two with two-level (glottis + trachea, glottis + subglottis) were used to reconstruct patient-specific three-dimensional upper airway models. Airflow and orally inhaled drug particle transport were simulated using computational fluid dynamics modeling. Drug particle transport was simulated for 1-20 μm particles released into the mouth at velocities of 0 m/s, 1 m/s, 3 m/s, and 10 m/s for metered dose inhaler (MDI) and 0 m/s for dry powder inhaler (DPI) simulations. Airflow resistance and stenotic drug deposition in the patients' airway models were compared.

RESULTS

Overall, there was increased airflow resistance at stenotic sites in subjects with two-level versus one-level stenosis (0.136 Pa s/ml vs. 0.069 Pa s/ml averages). Subjects with two-level stenosis had greater particle deposition at sites of stenosis compared to subjects with one-level stenosis (average deposition 2.31% vs. 0.96%). One-level stenosis subjects, as well as one two-level stenosis subject, had the greatest deposition using MDI with a spacer (0 m/s): 2.59% and 4.34%, respectively. The second two-level stenosis subject had the greatest deposition using DPI (3.45%). Maximum deposition across all stenotic subtypes except one-level tracheal stenosis was achieved with particle sizes of 6-10 μm.

CONCLUSIONS

Our results suggest that patients with two-level LTS may experience a more constricted laryngotracheal airflow profile compared to patients with one-level LTS, which may enhance overall stenotic drug deposition.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:366-374, 2023.

Tissue Engineering for Tracheal Replacement: Strategies and Challenges

The critical feature in trachea replacement is to provide a hollow cylindrical framework that is laterally stable and longitudinally flexible, facilitating cartilage and epithelial tissue formation. Despite advanced techniques and sources of materials used, most inherent challenges are related to the complexity of its anatomy. Limited blood supply leads to insufficient regenerative capacity for cartilage and epithelium. Natural and synthetic scaffolds, different types of cells, and growth factors are part of tissue engineering approaches with varying outcomes. Pre-vascularization remains one of the crucial factors to expedite the regenerative process in tracheal reconstruction. This review discusses the challenges and strategies used in tracheal tissue engineering, focusing on scaffold implantation in clinical and preclinical studies conducted in recent decades.

Effects of Platelet Rich Plasma and Amniotic Cell Culture Medium on Wound Healing Following Experimental Animal Tracheal Injury Model: A Comparative Study

INTRODUCTION

Prolonged inflammation after tracheal injury invariably results in a degree of stenosis. The topical application of platelet-rich plasma (PRP) and human amniotic fluid-derived cell culture medium (ACCM) have been shown to promote wound healing. The effects of PRP and amniotic cell culture medium (Gibco AmnioMAX - II ) were investigated in a rat model through morphometric, histological, and biochemical parameters.

MATERIAL METHODS

Thirty-two male Sprague Dawley rats were included in the study: 4 rats provided for the preparation of PRP. Three groups of 7 rats were divided into PRP and ACCM groups, a control and a sham group respectively. A transverse incision on the ventral aspect of the third trachea spanning half of the tracheal circumference was performed. The incision was repaired with 7/0 polypropylene in the sham group. In the control group, 0.5 ml saline solution was applied on to the repaired injury site. In the other two groups, 0.5 mL PRP or ACCM were applied topically on the tracheal repair. Tissue samples were harvested 30 days after surgery for morphometric measurements and biochemical analyses for oxidative stress markers, IL-1beta, IL-6, and VEGF. Connective tissue thickness was evaluated histologically. Statistical analysis included the Mann-Whitney U and Kruskal Wallis tests.

RESULTS

A notable difference was detected (P = 0,025) in cartilage segment length measurements of the trachea between the ACCM group and the sham and control groups (P < 0.03). A significant difference was found in the analysis of TAS, TOS, and OSI values between the study groups and the control and sham groups (P < 0.005). There were also differences in IL1-beta and IL-6 levels between ACCM and PRP groups (P < 0.05). For the same parameters, the differences were significant between the PRP and, sham and control groups (P = 0,004 and P = 0,002 respectively), and between the ACCM and, sham and control groups (P = 0,003 and P = 0,002 respectively).VEGF values demonstrated a significant difference between the PRP and sham group (P = 0,002), and between ACCM and sham/control groups (p=0,002 for both), the highest VEGF value was in ACCM group while the lowest value was in the sham group. In the histological assessment of connective tissue, a significant difference was observed between ACCM and the other groups.

CONCLUSION

Amniotic fluid-derived cell culture medium shows less oxidative stress status than the other applications. ACCM is more effective on inflammatory and angiogenetic processes. Connective tissue thickness results were consistent with those biochemical and morphologic results. Additionally, a significant difference was observed in histological data between ACCM and PRP. Overall, ACCM proved to be efficient on tracheal healing. These effects can be attributed to the abundance of growth factors in both PRP and amniotic fluid-derived cell culture medium (ACCM).

Laryngotracheal stenosis following intubation and tracheostomy for COVID-19 pneumonia: a case report

Laryngotracheal stenosis (LTS) is a rare but serious condition characterized by narrowing of the airway. Iatrogenic injury from endotracheal intubation or tracheostomy insertion is the most common cause of LTS. We present the first reported experience of managing a patient diagnosed with subglottic stenosis (a subtype of LTS) following previous intubation and tracheostomy for coronavirus disease 2019 (COVID-19). This patient required an urgent surgical tracheostomy and subsequent referral to a tertiary airway surgery unit for definitive treatment, which included microlaryngoscopy, laser excision and balloon dilatation. This case highlights that LTS should be included in the differential diagnosis for patients re-presenting with breathing difficulties after prolonged intubation or tracheostomy for COVID-19. Furthermore, it raises the concern of a rise in the incidence of this condition and an increased burden on the few units specializing in airway surgery.

Otoendoscope combined with ablation electrodes for treatment of benign tracheal stenosis caused by granulation tissue hyperplasia after tracheotomy

Benign tracheal stenosis mainly appears due to tracheotomy, tuberculosis, trauma, benign tumor, or ventilation. With the increase in the number of tracheotomies and the prolongation of the life span of patients after incision, the long-term complications after tracheotomy gradually increase, among which intratracheal granulation hyperplasia is a more serious complication. The present case describes a 59-year-old male with granulation tissue hyperplasia induced by tracheotomy. He underwent tracheal resection to remove the granulation tissue and he remained well after the follow-up. Even though the endoscopic intervention and tracheal resection are readily accessible, they usually quite challenging. Here we summarize the present details on this condition.

Effect of resected length in reconstructive surgery for tracheobronchial injury

Background

Mechanical injury to the trachea and bronchi may cause mild to severe stenosis requiring surgical intervention for reconstructing the damaged trachea. The location, length, and cause of injury are important factors affecting the surgical outcome.

Method

We conducted a retrospective study to evaluate the results of reconstructive surgery on noncancerous tracheobronchial lesions in 75 patients aged 5–55 years who had undergone reconstructive tracheobronchial surgery in our hospital from 2009 to 2018.

Results

The causes of tracheobronchial injury included blunt trauma in 38 patients, sharp penetrating trauma in 24, a postintubation lesion in 6, a post-tracheotomy lesion in 3, tuberculosis in 3, and an adult congenital lesion in one. In 59 cases of a lesion in the trachea, the length of missing segment before reconnection was 1–2 cm in 6 cases, 3 cm in 22, 4 cm in 18, 5 cm in 13, and >5.5 cm in 1 case. The length of the resected segment was <5.5 cm in all survivors, whereas one death occurred when the resected length was approximately 6 cm.

Conclusions

The length of the resected segment and precision of the surgery are crucial for determining the outcome of surgery.

Management of subglottic stenosis in pregnancy using advanced apnoeic ventilatory techniques

Objective

To describe the use of balloon dilation with non-invasive ventilation in the treatment of pregnant patients with idiopathic subglottic stenosis.

Methods

The medical charts of four consecutive patients who underwent jet ventilation or high-flow nasal cannula oxygenation with balloon dilation for the treatment of idiopathic subglottic stenosis during pregnancy were reviewed.

Results

Objective improvement of subglottic stenosis was seen in all four cases, with end-result Myer–Cotton grade 1 lesions down from pre-procedure grade 3 lesions. Patients also reported subjective improvements in symptomatology, with no further airway issues. All patients delivered normally, at term.

Conclusion

Laryngeal dilation with continuous radial expansion pulmonary balloons using non-invasive ventilation for the treatment of idiopathic subglottic stenosis in pregnant patients is safe and efficacious, and should be the first line treatment option for this patient population. The improvement in symptoms, and lack of labour and pregnancy complications, distinguish this method of treatment from others reported in the literature.

Laryngotracheal Reconstruction in Adults Aged 60 Years and Older

Objective

The primary aim of this study is to evaluate the safety, efficacy, and execution of major open laryngotracheal operations for patients in the advanced decades.

Study Design

Case series with chart review.

Setting

Multidisciplinary clinic at a tertiary care academic hospital.

Subjects and Methods

Patient characteristics, operative course, and postoperative outcomes were retrospectively recorded for all airway reconstruction operations performed between 1999 and 2016 on patients aged ≥60 years Long-term success was defined as prosthesis-free survival at last follow-up. Descriptive statistics were performed.

Results

Twenty-nine patients met inclusion criteria, and the median age was 71 years (interquartile range, 63-74). Tracheal resection was the most common procedure (13 patients), followed by laryngotracheal reconstruction (7 patients). Fifteen patients began their operation with a tracheostomy, 6 of whom underwent decannulation prior to leaving the operating room. Three additional patients underwent decannulation at follow-up appointments and were prosthesis-free at most recent follow-up. The mean time to decannulation among these patients was 3 months. Of the 14 patients beginning their procedure without a tracheostomy, only 2 required permanent airway prosthesis. The overall long-term rate of prosthesis-free survival was 72.4% (21 of 29 patients). Factors suggestive of long-term success include lower McCaffrey grade and lack of pulmonary disease, hypertension, or diabetes, as well as decreased red blood cell distribution width on preoperative complete blood count.

Conclusion

Through careful patient selection, preoperative workup, and meticulous postoperative care, airway reconstruction procedures in patients aged ≥60 years are reasonably successful. Of 29 patients, 21 (72.4%) were successfully breathing long-term without airway prosthesis.

Health Care Costs and Cost-effectiveness in Laryngotracheal Stenosis

OBJECTIVE

Laryngotracheal stenosis (LTS) is resource-intensive disease. The cost-effectiveness of LTS treatments has not been adequately explored. We aimed to conduct a cost-effectiveness analysis comparing open reconstruction (cricotracheal/tracheal resection [CTR/TR]) with endoscopic dilation in the treatment of LTS.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center (2013-2017).

SUBJECTS AND METHODS

Thirty-four LTS patients were recruited. Annual costs were derived from the Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University. Cost-effectiveness analysis compared CTR/TR versus endoscopic dilation at a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) over 5- and 10-year time horizons. The incremental cost-effectiveness ratio (ICER) was calculated with deterministic analysis and tested for sensitivity with univariate and probabilistic sensitivity analysis.

RESULTS

Mean LTS costs were $4080.09 (SE, $569.29) annually for related health care visits. The major risk factor for increased cost was etiology of stenosis. As compared with idiopathic patients, patients with intubation-related stenosis had significantly higher annual costs ($5286.56 vs $2873.62, P = .03). The cost of CTR/TR was $8583.91 (SE, $2263.22). Over a 5-year time horizon, CTR/TR gained $896 per QALY over serial dilations and was cost-effective. Over a 10-year time horizon, CTR/TR dominated dilations with a lower cost and higher QALY.

CONCLUSION

The cost of treatment for LTS is significant. Patients with intubation-related stenosis have significantly higher annual costs than do idiopathic patients. CTR/TR contributes significantly to cost in LTS but is cost-effective versus endoscopic dilations for appropriately selected patients over a 5- and 10-year horizon.

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

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.

Laryngotracheal stenosis in burn patients requiring mechanical ventilation

Objective

To identify the incidence of laryngotracheal stenosis (LTS) in burn patients requiring mechanical ventilation at a regional academic burn center.

Methods

A retrospective review of all burn patients requiring endotracheal intubation or tracheostomy for airway management between 2003 and 2009 was performed. A group of trauma patients requiring similar airway instrumentation during the same period of time was used as a control.

Results

None of the trauma patients and 2 of the burn patients developed LTS. Both presented with stridor and were diagnosed within 2–5 weeks after extubation. One patient underwent successful carbon dioxide laser radial incision and dilation and continues to do well. The other patient failed endoscopic treatment and required T-tube placement. The incidence of LTS in burn patients requiring mechanical ventilation was 2.98% overall and 4.76% among those with inhalational injury.

Conclusions

Patients become symptomatic within weeks of the initial injury. Treatment is challenging and multiple surgical procedures are often required. A larger study is necessary to determine if the incidence is higher among burn patients.

Multimodality Surgical Approach in Management of Laryngotracheal Stenosis

Introduction

Postintubation laryngotracheal stenosis requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. This report presents surgically treated cases of laryngotracheal stenosis secondary to long-term intubation/tracheostomy with review of the literature.

Materials and Methods

In this retrospective study, we present 5 cases (a 23-year-old male, 13-year-old male, 22-year-old male, 19-year-old male, and 33-year-old female) of postintubation/tracheostomy laryngotracheal (glottic/subglottic) stenosis in the years 2016 and 2017. Each patient was managed differently. Intubation characteristics, localization of stenosis, surgical technique and material, postoperative complications, and survival of patients were recorded.

Results

The site of stenosis was in the subglottis in 4 patients and glottis in 1 patient. The mean length of the stenosis was greater in the postintubation group. Postintubation stenosis had a mean duration of intubation of 6.8 days, compared to 206.25 days of cannulation following tracheostomies. Each patient underwent an average of 2 procedures during their treatment course. One patient underwent open surgical anastomosis because of recurrent subglottic stenosis after multiple treatments. Phonation improved immediately in almost all except in the patient who underwent only endoscopic dilatation.

Discussion

The reasons for laryngeal stenosis and its delayed diagnosis have been reviewed from the literature. Suture tension should be appropriate, and placement of the suture knot outside the trachea minimizes formation of granulation tissue. The published reports suggest that resection by endoscopy with laser and open technique resection and primary anastomosis are the best treatment modality so far as the long-term results are concerned.

Conclusion

Resection of stenotic segment by open surgical anastomosis and laser-assisted resection is a safe option for the treatment of subglottic stenosis following intubation without the need for repeated dilation. Endoscopic dilation can be reserved for unfit patients.

Analysis of Age-Related Differences of Risk Factors and Comorbidities in Laryngotracheal Stenosis Patients

Laryngotracheal stenosis (LTS) is a life threatening airway problem that is mainly caused by prolonged intubation. The authors intend to assess whether there was variability in the risk factors depending on age, and to determine which risk factors and comorbidities were more important in the development of LTS at older or younger ages. Fifty-two LTS patients were evaluated for comorbidities and risk factors retrospectively. The LTS etiologies, demographics, and medical and surgical histories of the patients were determined by the medical records. The patients under 40 years old were defined as group 1, and the patients 40 years of age or older were defined as group 2. Our study revealed that with regard to GERD, hypertension, DM2, and pulmonary infection, there was a statistically significant difference between group 1 and group 2 (p = 0.025, p = 0.0005, p = 0.002, and p = 0.000, respectively). Those patients ≥ 40 years old exhibited higher rates of GERD, hypertension, DM2, and pulmonary infection. However, there were no statistically significant differences between the groups with regard to smoking, alcohol consumption, COPD/asthma, immunological disease, and obesity (BMI > 30). There was a statistically significant difference between the groups for all the risk factors except a previous tracheotomy (p = 0.115). The risk factors and comorbidities thought to be involved in the development of LTS could show age-related variability. Therefore, in patients over 40 years of age with comorbidities (GERD, hypertension, DM2, and pulmonary infection), it is necessary to take precautions before the development of LTS. Prolonged intubation and tracheotomy history are the main risk factors for all patients, regardless of age.

Experience with Transcordal Silicone Stents in Adult Laryngotracheal Stenosis: A Bicentric Retrospective Study

BACKGROUND

Benign stenosis involving laryngeal and upper tracheal structures represents a therapeutic challenge. Open surgery and endoscopic management have to be discussed by a multidisciplinary board in order to evaluate the risk and benefit for each patient.

OBJECTIVE

The objective of this retrospective study was to report the experience of two French centers with transcordal silicone stents (TSS) in the endoscopic management of benign laryngotracheal stenosis (BLTS) in adults, with focus on efficacy, safety, and tolerability.

METHODS

We performed a retrospective chart review of all cases of BLTS treated with TSS between January 2001 and June 2017 at two tertiary centers in France: the Centre Hospitalier Régional Universitaire de Strasbourg and the Hôpital Nord de Marseille.

RESULTS

A total of 17 patients were included. Eleven had a tracheostomy at initial management which consisted of 8 T-tubes and 9 strictly endoluminal stents placements. The main complications were minor aspirations in 5 patients (29%), granulation in 3 patients (18%), migration in 2 patients (12%), and severe dysphonia in 3 patients (18%). After a mean duration of 18.3 months, 11 patients (65%) had had their TSS definitely removed, 13 patients were tracheostomy free (76%), and a TSS remained in place in 4 patients (24%).

CONCLUSIONS

Adult BLTS treatment with TSS placement is associated with low morbidity and excellent clinical outcomes, with a large proportion of patients free of airway instrumentation on long-term follow-up.

Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics

OBJECTIVE

Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures.

METHODS

Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO).

RESULTS

Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance.

CONCLUSION

This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:E141-E149, 2018.

Initial Load Stability of Different Trachea Suture Techniques: Tests on an Ex Vivo Model

Objective Tracheal anastomosis can be performed with different suture techniques. In this experimental work, the resilience of anastomotic techniques to pressure and tensile stress was studied. Study Design Ex vivo pig model. Setting Experimental. Subjects and Methods The trachea with the 2 main bronchi in freshly slaughtered pigs was isolated and intubated (CH 8.0). Both main bronchi were closed distally by a stapler. After resection of the trachea, an anastomosis (n = 15 per group) was created: group 1, single interrupted sutures; group 2, continuous running suture; group 3, mixed technique. A continuous tensile stress of 0, 500, 1000, or 1500 g was applied to the preparations. Mechanical ventilation with a maximum pressure of 70 mbar was initiated. The airtightness of the anastomosis was verified by submerging the entire preparation under water. Results At tensile loads of 0.5 and 1.0 kg, all anastomoses created in the single-stitch technique were airtight; at 1.5 kg, 93.3% were without leaks. In the continuous suture technique, the airtightness of anastomoses decreased with increasing tensile load: from 93.3% at 500 g to 73.3% at 1 kg and 66.6% at 1.5 kg ( P = .02 at 1.5 kg). Anastomoses in the mixed technique were airtight in 80% at 500 g, 66.6% at 1 kg, and 46.6% at 1.5 kg ( P = .01 in comparison with single stitches). Conclusion Anastomoses created with single interrupted sutures showed the highest resilience against combined pressure and tensile stress.

Profilactic role of simvastatin and mitomycin C in tracheal stenosis after tracheal damage: Study in rats

OBJECTIVES

We aimed to investigate the prophylactic effect simvastatin of and mitomycin C (MMC) on laryngeal and tracheal stenosis in tracheotomised rats by histopathological evaluation of laryngotracheal segment. Randomized prospective single-blind.

MATERIAL AND METHOD

Standard vertical tracheotomy was performed on 24 rats. Then the animals were randomly divided into three groups as A, B and C. In group A 0.4 mg/day once daily mitomycin C was injected to the paratracheal region for 14 days. In group B daily 30 mg/kg/day simvastatin was given via gavage to rats for 14 days. In group C 2 cc/day intraperitoneal saline given to rats and the created control group by 14 days follow up. After 10 days, tracheal cannulas were removed. Three weeks later, all animals were euthanized and trachea specimens were harvested. The present study investigates the effects of MMC and Simvastatin on fibrosis, inflammation, stenosis index and tracheal wall thickness in a tracheal injury model.

RESULTS

The difference between the groups in terms of degree of inflammation scores was statistically insignificant (P = 0,187). Differences between the groups were found to be insignificant in terms of the preventionof fibrosis (P = 0,993). There was no significant difference between groups in terms of stenosis index (P = 0.645). In terms of wall thickness, control, simvastatin and mitomycin C groups were statistically different (p = 0.038). The difference between post-hoc test results was between Mitomycin C and control groups (p = 0.036). Maximum wall thickness in the MMC group (0,299 mm) was significantly lower compared to the control group (0,382 mm)(P < 0,0001). Maximum wall thickness was statistically lower in the simvastatin (0.324 mm) group compared with the control group (0.382 mm) (P < 0.0001). There was no statistically significant difference between the simvastatin group (0,198 mm) and control group (0,200 mm) with respect to minimum wall thickness (P = 0.982). Minimum wall thickness was significantly lower in the mitomycin-C group (0,160 mm) comparison to the control group (0,200 mm) (P < 0.0001).

CONCLUSION

It was detected that the simvastatin and MMC is not effective in preventing the tracheal stenosis, inflammation and fibrosis formation.

End-to-end anastomosis in the management of laryngotracheal defects

OBJECTIVE

To present clinical experience and surgical outcomes of end-to-end anastomosis in the management of laryngotracheal stenosis and tracheal defects following invasive thyroid malignancy resection.

METHODS

A retrospective analysis was performed of 14 patients with laryngotracheal stenosis and tracheal invasive thyroid malignancy. All patients underwent tracheal or cricotracheal resection and primary end-to-end anastomosis.

RESULTS

Length of stenosis was 1.7-4 cm. Stenosis was classified as Myer and Cotton grade II in 4 patients, grade III in 6 and grade IV in 2. Surgical procedures included tracheotracheal end-to-end anastomosis (n = 4), cricotracheal anastomosis (n = 2) and thyrotracheal anastomosis (n = 6). Patients with invasive thyroid malignancy underwent segmental resection of the involved segment with tumour-free margins, and tracheal or cricotracheal end-to-end anastomosis. Successful decannulation was achieved in 13 patients (93 per cent). Post-operative complications were: wound infection (n = 1), subcutaneous emphysema (n = 1), temporary unilateral vocal fold palsy (n = 1), granulation tissue development (n = 1), and restenosis (n = 2).

CONCLUSION

End-to-end anastomosis can be used safely and successfully in the management of advanced laryngotracheal stenosis and wide laryngotracheal defects. Greater success can be achieved using previously described surgical rules and laryngotracheal release manoeuvres.

Idiopathic Subglottic Stenosis: Long-Term Outcomes of Open Surgical Techniques

Objectives

Idiopathic subglottic stenosis (iSGS) is rare, and its cause remains elusive. Treatment options include empiric medical therapy and endoscopic or open surgery. We present our results for open surgical technique.

Study Design

Case series with chart review (1978-2015).

Setting

Tertiary academic center.

Subjects/Methods

Thirty-three patients (32 female; median age, 51 years) met inclusion criteria and underwent cricotracheal resection with thyrotracheal anastomosis, tracheal resection with primary anastomosis, or laryngotracheoplasty with rib grafting. Continuous variables were summarized using medians and ranges while categorical features are presented using frequency counts and percentages.

Results

Sixteen patients (48%) underwent a single-stage approach with immediate extubation or temporary intubation following surgery (median, 1 day; range, 1-3 days). Seventeen patients (52%) underwent a double-staged approach with a median time to decannulation of 35 days (range, 13-100 days). Twenty-four (73%) patients underwent a previous intervention. Median stay in the intensive care unit was 1 day (range, 0-3 days), with a median hospital stay of 4 days (range, 2-7 days). Recurrence requiring further surgical intervention was observed in 12 patients (36%). The median time to recurrence was 8 years over an average follow-up of 9.7 years. The most common complaint following surgery was change in voice quality (fair to poor; n = 10; 30%).

Conclusions

Open surgery should be reserved for refractory cases of iSGS; cricotracheal resection with thyrotracheal anastomosis is the preferred open technique. Recurrence may occur after open treatment, highlighting the importance of long-term follow-up. Patients should be counseled about the potential for worsening voice quality with the open approach.

Application of paclitaxel as adjuvant treatment for benign cicatricial airway stenosis

Benign cicatricial airway stenosis (BCAS) is a potentially life-threatening disease. Recurrence occurs frequently after endoscopic treatment. Paclitaxel is known to prevent restenosis, but its clinical efficacy and safety is undetermined. Therefore, in this study, we investigated the efficacy and associated complications of paclitaxel as adjuvant treatment for BCAS of different etiologies. The study cohort included 28 patients with BCAS resulting from tuberculosis, intubation, tracheotomy, and other etiologies. All patients were treated at the Department of Respiratory Diseases, Beijing Tian Tan Hospital, Capital Medical University, China, between January 2010 and August 2014. After primary treatment by balloon dilation, cryotherapy, and/or high-frequency needle-knife treatment, paclitaxel was applied to the airway mucosa at the site of stenosis using a newly developed local instillation catheter. The primary outcome measures were the therapeutic efficacy of paclitaxel as adjuvant treatment, and the incidence of complications was observed as well. According to our criteria for evaluating the clinical effects on BCAS, 24 of the 28 cases achieved durable remission, three cases had remission, and one case showed no remission. Thus, the durable remission rate was 85.7%, and the combined effective rate was 96.4%. No differences in outcomes were observed among the different BCAS etiologies (P=0.144), and few complications were observed. Our results indicated that paclitaxel as an adjuvant treatment has greater efficacy than previously reported BCAS treatment methods.

First-line tracheal resection and primary anastomosis for postintubation tracheal stenosis

Introduction Tracheal stenosis following intubation is the most common indication for tracheal resection and reconstruction. Endoscopic dilation is almost always associated with recurrence. This study investigated first-line surgical resection and anastomosis performed in fit patients presenting with postintubation tracheal stenosis. Methods Between February 2011 and November 2014, a prospective study was performed involving patients who underwent first-line tracheal resection and primary anastomosis after presenting with postintubation tracheal stenosis. Results A total of 30 patients (20 male) were operated on. The median age was 23.5 years (range: 13-77 years). Seventeen patients (56.7%) had had previous endoscopic tracheal dilation, four (13.3%) had had tracheal stents inserted prior to surgery and one (3.3%) had undergone previous tracheal resection. Nineteen patients (63.3%) had had a tracheostomy. Eight patients (26.7%) had had no previous tracheal interventions. The median time of intubation in those developing tracheal stenosis was 20.5 days (range: 0-45 days). The median length of hospital stay was 10.5 days (range: 7-21 days). The success rate for anastomoses was 96.7% (29/30). One patient needed a permanent tracheostomy. The in-hospital mortality rate was 3.3%: 1 patient died from a chest infection 21 days after surgery. There was no mortality or morbidity in the group undergoing first-line surgery for de novo tracheal lesions. Conclusions First-line tracheal resection with primary anastomosis is a safe option for the treatment of tracheal stenosis following intubation and obviates the need for repeated dilations. Endoscopic dilation should be reserved for those patients with significant co-morbidities or as a temporary measure in non-equipped centres.

Bronchoscopic Indocyanine Green Fluorescence Imaging of the Anastomotic Perfusion After Tracheal Surgery

BACKGROUND

Anastomotic failure is a rare but severe complication after airway surgery. A sufficient blood supply is crucial for the healing of the anastomosis. Currently, judging the appearance of the mucosa by conventional bronchoscopy is the only available technique to monitor the anastomosis. Near-infrared imaging using indocyanine green (ICG) as an intravasal fluorescent can be used to directly assess tissue perfusion. For technical reasons, bronchoscopic ICG angiography to evaluate blood supply of airway anastomosis was unavailable in the past. We sought to investigate the technical feasibility of ICG perfusion using a newly developed bronchoscopy unit with an integrated near-infrared filter to monitor perfusion during the healing of tracheal anastomosis.

METHODS

Twelve patients who underwent elective airway surgery were included in this prospective, single-center feasibility study. The ICG was administered intravenously at 0.2 mg/kg body weight at three timepoints: at the end of surgery; 3 to 5 days postoperatively; and 2 months postoperatively. A custom-made bronchoscopy unit (Karl Storz, Tuttlingen, Germany) was used to assess the anastomosis with white light and additionally with near-infrared light to monitor the distribution and intensity of the fluorescence signal.

RESULTS

A total of 32 ICG fluorescence bronchoscopies were performed in our study cohort. In all measurements, a sufficient fluorescence signal was detected. A lack of perfusion was detected in all patients confined to the anastomotic suture line immediately after the operation. This malperfusion resolved gradually after 3 to 5 days and disappeared completely after 2 months. No anastomotic complication developed in our series of patients during follow-up (median 7 months).

CONCLUSIONS

To the best of our knowledge, this is the first report on ICG fluorescence bronchoscopy in the literature. It is an easy and effective method to evaluate the perfusion at the tracheal anastomosis. In the future, it might contribute to an early detection of anastomotic failure and reduce morbidity and mortality after airway surgery.

Tacrolimus prevents laryngotracheal stenosis in an acute-injury rat model

OBJECTIVES/HYPOTHESIS

Acquired laryngotracheal stenosis is a challenging problem for otolaryngologists. Several studies suggest tacrolimus may inhibit post-transplant airway stenosis that occurs with coronary drug-eluting stents. The objective of the present study was to determine whether tacrolimus modulates wound healing of the airway mucosa and prevents laryngotracheal stenosis in an acute injury animal model.

STUDY DESIGN

Basic science.

METHODS

The laryngotracheal mucosa of rats was scraped with a nylon brush through the tracheostoma. Tacrolimus (0.2 mg/kg or 1.0 mg/kg) was systemically administered intramuscularly for 5 days. Nine days after scraping, the pathological changes and the degree of stenosis were assessed by hematoxylin and eosin staining or by immunohistochemical staining for nuclear factor of activated T cell and interleukin 2.

RESULTS

Lumen stenosis resulted from hyperplasia of the airway epithelium and a thickened submucosal layer with extensive fibrosis, angiogenesis, and collagen deposition. There was a significant preventive effect on airway stenosis at the tracheal and cricoid levels in the low-dose (0.2 mg/kg) tacrolimus-treated animals, compared to the untreated animals (P < .05). This effect was insignificant with treatment by high-dose tacrolimus (1.0 mg/kg). Immunohistochemistry showed that, after tacrolimus treatment, the expressions of nuclear factor of activated T cell and interleukin 2 were downregulated in submucosal fibroblasts, neovascular cells, and glandular cells.

CONCLUSIONS

This study suggests that low-dose systemic tacrolimus has a preventive effect on laryngotracheal stenosis by inhibiting the activation of immune cells in the injured airway mucosa via the calcineurin/nuclear factor of activated T cell/interleukin 2 pathway.

LEVEL OF EVIDENCE

NA.

Gene therapy of c-myc suppressor FUSE-binding protein-interacting repressor by Sendai virus delivery prevents tracheal stenosis

Acquired tracheal stenosis remains a challenging problem for otolaryngologists. The objective of this study was to determine whether the Sendai virus (SeV)-mediated c-myc suppressor, a far upstream element (FUSE)-binding protein (FBP)-interacting repressor (FIR), modulates wound healing of the airway mucosa, and whether it prevents tracheal stenosis in an animal model of induced mucosal injury. A fusion gene-deleted, non-transmissible SeV vector encoding FIR (FIR-SeV/ΔF) was prepared. Rats with scraped airway mucosae were administered FIR-SeV/ΔF through the tracheostoma. The pathological changes in the airway mucosa and in the tracheal lumen were assessed five days after scraping. Untreated animals showed hyperplasia of the airway epithelium and a thickened submucosal layer with extensive fibrosis, angiogenesis, and collagen deposition causing lumen stenosis. By contrast, the administration of FIR-SeV/ΔF decreased the degree of tracheal stenosis (P < 0.05) and improved the survival rate (P < 0.05). Immunohistochemical staining showed that c-Myc expression was downregulated in the tracheal basal cells of the FIR-SeV/ΔF-treated animals, suggesting that c-myc was suppressed by FIR-SeV/ΔF in the regenerating airway epithelium of the injured tracheal mucosa. The airway-targeted gene therapy of the c-myc suppressor FIR, using a recombinant SeV vector, prevented tracheal stenosis in a rat model of airway mucosal injury.

[The experience with the use of the two-step laryngotracheoplasty for the management of subglottic and combined subglottic and upper tracheal cicatrical stenosis in the adult patients]

The objective of the present retrospective study was to evaluate the clinical experience with the use of the two-step laryngotracheoplasty for the treatment of subglottic and combined subglottic and upper tracheal cicatrical stenosis in the adult patients during the period between 2003 and 2012. A total of 13 patients were retrospectively reviewed following the surgical treatment for the management of subglottic and combined subglottic and upper tracheal cicatrical stenosis based at the Lugansk regional clinical hospital. The effectiveness of two-stage laryngotracheoplasty was estimated to be 84.6%. The number of the surgical procedures per patient depended on the extent of tracheal stenosis while the overall rehabilitation period mainly depended on the severity of the concomitant pathologies. The technical aspects and the results of the surgical treatment are discussed.

Complications After Tracheal and Cricotracheal Resection and Anastomosis for Inflammatory and Neoplastic Stenoses

Objective:

This study aimed to evaluate complications and success rates of tracheal resection and anastomosis (TRA) and cricotracheal resection and anastomosis (CTRA) in patients treated in 2 academic institutions.

Methods:

Retrospective charts review of 137 patients submitted to TRA/CTRA. Fifty (36.5%) had neoplastic (group A) and 87 (63.5%) benign (group B) stenoses. Using univariate analysis, age, medical comorbidities, previous radiotherapy, type of TRA/CTRA, association with neck dissection and thyroidectomy, length of resected airway, and preoperative tracheotomy were evaluated to identify factors predictive of complications and outcomes.

Results:

The mean length of resected airway was 2.7 and 3 cm in groups A and B, respectively. Overall decannulation and complication rates for group A were 96% and 36%, and 99% and 46% for group B, respectively. Length of airway resected and presence of preoperative tracheotomy had a statistically significant effect on major surgical complications. Age older than 70 and cardiovascular and pulmonary comorbidities were significantly associated with the incidence of major medical complications. No statistically significant difference was found considering the complication rates of group A versus group B.

Conclusion:

Even though the overall success rate of TRA/CTRA is high, it should always be regarded as a major surgical procedure with a non-negligible incidence of complications.

Surgical outcomes of post intubational or post tracheostomy tracheal stenosis: report of 18 cases in single institution

PURPOSE

Tracheal resection and end-to end anastomosis (TRE) is known as standard treatment of tracheal stenosis (TS) and there are various methods to keep ventilation during operation. We reviewed ventilation methods and postoperative outcomes in patients with postintubational (PI) or posttracheostomy (PT) TS.

PATIENTS AND METHODS

From May 2006 to May 2013, 18 patients with PI or PTTS underwent TRE in our hospital. All patients' records were retrospectively reviewed.

RESULTS

The mean duration of intubation and tracheostomy were 14.2 days (range: 2 to 27 days) and 114.9 days (range: 43 to 215 days). The location of stenosis was tube cuffs (n = 10), stoma (n = 6) and double stenosis involving cuff and stoma (n = 2). The mean diameter of stenotic lesion was 5.4 mm (range: 2 to 9 mm. ECMO (n = 4) was performed in critical stenosis. Of two cases with double stenosis, one underwent preoperative endotracheal balloon dilatation and the other underwent TRE with cricoplasty. The overall complication rate was 11.8%. The mean follow-up duration was 14.0 months (range: 0.9 to 56.3 months).

CONCLUSION

Comparing with the literatures, TS treated by TRE in our hospital has shown satisfactory outcomes. To maintain appropriate ventilation for critical stenosis, ECMO could be one of safe methods.

Surgical treatment of non-malignant laryngotracheal stenosis

The objectives of this study were the following: (1) to analyze the results of surgical treatment of non-malignant subglottic laryngeal and tracheal stenosis, (2) to evaluate the feasibility and technical aspects of the video mediastinoscopy for the mobilization of the mediastinal trachea, (3) to evaluate the influence of the early internal condition of the anastomosis on the development of restenosis. From 1996 up to 2013, 75 patients aged 11-78 years underwent surgery for post-intubation/tracheostomy (71 patients), post-traumatic (3 patients), and idiopathic (1 patient) subglottic laryngeal and tracheal stenosis. Twenty-three (30.7 %) patients with subglottic laryngeal and upper tracheal stenosis underwent cricotracheal resection and thyrotracheal anastomosis (group A), while 52 (69.3 %) patients with tracheal stenosis underwent tracheal resection and cricotracheal or tracheotracheal anastomosis (group B). The length of the resected segment in patients of groups A and B was 28-55 (42 ± 11) mm and 18-65 (36 ± 14) mm, respectively, (p = 0.22). Perioperative complications within 30 days occurred in eight (34.8 %) patients of group A, and in six (11.5 %) patients of group B (p = 0.04). There was one intraoperative and one postoperative death on the third day due to heart failure. The excellent results were achieved in 63 (86.3 %), satisfactory in 8 (11.0 %), and unsatisfactory in 2 (2.7 %) patients. The incidence rate of perioperative complications is related to the location of the stenosis and the type of the resection and anastomosis. Video mediastinoscopy simplifies the mobilization of the mediastinal trachea, which allows for carrying out the anastomosis with minimal tension. Early internal abnormalities of the anastomosis predict its restenosis.

Postintubation laryngotracheal stenosis: assessing the success of surgery

OBJECTIVE

This study evaluated the outcome in adult patients with laryngotracheal stenosis (LTS) and assessed the effect of procedures on their quality-of-life scores.

METHODS

The study included 15 adult patients with LTS (11 males [73.3%], 4 females [26.7%]; mean age, 32 years [range, 10-52 years]) treated at the Department of Otolaryngology Head and Surgery Clinic, İzmir Atatürk Research Hospital, Turkey, from 1997 to 2008. Success of the surgery is evaluated by decanullation rate, Short form-36 (SF-36), and the Medical Research Council dyspnea scale.

RESULTS

The etiology of the LTS was intubation related in 14 cases (93.3%) and idiopathic in 1 case. According to the Myers-Cotton classification, 2 (13%), 8 (54%), and 5 (33%) patients were at stages 2 to 4, respectively. Fourteen patients had a mean follow-up of 57 months (range, 24-256 months). The stenotic segment involved 1 to 3 cm (mean, 1.7 cm) of trachea, and 2 to 5 tracheal rings (mean, 3.1) were resected. Postoperative decannulation was achieved in 13 patients (86.6%). In the short form-36 questionnaire, all of the parameters except for "role-emotional" were found to be significant (P < 0.01). The Medical Research Council dyspnea scale assessment revealed a significant (P < 0.001) decrease postoperatively.

CONCLUSIONS

Segmental resection with primary anastomosis is an effective method and can be used as the first option in selected cases of advanced stenosis.

Influence of subglottic stenosis on the flow-induced vibration of a computational vocal fold model

The effect of subglottic stenosis on vocal fold vibration is investigated. An idealized stenosis is defined, parameterized, and incorporated into a two-dimensional, fully-coupled finite element model of the vocal folds and laryngeal airway. Flow-induced responses of the vocal fold model to varying severities of stenosis are compared. The model vibration was not appreciably affected by stenosis severities of up to 60% occlusion. Model vibration was altered by stenosis severities of 90% or greater, evidenced by decreased superior model displacement, glottal width amplitude, and flow rate amplitude. Predictions of vibration frequency and maximum flow declination rate were also altered by high stenosis severities. The observed changes became more pronounced with increasing stenosis severity and inlet pressure, and the trends correlated well with flow resistance calculations. Flow visualization was used to characterize subglottal flow patterns in the space between the stenosis and the vocal folds. Underlying mechanisms for the observed changes, possible implications for human voice production, and suggestions for future work are discussed.

Surgical management of scleromatous laryngotracheal stenosis

OBJECTIVE

Scleroma is a chronic specific granulomatous disease of the upper respiratory tract caused by Klebsiella Rhinoscleromatis. It usually affects the subglottic region and upper trachea resulting in various degrees of stenosis. Patients with laryngotracheal stenosis may present with stridor, shortness of breath or exercise intolerance and may be tracheostomy dependent. In this work, we presented the experience of our Institute in the management of patients with scleromatous laryngotracheal stenosis using the already designed procedures for traumatic laryngotracheal stenosis.

PATIENTS AND METHODS

The study was a non controlled prospective study. It was conducted in Oto-Rhino-Laryngology and Head and Neck Surgery Department of Zagazig University Hospitals, Egypt. It included 38 patients with scleromatous subglottic stenosis and/or upper tracheal stenosis. The patients were classified into four grades according to Myer-Cotton's scale. The surgical treatment modalities included endoscopic CO2 laser surgery with dilatation, laryngotracheal reconstruction, and partial cricotracheal resection with thyrotracheal anastomosis.

RESULTS

The average follow-up period was 32.1 months. Twenty four patients (63%) had an excellent outcome. Nine patients (24%) had a good outcome. Five patients (13%) were still tracheostomy dependent. Eleven patients (29%) developed postoperative granulation tissue. The overall success rate was 87%.

CONCLUSION

Scleromatous laryngotracheal stenosis is considered a challenging surgical problem. It requires a multidisciplinary approach by well-trained personnel. The surgical techniques designed for cases of laryngotracheal stenosis of a traumatic etiology can be applied for cases of scleroma with approximately the same success rates.

Polymeric implant materials for the reconstruction of tracheal and pharyngeal mucosal defects in head and neck surgery

The existing therapeutical options for the tracheal and pharyngeal reconstruction by use of implant materials are described. Inspite of a multitude of options and the availability of very different materials none of these methods applied for tracheal reconstruction were successfully introduced into the clinical routine. Essential problems are insufficiencies of anastomoses, stenoses, lack of mucociliary clearance and vascularisation. The advances in Tissue Engineering (TE) offer new therapeutical options also in the field of the reconstructive surgery of the trachea. In pharyngeal reconstruction far reaching developments cannot be recognized at the moment which would allow to give a prognosis of their success in clinical application. A new polymeric implant material consisting of multiblock copolymers was applied in our own work which was regarded as a promising material for the reconstruction of the upper aerodigestive tract (ADT) due to its physicochemical characteristics. In order to test this material for applications in the ADT under extreme chemical, enzymatical, bacterial and mechanical conditions we applied it for the reconstruction of a complete defect of the gastric wall in an animal model. In none of the animals tested either gastrointestinal complications or negative systemic events occurred, however, there was a multilayered regeneration of the gastric wall implying a regular structured mucosa.

In future the advanced stem cell technology will allow further progress in the reconstruction of different kind of tissues also in the field of head and neck surgery following the principles of Tissue Engineering.

Laryngotracheal stenosis in critically ill patients

CONCLUSIONS

Prolonged artificial pulmonary ventilation by tracheostomy tube (>30 days) doubled the risk of stenosis (relative risk, RR = 2.04, p = 0.002). Critically ill patients with repeated tracheotomies were more than six times likely to experience stenosis (RR = 6.44, p< 0.001) than other critically ill patients.

OBJECTIVE

In this retrospective study, we describe the occurrence of laryngotracheal stenosis (LTS) in critically ill patients after elective tracheostomy who had undergone treatment for LTS at the Na Homolce Hospital in Prague, Czech Republic.

METHODS

We studied 28 patients who were diagnosed with symptomatic LTS. Basic major demographic data, duration of mechanical ventilation, onset of tracheal stenosis after decannulation, and tracheostomy type (percutaneous dilatational or surgical tracheostomy) were recorded. The number of patients requiring repeated tracheostomies was also recorded.

RESULTS

Neither the demographic data nor the type of tracheostomy represented statistically significant risk factors. The risk factors for LTS were prolonged artificial pulmonary ventilation using the tracheostomy tube (p = 0.005) and repeated tracheostomy (p< 0.001). The mean onset of stenosis symptoms was 53.7 days (range 2-300 days), with a median of 58 days. Stenosis involved the trachea in 20 patients, subglottis in five cases, and glottis and subglottis in three cases. Seven patients (25%) underwent a tracheal resection and primary end-to-end reconstruction. One patient underwent laryngotracheoplasty with dilatation. The procedure was endoscopic in 18 patients (64.3%). Two patients (7.1%) received permanent tracheostomies.

Tracheal resection with primary anastomosis: 10 years experience

OBJECTIVE

The aim of the study was to review clinical, imagiologic, and surgical outcomes of tracheal resection in the management of laryngotracheal stenosis.

METHODS

The study used a retrospective analysis of adult patients managed in a tertiary academic hospital who underwent thyrotracheal, cricotracheal, or tracheal end-to-end anastomosis between 1997 and 2006.

RESULTS

Twelve patients, aged 15 to 79 years old, were included. Prolonged tracheal intubation was the leading cause of stenosis (11 patients) that was classified according to Myer-Cotton (Ann Otol Rhinol Laryngol. 1994;103:319-323) classification as follows: grade II (25%), grade III (58%), and grade IV (17%). The stenosis extension ranged from 1 to 6 cm. Surgeries varied from tracheal end-to-end anastomosis (n = 5), cricotracheal anastomosis (n = 4), and thyrotracheal anastomosis (n = 3). Extubation was achieved in 11 patients (92%). One patient maintains a T tube stent. The most common complication was the presence of granulation tissue in the anastomosis region (33%). There was no mortality associated.

CONCLUSIONS

Tracheal resection with primary anastomosis appears to be a successful and safe procedure mainly due to its high decannulation rate and few complications associated.

[Experiences with treatment of extended laryngo-tracheal stenosis with employment of transversal resection of trachea]

The aim of this study is to evaluate the results obtained in Department of Otolaryngology et Oncology with transversal resection of trachea acc. to Pearson technique for postintubation stenosis.

METHODS

from January 2000 to January 2008 ten patients with subglottic postintubation stenosis underwent surgical treatment, using Pearsons method of operation with preservation of recurrent nerves and no postopereative tracheostomy. Mean stenosis length was 2 cm, the length of of airway resection was 1,5-4 cm.

RESULTS

There was no surgical or postoperative complications, all the patients get totally health, no restenosis was observed. The results confirm that the Pearsons method of operation is an adequate treatment for subglottic stenosis.

Model of extensive and severe tracheal stenosis in dogs

PURPOSE: To create an animal model of extensive longitudinal tracheal stenosis (TS) that can be useful to test different surgical techniques of tracheal reconstruction. METHODS: Twenty male mongrel dogs were submitted to standard TS and randomly distributed to observation for 3 weeks (n=10) or 6 weeks (n=10). Under general anesthesia, an elliptical area (major axis from 1st to 20th ring and minor axis 40% of tracheal diameter) was resected and the stumps were sutured. The internal and external diameters were measured (before and after the observation time) and the stenosis index was calculated. Blood samples were collected (gasometry, hematocrit and hemoglobin.) before and after the surgical proceedings. RESULTS: The weight was significant lower in the animals of 6 weeks (15,551±3286.2) in comparison with those of 3 weeks observation (17,250±3575.0). No significant differences were noted in the extension of the trachea on the 21st day (21.2± 1.8) or 42nd day (21.1±1.7). The mean (40.1) and the median (40.5) of rings counted on the 21st day were quite similar to mean (38.1) and median (39.0) that were counted on the 42nd day. In the animals of group A (3 weeks) the mean (46.8%) and the median (49.8%) of index stenosis showed no significant difference (Mann Whitney test p<0.001) in comparison with the mean (55.1%) and median (52.4%) of the animals from group B (6 weeks). No mechanical or biochemical distresses were recorded through all period of observation. CONCLUSION: The surgical proceeding was effective to promote a model of longitudinal and extensive tracheal stenosis.