Surgery for Aspiration: Analysis of Laryngotracheal Separation in 23 Children

Clinical characteristics of children with severe neurologic impairment: A scoping review

OBJECTIVE

The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies.

METHODS

Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics.

RESULTS

We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials.

CONCLUSIONS

Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.

Tracheoesophageal Diversion and Laryngotracheal Separation Procedures for Radiotherapy-Related Intractable Aspiration Pneumonia in Nasopharyngeal Carcinoma

Background

Intractable aspiration and aspiration pneumonia are complications after radiotherapy for nasopharyngeal carcinoma (NPC), and they may be life-threatening in severe cases. In the past, the efficacy of controlling aspiration and aspiration pneumonia in such patients was not ideal.

Objectives

We aimed to evaluate the effect of tracheoesophageal diversion and laryngotracheal separation (TED-LTS) procedures for these patients. Material and Methods. We retrospectively analyzed the medical data of five patients with intractable aspiration and recurrent aspiration pneumonia caused by NPC radiotherapy who underwent TED-LTS surgery. The patients were evaluated in terms of aspiration pneumonia control, body weight improvement, removal of tube feeding, oral feeding, and complications.

Results

Intractable aspiration and aspiration pneumonia were completely controlled in all cases, and the patients' body weight increased from 46.46 ± 4.6 (38.9-50.3) kg to 55.32 ± 2.7 (51.4-56.7) kg. Four patients were able to consume an oral semisolid diet, and one patient maintained an oral liquid diet. Tube feeding was not required in 4 patients. One patient developed postoperative esophageal fistula, which improved after conservative treatment.

Conclusion

TED-LTS is effective for intractable aspiration and aspiration pneumonia caused by NPC radiotherapy and can be used to restore partial oral feeding. However, strict surgical indications should be followed.

Laryngotracheal separation in pediatric patients: 13-year experience in a reference service

Objective:

To evaluate clinical stability of neurologically impaired children and adolescents with recurrent pneumonia submitted to laryngotracheal separation.

Methods:

Between October 2002 and June 2015, 92 neurologically impaired children from a reference service, with median age of 68.5 months were submitted to laryngotracheal separation. Data were evaluated and statistical analysis was made by Student's t test and Pearson's χ² test (significance level adopted of 95%).

Results:

Fifty-three children were male (57.6%). Forty-six children required admission to intensive care, and 42.4% needed mechanical ventilation. We observed that 90.2% of patients were exclusively fed by gastrostomy and 72.4% of the gastrostomies were performed before the tracheal surgery. Thirteen (14.1%) children had postoperative complications as follows: fistulae (5.4%), bleeding (4.3%), granuloma (2.2%) and stenosis (3.2%). A total of 24 patients had pneumonia in the postoperative period (26.1%), but there was a significant drop in occurrence of this condition after surgery (100% versus 26.1%; p<0.001). Twenty-three patients (25%) died. Postoperative complications were similar when comparing patients who died and those that presented good outcome (16.7% versus 13.2%; p=0.73).

Conclusion:

When well-indicated, the laryngotracheal separation reduces the incidence of postoperative pulmonary infections, thus improving quality of life and reducing admissions to hospital. Laryngotracheal separation should be indicated as a primary procedure in patients with cerebral palsy and recurrent aspiration pneumonia.

Clinical outcomes of tracheoesophageal diversion for intractable aspiration

Objectives:

The purpose of the present study was to examine the clinical outcomes of using tracheoesophageal diversion for preventing intractable aspiration.

Method:

We retrospectively reviewed 25 patients who underwent tracheoesophageal diversion from 2003 to 2009 at our hospital (median age, 25 years; range, 0–78 years). End-to-side anastomosis was used in 16 cases and side-to-side anastomosis was used in 9.

Results:

The average operative time was 141 minutes for end-to-side anastomosis and 191 minutes for side-to-side anastomosis. Peri-operative complications were observed in only two (8 per cent) cases: one with infection and one with haematoma. No fistulas were observed. Aspiration was prevented in all cases, but the nutritional route depended on the swallowing function of the patient. Oral feeding was the main nutritional route after surgery in only four patients (16 per cent).

Conclusion:

This procedure is well suited to patients who lack speech communication and are at high risk of aspiration.

Clinical outcomes of tracheoesophageal diversion and laryngotracheal separation in neurologically impaired children

OBJECTIVE

Outcomes of tracheoesophageal diversion and laryngotracheal separation were evaluated in 15 neurologically impaired children treated for intractable aspiration.

METHODS

A retrospective analysis of the hospital records was carried out in 15 consecutive pediatric patients who underwent either tracheoesophageal diversion or laryngotracheal separation with trumpet-shaped tracheotomy from 1999 to 2006 in Kagawa Children's Hospital.

RESULTS

The number of hospital admissions for aspiration pneumonia after surgery was significantly decreased in 6 patients who were cared for at home. The parent-reported number of secretion suctioning was decreased after surgery especially in patients with pre-operative tracheotomy or intubation. Four patients fed through naso-gastric tube progressed with oral diet post-operatively, whereas 3 patients who had pre-operative tracheotomy developed temporary post-operative tracheocutaneous fistula that was managed by local wound care.

CONCLUSION

It is suggested that tracheoesophageal diversion and laryngotracheal separation decrease the morbidity of pediatric patients and improve their quality of life and that of their parents. It is suggested that the risk of developing post-operative fistula is higher in pediatric patients with than without pre-operative tracheotomy.

Dysphagia and aspiration in children

Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.

Reducing Fistula Rates following Laryngotracheal Separation

Objectives:

Laryngotracheal separation (LTS) is an uncommonly performed but highly effective procedure for intractable aspiration in patients with amyotrophic lateral sclerosis and other neurodegenerative conditions. Previously published series have noted rates of postoperative tracheocutaneous fistula formation as high as 1 in 3 patients. This report details the use of a muscle flap–reinforced imbrication technique to reduce the incidence of fistula formation after LTS surgery.

Methods:

All patients who underwent LTS surgery at the reporting institutions between 2004 and 2010 were identified. The principal diagnosis, patient characteristics, the presence of a preexisting tracheotomy, and postoperative complications were recorded. We describe the technique for imbrication closure of the proximal stump with strap muscle reinforcement.

Results:

Thirteen patients (10 male, 3 female; median age, 53 years; interquartile range, 45 to 66 years) underwent the LTS procedure; amyotrophic lateral sclerosis was the principal diagnosis in 8 of the 13 patients. Six patients had a preexisting tracheotomy. None developed tracheocutaneous fistula, hematoma, or wound infection. Two patients required stomaplasty at a later date.

Conclusions:

Strap muscle flap–reinforced imbrication closure of the proximal tracheal stump after LTS surgery allows for a low incidence of postoperative fistula formation.

Tracheocutaneous fistula as a complication of laryngotracheal separation surgery

To evaluate the relationship between the occurrence of tracheocutaneous fistula of the proximal tracheal stump regarding the indication (therapeutic or prophylactic) of laryngotracheal separation surgery (LTS) and regarding the presence of a current or previous tracheostomy when LTS was performed. Retrospective analysis of 66 patients submitted to LTS. The tracheocutaneous fistula occurred in 14 (21.2%) patients. Twelve (33.3%) of 36 patients whose indication was therapeutic and in two (6.7%) of 30 patients whose indication was prophylactic (p = 0.019). It occurred in 8 (57.1%) of 14 patients who had undergone tracheostomy prior to completion of LTS, while occurred in 6 (11.5%) patients who had not previously undergone tracheostomy (n = 52) (p = 0.0009). The incidence of tracheocutaneous fistula as a postoperative complication of laryngotracheal separation is high and occurs mainly in patients whose indication is therapeutic and for those with a current or previous tracheostomy. Despite the significant incidence, most of them closed spontaneously through the adoption of conservative therapy.

Safety and caregiver satisfaction with gastrostomy in patients with Ataxia Telangiectasia

Background

Ataxia Telangiectasia (A-T) is a rare monogenetic neurodegenerative disease with pulmonary, nutritional, and dysphagic complications. Gastrostomy tube (GT) feedings are commonly recommended to manage these co-morbidities. In general, outcomes of GT placement in patients with progressive diseases that develop during childhood are not well characterized. The primary purposes of this study were to determine whether GT placement in patients with A-T would be tolerated and associated with caregiver satisfaction.

Methods

We completed a retrospective review of 175 patients who visited the A-T Children's Center at Johns Hopkins Hospital from 2001 through 2008, and identified 28 patients with A-T (19 males, 9 females) who underwent GT placement for non-palliative reasons. Information was obtained from medical records, interviews with primary health care providers, and 24 (83%) caregivers of patients with GT's who responded to survey requests.

Results

Twenty-five (89%) patients tolerated GT placement and were a median of 5.0 (0.4-12.6) years post GT placement at the time of this investigation. Three (11%) patients died within one month of GT placement. In comparison to patients who tolerated GT placement, patients with early mortality were older when GT's were placed (median 24.9 vs. 12.3 years, p = 0.006) and had developed a combination of dysphagia, nutritional, and respiratory problems. Caregivers of patients tolerating GT placement reported significant improvements in mealtime satisfaction and participation in daily activities.

Conclusions

GT placement can be well tolerated and associated with easier mealtimes in patients with A-T when feeding tubes are placed at young ages. Patients with childhood onset of disorders with predictable progression of the disease process and impaired swallowing may benefit from early versus late placement of feeding tubes.

Laryngotracheal separation in neonatal brainstem dysfunction

INTRODUCTION

Neonatal brainstem dysfunction (NBD) associates four symptoms of variable presence and intensity: suction-swallowing dysfunction, abnormal laryngeal sensitivity and motility, gastroesophageal reflux, and cardiac vagal overactivity.

MATERIALS AND METHODS

We report three cases of severe NBD with chronic aspiration which required surgical management. Successive failures and clinical deterioration led us to perform laryngotracheal separation. The surgical procedure consisted in suturing the distal segment of the trachea to the cervical skin after complete closure of the larynx.

RESULTS

After surgery, these children did not present any pulmonary infection and were allowed oral nutrition. However, oral communication was no longer possible. Although it is a theoretically reversible procedure, the decision is ethically difficult in children free of mental deficiency, because of the vocal loss and the unpredictable NBD outcome.

CONCLUSION

Laryngotracheal separation may be recommended after multidisciplinary decision for severe chronic aspiration in the particular case of children presenting with NBD.

[Laryngotracheal separation as treatment for severe bronchopulmonary aspiration]

We present the case of a patient with brain stem tumour and severe chronic aspiration. The bilateral dysfunction of lower cranial nerves and the severe gastroesophageal reflux contributed to the aspirations. Despite medical treatment and cuffed tracheotomy tube, she required almost constant hospitalization for a year and a half due to respiratory infections. Laryngotracheal separation dramatically reduced the infections and improved her quality of life.

Drainage of the tracheal blind pouch created by laryngotracheal separation

Laryngotracheal separation is a simple and reliable operation for the treatment of patients with repetitive and intractable aspiration; however, it is apprehended that pooling in the tracheal blind pouch may cause postoperative complications. In the present study, we examined drainage of the blind pouch created by laryngotracheal separation. Fourteen patients aged 3-63 years with repetitive aspiration pneumonia underwent laryngotracheal separation by the modified Lindeman procedure. A barium swallow was performed 10-30 days after surgery. X-rays of the lateral view of the neck were taken at 6 and 24 h after the swallow, and then every 24 h until the contrast medium cleared. The contrast medium in the blind pouch cleared within 24 h in nine patients. In the remaining five, the clearance time was < or =48 and < or =72 h in two patients each, and 96 h in one patient. The clearance time in patients aged under 20 years was < or =24 h, while middle-aged to elderly patients showed prolonged clearance time. No late complications of the blind pouch, such as infections, were observed. The potential risk of complications caused by pooling in the tracheal blind pouch in laryngotracheal separation is prevented presumably due to the slow but continuous turnover of pooling material. This result supports the validity and usefulness of laryngotracheal separation for the treatment of intractable aspiration.

Pulmonary care of children and adolescents with developmental disabilities

Caring for children and adolescents with developmental disabilities is challenging because of their susceptibility to varying degrees of respiratory morbidity and mortality. This article discusses the common pulmonary problems affecting children with developmental disabilities. Topics to be discussed include gastroesophageal reflux, drooling, and dysphagia and their relation to aspiration and aspiration pneumonia, upper airway obstruction and obstructive sleep apnea, and the role of airway clearance. Case studies are used to introduce a discussion of the underlying etiology, currently accepted methods to evaluate the conditions, and evidence-based treatment options. The goal of managing these problems is to use anticipatory guidance when possible and choose therapies that improve the child's quality of life with minimal side effects.

Simple and new surgical procedure for laryngotracheal separation in pediatrics

OBJECTIVES

In children with severe physical and mental disabilities who repeatedly develop aspiration pneumonia due to intractable aspiration, laryngotracheal separation/tracheoesophageal anastomosis or laryngotracheal separation has been performed in many institutions for the prevention of aspiration, and good results have been reported. However, families sometimes show a marked reluctance to give consent to these surgical techniques because of tracheal transection. A purpose of this study is to evaluate a new surgical procedure for laryngotracheal separation without tracheal transection.

STUDY DESIGN

Case-series study.

METHODS

As a new, simple, less invasive surgical technique for the prevention of aspiration without tracheal transection, we performed tracheal closure (tracheal flap method) in six children. A U-shaped flap of the tracheal anterior wall from the 2nd to the 4th/5th tracheal ring was produced, bent toward the tracheal lumen, and sutured to the tracheal posterior/lateral walls by mattress stitches for tracheal closure. In addition, the closure was covered with a cutaneous U-shaped flap for reinforcement and a permanent tracheal stoma was constructed.

RESULTS

In all six patients, aspiration pneumonia could be prevented without severe complications.

CONCLUSIONS

Tracheal closure (tracheal flap method) has effects comparable to those of other surgical techniques for the prevention of aspiration, and may be useful for aspiration prevention in children with severe physical and mental disabilities.