Laryngotracheal separation in pediatric patients: 13-year experience in a reference service / Separação laringotraqueal em pacientes pediátricos: 13 anos de experiência em um serviço de referência

ABSTRACT 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.

RESUMO Objetivo: Avaliar a estabilidade clínica da criança e do adolescente neuropata com episódios de pneumonia de repetição submetidos a procedimento cirúrgico de separação laringotraqueal. Métodos: Entre outubro 2002 a junho 2015, 92 crianças neuropatas de um único serviço com idade mediana de 68,5 meses foram submetidas à separação laringotraqueal. Os dados foram avaliados e foi realizada análise estatística pelo teste t de Student e pelo teste do χ2 de Pearson, com nível de significância adotado de 95%. Resultados: Dentre as 92 crianças, 53 eram do sexo masculino (57,6%). Quarenta e seis crianças necessitaram de internação em unidade de terapia intensiva, e 42,4% fizeram uso de ventilação mecânica. Dessas crianças, 90,2% alimentavam-se exclusivamente via gastrostomia, e 72,4% foram realizadas antes da separação laringotraqueal. As complicações pós-operatórias ocorreram em 13 crianças (14,1%), na seguinte ordem: fístula (5,4%), sangramento (4,3%), granuloma (2,2%) e estenose (3,2%). Observaram-se 24 episódios de pneumonia no período pós-operatório (26,1%). Houve diminuição significativa de ocorrência de pneumonias após a cirurgia (100% versus 26,1%, p<0,001). Óbito foi registrado em 23 pacientes (25%). A frequência de complicações pós-operatórias foi semelhante entre os pacientes que evoluíram ou não para óbito (16,7% versus 13,2%; p=0,73). Conclusão: A cirurgia bem indicada reduz o número de infecção pulmonar após o procedimento, melhorando a qualidade de vida desses pacientes e, consequentemente, reduzindo o número de internações. A separação laringotraqueal deve ser indicada como procedimento primário nos pacientes com paralisia cerebral e episódios repetidos de pneumonia aspirativa.

Estenosis traqueal media por intubación prolongada / Media tracheal stenosis for prolonged intubation

RESUMEN Fundamento: la estenosis traqueal se ha convertido en una de las complicaciones más frecuentes de la intubación prolongada y accidentes de tránsito. Se precisa que alrededor del 20 % de los pacientes intubados o traqueostomizados pueden presentarla. Objetivo: describir un caso de estenosis traqueal media por intubación prolongada que recibió tratamiento quirúrgico en el Hospital Militar Clínico Quirúrgico Docente Dr. Octavio Concepción de la Pedraja en el 2017. Caso clínico: paciente femenina de 28 años de edad, con antecedentes de infección respiratoria complicada con una endocarditis infecciosa para lo cual fue necesario intubación endotraqueal, esta se prolongó durante nueve días. Refiere disnea que al principio fue al esfuerzo físico, para luego convertirse en dificultad respiratoria en reposo, que aliviaba en ocasiones a los cambios de posición. Al examen físico se precisó estridor laríngeo, asociado a tiraje intercostal y supraclavicular, con murmullo vesicular disminuido en ambos campos pulmonares, asociado a la presencia de estertores sibilantes y roncos diseminados. Se le realizó una tomografía axial computarizada donde se constata una estenosis traqueal severa a nivel del cuerpo vertebral D-l. La paciente fue sometida a intervención quirúrgica en la cual se procedió a resección de los dos anillos traqueales correspondientes a la estenosis con anastomosis término-terminal. Conclusiones: la estenosis traqueal media, es una complicación frecuente a causa de la intubación prolongada, el examen físico, la laringoscopia y la tomografía axial computarizada son indispensables para el diagnóstico y clasificación de la misma. La cirugía con equipo multidisciplinario constituye un pilar importante en el resultado de la operación.

ABSTRACT Background: the tracheal stenosis has become one of the most frequent complications in the prolonged intubation and traffic accidents. It is necessary that approximately 20 % of the intubated or tracheostomized patient can present it. Objective: to describe a case of media tracheal stenosis for prolonged intubation that she received surgical treatment in the Educational Surgical Clinical Military Hospital Dr. Octavio Concepción of the Pedraja in the 2017. Clinical case: 28-years-old female patient, with antecedents of complicated breathing infection with an infective endocarditis for that it was necessary endotracheal intubation, this she was prolonged during nine days. She refers dyspnea that at the first went to the physical effort, then to become breathing difficulty in rest that alleviated in occasions to the position changes. To the physical exam was determined voice stridency, associated to intercostal and supraclavicular printing, with vesicular murmur diminished in both lung fields, associated to the presence of disseminated sibilant and hoarse rales. A computed axial tomography was performed where a severe tracheal stenosis is verified at level of the vertebral body D-1. The patient was subjected to surgical intervention in which it was proceeded to resection of the two tracheal rings corresponding to the stenosis with terminal anastomosis. Conclusions: the stenosis tracheal, is a frequent complication because of the prolonged intubation, the physical exam, the laryngoscopy and the computed axial tomography are indispensable for the diagnosis and classification of the same one. The surgery with multidisciplinary team constitutes an important pillar in the result of the operation.

Repair of Long-segment Congenital Tracheal Stenosis

Long-segment tracheal stenosis in infants and small children is difficult to manage and can be life-threatening. A retrospective review of 12 patients who underwent surgery for congenital tracheal stenosis between 1996 and 2004 was conducted. The patients' median age was 3.6 months. All patients had diffuse tracheal stenosis involving 40-61% (median, 50%) of the length of the trachea, which was suspected to be associated with complete tracheal ring. Five patients had proximal bronchial stenosis also. Ten patients had associated cardiac anomalies. Three different techniques were performed; pericardial patch tracheoplasty (n=4), tracheal autograft tracheoplasty (n=6), and slide tracheoplasty (n=2). After pericardial tracheoplasty, there were 2 early and 2 late deaths. All patients survived after autograft and slide tracheoplasty except one who died of pneumonia one year after the autograft tracheoplasty. The duration of ventilator support was 6-40 days after autograft and 6-7 days after slide tracheoplasty. The duration of hospital stay was 13-266 days after autograft and 19-21 days after slide tracheoplasty. Repeated bronchoscopic examinations were required after pericardial and autograft tracheoplasty. These data demonstrate that pericardial patch tracheoplasty show poor results, whereas autograft or slide tracheoplasty gives excellent short- and long-term results.