Management of airway obstruction following lidocaine nebulization in a case of tracheal stenosis: case report

Abstract Stenting for lower tracheal stenosis is a tricky situation and for the safe conduct of anesthesia, it is imperative to maintain spontaneous respiration. Airway topicalization is routinely recommended for anticipated difficult airway. We report a case of upper airway obstruction following lidocaine nebulization in a patient to be taken for tracheal stenting for lower tracheal stenosis. We would like to highlight that close monitoring of the patient is advisable during airway topicalization to detect any airway obstruction at the earliest and how fiberoptic intubation can play a pivotal role to secure the airway in an emergency scenario.

The role of bronchoscopy in slide tracheoplasty in children / 中国当代儿科杂志

OBJECTIVES@#To study the role of bronchoscopy in slide tracheoplasty.@*METHODS@#A retrospective analysis was conducted on the diagnosis and treatment of four children with tracheal stenosis admitted to Hunan Provincial People's Hospital from 2017 to 2020. The role of bronchoscopy was summarized in the preoperative evaluation, intraoperative positioning and measurement, and postoperative wound evaluation and treatment during slide tracheoplasty.@*RESULTS@#Bronchoscopy evaluation before slide tracheoplasty showed that 3 of the 4 children had complete trachea rings, 2 had pulmonary artery sling, and 2 had multiple stenosis. Slide tracheoplasty was performed in the hospital on 3 children, and the midpoint of the stenosis segment was judged under bronchoscopy, and the length of the stenosis segment was measured, which assisted in the resection of the stenosis segment of the trachea. The pathogens were identified by lavage after the surgery. One child who developed scar traction 9 months after slide tracheoplasty in another hospital was improved by interventional treatment under bronchoscopy. Mucosal changes were found under bronchoscopy in 2 children 4 days after surgery, and the treatment plan was adjusted. One month after surgery, 2 children had granulation hyperplasia, which was improved by cryotherapy under bronchoscopy. One child abandoned treatment due to anastomotic necrosis and died. Three survivors were followed up for over 6 months with good prognosis, but all had tracheobronchial malacia.@*CONCLUSIONS@#Bronchoscopy can be used for the management of slide tracheoplasty in children with tracheal stenosis, which is helpful to postoperative rehabilitation and follow-up.

Asociación del complejo ring-sling con pig bronchus: a propósito de un caso pediátrico / Ring-sling complex association with pig bronchus: a pediatric case report

El complejo ring-sling es una asociación entre el sling de la arteria pulmonar y la estenosis traqueal congénita por anillos traqueales completos. El sling de la arteria pulmonar es una forma rara de anillo vascular dentro de las cardiopatías congénitas. Se presenta el caso clínico de un niño con estridor laríngeo asociado a dificultad respiratoria evaluado en otro centro, donde se realizó endoscopia respiratoria y se observó compresión traqueal extrínseca. Ante la sospecha clínica de anillo vascular, se solicitó angiotomografía computada (angioTC) y se confirmó diagnóstico de sling de arteria pulmonar. Fue derivado a nuestro hospital y durante la intervención quirúrgica se realizó nueva endoscopia respiratoria y traqueobroncografía. Se llegó al diagnóstico de estenosis traqueal congénita con bronquio derecho accesorio (pig bronchus) y anillos vasculares completos, ambos reparados en el mismo acto quirúrgico.

The ring-sling complex is an association between pulmonary artery sling and congenital tracheal stenosis. Pulmonary artery sling is a rare form of vascular ring in congenital heart disease. The clinical case of a child with inspiratory laryngeal stridor associated with respiratory distress is presented, evaluated in another center where respiratory endoscopy was performed, observing extrinsic tracheal compression. Given the clinical suspicion of a vascular ring, CT angiography was requested, confirming the diagnosis of pulmonary artery sling. He was referred to our hospital and during the surgical intervention a new respiratory endoscopy and tracheobronchography were performed, reaching the diagnosis of congenital tracheal stenosis, right accessory bronchus (pig bronchus) and complete vascular rings, both repaired in the same surgical act.

Surgical tracheoplasty for children with congenital tracheal stenosis undergoing previous balloon dilatation or tracheal metal stent placement: a series of 9 cases / 中华外科杂志

Objective: To examine the outcomes of Slide tracheoplasty for the children with severe congenital tracheal stenosis received previous repeated balloon dilatation or metal stent placement under endoscopy. Methods: A retrospective study was conducted in 9 children with congenital tracheal stenosis undergoing previous interventional therapy under tracheoscopy and later received Slide tracheoplasty due to obvious respiratory symptoms at Department of Cardiac Surgery, Qilu Children's Hospital of Shandong University between February 2017 and July 2021. There were 7 males and 2 females with a median age at operation of 72.4 months (range: 13.3 to 98.9 months), and the median weight was 19.0 kg (range: 9.0 to 33.0 kg). Among the 9 patients, 2 patients began to receive repeated balloon dilatation (more than 3 times) 17.8 and 51.8 months ago respectively. One patient received metal stents placement into the trachea for 4 days and the other 6 children for median 56.8 months (range: 21.6 to 74.2 months). Complete tracheal cartilage rings and long segmental stenosis were present. in all 9 children. Operative details and outcome measures, including the need for endoscopic airway intervention and mortality, were collected. Results: Slide tracheoplasty was performed in all cases. Two patients with repeated balloon dilatation had different thickness of tracheal wall, local scar hyperplasia and irregular lumen. Among them, 1 case had obvious local calcification of tracheal wall, which was difficult to suture. The metal stent in one patient with short time of placement was completely removed. However, only part of the metal stents could be removed due to the long placement time in the other 6 cases. There was no operative death in the 9 children. The median postoperative tracheal intubation time was 25.3 hours (range: 17.4 to 74.5 hours). A silicone stent was placed in the trachea of 1 child due to obvious respiratory symptoms. Follow-up of median 11 months (range: 1 to 23 months) showed that no death occurred after discharge and all children had basically normal activity tolerance with no obvious respiratory symptoms. Conclusions: Slide tracheoplasty is feasible for children undergoing prior balloon dilatation or metal stents placement. Previously repeated balloon dilatation or metal stent placement under endoscopy increased the difficulty of slide tracheoplasty, the metal stent could not be completely removed after a long time.

Pediatric airway reconstruction: results after implementation of an airway team in Brazil / Reconstrução de vias aéreas pediátricas: resultados após a implantação de uma equipe de vias aéreas no Brasil

Abstract Introduction Since development of pediatric intensive care units, children have increasingly and appropriately been treated for complex surgical conditions such as laryngotracheal stenosis. Building coordinated airway teams to achieve acceptable results is still a challenge. Objective To describe patient demographics and surgical outcomes during the first 8 years of a pediatric airway reconstruction team. Methods Retrospective chart review of children submitted to open airway reconstruction in a tertiary university healthcare facility during the first eight years of an airway team formation. Results In the past 8 years 43 children underwent 52 open airway reconstructions. The median age at surgery was 4.1 years of age. Over half of the children (55.8%) had at least one comorbidity and over 80% presented Grade III and Grade IV subglottic stenosis. Other airway anomalies occurred in 34.8% of the cases. Surgeries performed were: partial and extended cricotracheal resections in 50% and laryngotracheoplasty with anterior and/or posterior grafts in 50%. Postoperative dilatation was needed in 34.15% of the patients. Total decannulation rate in this population during the 8-year period was 86% with 72% being decannulated after the first procedure. Average follow-up was 13.6 months. Initial grade of stenosis was predictive of success for the first surgery (p = 0.0085), 7 children were submitted to salvage surgeries. Children with comorbidities had 2.5 greater odds (95% CI 1.2-4.9, p = 0.0067) of unsuccessful surgery. Age at first surgery and presence of other airway anomalies were not significantly associated with success. Conclusions The overall success rate was 86%. Failures were associated with higher grades of stenosis and presence of comorbidities, but not with patient age or concomitant airway anomalies.

Resumo Introdução: Com o desenvolvimento de unidades de terapia intensiva pediátrica, o tratamento de crianças para situações cirúrgicas complexas, como a estenose laringotraqueal, tem sido cada vez mais adequado. Montar equipes coordenadas de via aérea para alcançar resultados aceitáveis ainda é um desafio. Objetivo: Descrever os dados demográficos e os resultados cirúrgicos dos pacientes durante os primeiros oito anos de uma equipe de reconstrução de via aérea pediátrica. Método: Revisão retrospectiva de prontuários de crianças submetidas à reconstrução aberta de via aérea em uma unidade de saúde universitária de nível terciário durante os primeiros oito anos de desenvolvimento de uma equipe de vias aéreas. Resultados: Nos últimos 8 anos, 43 crianças foram submetidas a 52 reconstruções abertas de vias aéreas. A mediana de idade na cirurgia foi de 4,1 anos. Mais da metade das crianças (55,8%) apresentavam pelo menos uma comorbidade e mais de 80% apresentavam estenose subglótica Grau III e Grau IV. Outras anomalias das vias aéreas ocorreram em 34,8% dos casos. As cirurgias feitas foram: ressecções cricotraqueais parciais e estendidas em 50% e laringotraqueoplastia com enxertos anterior e/ou posterior em 50%. A dilatação pós-operatória foi necessária em 34,15% dos pacientes. A taxa de decanulação total nesta população durante o período de 8 anos foi de 86%, com 72% dos pacientes decanulados após o primeiro procedimento. O seguimento médio foi de 13,6 meses. O grau inicial de estenose foi preditivo de sucesso para a primeira cirurgia (p = 0,0085), 7 crianças foram submetidas a cirurgias de resgate. Crianças com comorbidades apresentaram uma probabilidade 2,5 vezes maior (IC95% 1,2-4,9, p = 0,0067) de cirurgias sem sucesso. A idade na primeira cirurgia e a presença de outras anomalias das vias aéreas não foram significantemente associadas ao sucesso. Conclusões: A taxa global de sucesso foi de 86%. As falhas foram associadas a graus maiores de estenose e a presença de comorbidades, mas não com a idade do paciente ou anomalias concomitantes das vias aéreas.

Tratamiento quirúrgico de la estenosis traqueal adquirida en pediatría / Surgical treatment of acquired tracheal stenosis in pediatrics

La estenosis traqueal adquirida es muy poco frecuente en la edad pediátrica y puede responder a múltiples causas; la estenosis posintubación y la secundaria a traqueotomía son las más comunes.El manejo de la estenosis traqueal adquirida sigue siendo controvertido. El tratamiento endoscópico proporciona el alivio inmediato de los síntomas, pero se asocia a una alta tasa de recurrencia, y el uso de prótesis endoluminales puede incrementar la longitud de la estenosis y complicar una cirugía futura. Por el contrario, se han documentado buenos resultados a largo plazo con la resección traqueal con anastomosis primaria.Se describe nuestra experiencia con la resección traqueal con anastomosis término-terminal para el tratamiento de la estenosis traqueal posintubación en 8 pacientes.

Acquired tracheal stenosis is a very infrequent lesion in the pediatric age group and may be due to diverse causes, being post-intubation stenosis and stenosis secondary to tracheostomy the most common ones.The management of acquired tracheal stenosis remains controversial. Endoscopic treatment provides immediate relief of symptoms but it is associated with a high recurrence rate, and the use of endoluminal prostheses can increase the length of the stricture complicating future surgery. Conversely, good long-term results have been documented with tracheal resection and primary anastomosis.We describe our experience with tracheal resection followed by end-to-end anastomosis for the treatment of post-intubation tracheal stenosis in 8 patients.

A modified rabbit model of tracheal stenosis and a household endoscope. More simplicity and accessibility

Abstract Purpose: To develop a simpler animal model for benign tracheal stenosis and introduce a low-cost household endoscope for postmodeling endotracheal evaluation. Methods: Twenty rabbits were randomly divided into a model group (15 rabbits, subjected to transoral nylon brush scraping of the trachea) and a mock group (5 rabbits, merely exempted from scraping), a household endoscope was then introduced for weekly endoscopic examination. Meanwhile, other 15 rabbits (modeling like the model group) underwent batch tracheal resection at different postintervention times for pathological analysis. Results: The model group presented a low mortality and few complications. The endoscope could obtain adequate images for stenosis assessment, which showed that the models presented homogeneous injury after scraping and developed a mature scar stricture at 28 days postoperatively with a mean stenosis degree of 65.9%, and 71.4% (10/14) above Myer-Cotton's grade II. The pathological findings were consistent with the clinicopathological process of human. No stenosis was found in mock group. Conclusion: The modified model is simpler, minimally invasive and reliable, while the household endoscope is competent for model's follow-up, providing easily accessible and useful tools for facilitating more extensive studies of benign tracheal stenosis.

Sling de la arteria pulmonar en paciente preescolar con compromiso de la vía aérea / Pulmonary artery sling in preschool patient with airway compromise

Resumen Introducción: El sling de la arteria pulmonar izquierda es una rara malformación congénita del arco aórtico en la que la rama pulmonar izquierda se origina a partir de la arteria pulmonar derecha. Generalmente se sitúa entre la tráquea y el esófago, que frecuentemente la comprimen. Dependiendo del grado de compromiso de la vía aérea, el esófago y las anomalías cardíacas asociadas, las manifestaciones clínicas varían. El tratamiento de esta malformación es quirúrgico; con el paso de los años, este abordaje ha mejorado, y se ha logrado una disminución de la morbilidad y mortalidad en esta condición. Caso clínico: Se presenta el caso de una paciente preescolar con hallazgo de sling de la arteria pulmonar izquierda con compromiso de la vía aérea. Conclusiones: Después de la corrección quirúrgica, se logró una respuesta clínica favorable y una mejoría significativa en la vía aérea, evidenciada en los hallazgos en la fibrobroncoscopia, sin necesidad de intervenciones adicionales.

Abstract Background: Left pulmonary artery sling is a rare congenital malformation of the aortic arch in which this artery originates from the right pulmonary artery and courses over the trachea and the esophagus. Clinical manifestations vary depending on the degree of airway compromise, the esophagus and associated cardiac anomalies. The treatment for this malformation is surgical; over the years, this approach has improved, achieving a decrease in morbidity and mortality in this condition. Case report: A preschool patient with incidental finding of sling of the left pulmonary artery with compromise of the airway is presented. Conclusions: After the surgical procedure, a favorable clinical outcome was observed and a significant improvement in the airway was shown by a fibrobronchoscopy, without any additional intervention.

Tratamiento de la estenosis traqueobronquial con prótesis: factores de buena respuesta / Treatment of tracheobronchial stenosis with stents: good response factors

OBJETIVO: Determinar predictores de buena respuesta con el uso de prótesis en la estenosis traqueobronquial. MATERIALES Y MÉTODO: Estudio retrospectivo descriptivo de una serie de casos entre junio de 2014 y junio de 2016. Se revisaron registros clínicos, protocolos operatorios, estudios histopatológicos y de imagen. Se consignaron antecedentes demográficos y clínicos al ingreso y luego del procedimiento, etiología de la estenosis traqueal, necesidad de oxígeno en litros, estadía hospitalaria, morbilidad asociada al procedimiento, indicación de terapia complementaria posterior y sobrevida. Se analizaron los datos con estadística descriptiva y analítica. RESULTADOS: Se realizaron 68 procedimientos, en 44 pacientes, 24 mujeres, el diagnóstico principal fue estenosis traqueal con 40 casos. La etiología neoplásica fue el 88% de los casos. El Performance status (PS) de ingreso fue mayor o igual a 2 en el 68% y posterior al procedimiento disminuyó a 22% p < 0,05. En 36 casos los pacientes requerían al menos 1 L de oxígeno lo que disminuyó en 13 casos posterior a la intervención p < 0,05. El tiempo de hospitalización promedio fue 6,2 días (1-60). En 13 pacientes con patología neoplásica se indicó terapia paliativa complementaria. La morbilidad asociada al procedimiento fue de 2,9% dado por prótesis desplazada y lesión iatrogénica. La sobrevida fue de 27% a un año. CONCLUSIONES: La etiología benigna, el PS previo a la intervención menor o igual a 3, requerimiento de oxígeno de 1 litro y obstrucción tumoral menor al 70% del lumen fueron elementos de buena respuesta.

AIM: Determine good response predictors in use of stent in benign and malignant tracheobronchial stenosis. MATERIAL AND METHODS: We retrospectively reviewed medical records of patients submitted to the procedure in the period 2014 to 2016. Clinical records, operative protocols, and histopathological and imaging studies were reviewed. Demographic and clinical data, performance status (PS) at admission and after the procedure, etiology of tracheal stenosis, need for oxygen in liters (L) Post-intervention, hospital stay, procedure-related morbidity, indication of therapy (Chemotherapy and/or Radiotherapy) and survival. Data were analyzed with descriptive and analytics statistics. RESULTS: A total of 68 procedures were performed in 44 patients, 24 women. Tracheal stenosis 40 cases were diagnosed. The malignant etiology was 88%. The admission PS was greater than or equal to 2 in 68% and 22% after the procedure. The oxygen requirements prior to the procedure were at least 1 L in 36 cases and decreased in 13 cases after the procedure. The average hospitalization period was 6.2 days (1-60). Complementary therapy was indicated in 13 patients; the morbidity associated with the procedure was 2.9%, displaced installation and iatrogenic injury. The one year survival was 27%. CONCLUSIONS: Benign etiology, el PS minor than or equal to 3, oxygen requirements prior to the procedure of 1 L and tumoral obstruction less than 75% were good response predictors in our study.

Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study / Mitomicina C no tratamento endoscópico de estenose traqueal: estudo prospectivo de coorte

ABSTRACT Objective: To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods: Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results: Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions: MMC appears to be effective in the endoscopic treatment of tracheal stenosis.

RESUMO Objetivo: Avaliar a eficácia da mitomicina C (MMC) no tratamento endoscópico de estenose traqueal. Métodos: Pacientes com estenose laringotraqueal, traqueal ou traqueobrônquica foram tratados por meio de dilatação e MMC tópica. Foram empregados os seguintes critérios de inclusão: pacientes inaptos para cirurgia (por motivos médicos) no momento da avaliação; estenose membranosa com boa resposta a dilatação e estenose pós-operatória no local da anastomose. Foram analisadas as seguintes variáveis: etiologia da estenose; indicação de tratamento com MMC; local e extensão da estenose, bem como a porcentagem de estenose; presença de traqueostomia e tempo de seguimento. Os desfechos avaliados foram 12 meses ou mais sem sintomas, número de dilatações com aplicação de MMC tópica e complicações. Resultados: Vinte e dois pacientes (15 homens e 7 mulheres) foram tratados entre 2003 e 2010. As causas da estenose foram intubação endotraqueal em 15 pacientes e cirurgia em 8. A estenose traqueal pura foi observada em 13 pacientes, a subglótica, em 4, a traqueobrônquica, em 3 e a complexa, em 2. A extensão da estenose variou de 0,5 a 2,5 cm, e a porcentagem de estenose variou de 40 a 100%. Nove pacientes haviam sido submetidos a traqueostomia e apresentavam tubo T de Montgomery in situ. O tratamento teve êxito em 14 pacientes, que permaneceram sem sintomas durante pelo menos 12 meses. O número de aplicações de MMC tópica variou de 1 a 5, e as complicações foram infecção fúngica, queloide, granuloma e enfisema mediastinal. Conclusões: A MMC é aparentemente eficaz no tratamento endoscópico de estenose traqueal.

Holmium Laser for Endoscopic Treatment of Benign Tracheal Stenosis

Abstract Introduction Laryngotracheal stenosis is a difficult problem with varied etiology and various treatment options. The holmium laser represents another tool for the treatment of benign tracheal stenosis. Objectives To determine the utility of holmium laser treatment for benign tracheal stenosis with regards to safety and efficacy. Methods This was a retrospective case study examining patients with benign tracheal stenosis from 1998-2016 who underwent holmium laser treatment. Determining the safety of this procedure was the primary goal, and complications were monitored as a surrogate of safety. Results A total of 123 patients who underwent holmium laser treatment for benign tracheal stenosis were identified. In total, 123 patients underwent 476 procedures, with follow-up ranging from 1 month to 14 years. No intraoperative or post-operative complications were identified as a direct result of the use of this particular laser. Conclusions The holmium laser is an effective and safe laser to use for tracheal stenosis treatment. It is a contact laser with a short acting distance, which reduces the risk of injury to distal airway structures. Given the favorable experience reported here, the holmium laser should be considered when tracheal surgery is attempted.

Airway reconstruction: review of an approach to the advanced-stage laryngotracheal stenosis / Reconstrução de via aérea: revisão de uma abordagem à estenose laringotraqueal em estágio avançado

Abstract Introduction: The management of laryngotracheal stenosis is complex and is influenced by multiple factors that can affect the ultimate outcome. Advanced lesions represent a special challenge to the treating surgeon to find the best remedying technique. Objective: To review the efficacy of our surgical reconstructive approach in managing advanced-stage laryngotracheal stenosis treated at a tertiary medical center. Methods: A retrospective review of all patients that underwent open laryngotracheal repair/reconstruction by the senior author between 2002 and 2014. Patients with mild/moderate stenosis (e.g. stage 1 or 2), or those who had an open reconstructive procedure prior to referral, were excluded. Patients who had only endoscopic treatment (e.g. laser, balloon dilatation) and were not subjected to an open reconstructive procedure at our institution, were not included in this study. Variables studied included patient demographics, clinical presentation, etiology of the laryngotracheal pathology, the location of stenosis, the stage of stenosis, the type of corrective or reconstructive procedure performed with the type of graft used (where applicable), the type and duration of stent used, the post-reconstruction complications, and the duration of follow-up. Outcome measures included decannulation rate, total number of reconstructive surgeries needed to achieve decannulation, and the number of post-operative endoscopies needed to reach a safe patent airway. Results: Twenty five patients were included, aged 0.5 months to 45 years (mean 13.5 years, median 15 years) with 16 males and 9 females. Seventeen patients (68%) were younger than 18 years. Most patients presented with stridor, failure of decannulation, or respiratory distress. Majority had acquired etiology for their stenosis with only 24% having a congenital pathology. Thirty-two reconstructive procedures were performed resulting in decannulating 24 patients (96%), with 15/17 (88%) pediatric patients and 5/8 (62.5%) adult patients requiring only a single reconstructive procedure. Cartilage grafts were mostly used in children (84% vs. 38%) and stents were mostly silicone made, followed by endotracheal tubes. The number of endoscopies required ranged from 1 to 7 (mean 3). More co-morbidities existed in young children, resulting in failure to decannulate one patient. Adult patients had more complex pathologies requiring multiple procedures to achieve decannulation, with grafting less efficacious than in younger patients. The pediatric patients had double the incidence of granulation tissue compared to adults. The decannulated patients remained asymptomatic at a mean follow-up of 50.5 months. Conclusion: The review of our approach to open airway repair/reconstruction showed its efficacy in advanced-stage laryngotracheal stenosis. Good knowledge of a variety of reconstructive techniques is important to achieve good results in a variety of age groups.

Resumo Introdução: A conduta da estenose laringotraqueal é complexa e é influenciada por vários fatores que podem afetar o resultado final. Lesões em estágio avançado representam um desafio especial para o cirurgião encontrar a melhor técnica de tratamento. Objetivo: Avaliar a eficácia de nossa abordagem de reconstrução cirúrgica no tratamento de estenose laringotraqueal em estágio avançado em um centro médico terciário. Método: Revisão retrospectiva de todos os pacientes submetidos a tratamento cirúrgico/reconstrução laringotraqueal aberta pelo autor principal, entre 2002 e 2014. Os pacientes com estenose leve (por exemplo, estágio 1 ou 2) ou aqueles submetidos a procedimento de reconstrução aberta antes da indicação foram excluídos. Pacientes que tinham sido submetidos somente a tratamento endoscópico (por exemplo, laser, dilatação por balão) e não haviam sido submetidos a procedimento de reconstrução aberta em nossa instituição não foram incluídos. As variáveis estudadas incluíram dados demográficos dos pacientes, apresentação clínica, etiologia da doença laringotraqueal, local da estenose, estágio da estenose, o tipo de procedimento corretivo ou reconstrutor feito com o tipo de enxerto usado (onde aplicável), tipo e duração do stent usado, complicações pós-reconstrução e duração do seguimento. Os resultados incluíram taxas de decanulação, número total de cirurgias reconstrutoras necessárias para possibilitar a decanulação e o número de endoscopias pós-operatórias necessárias para obter uma via aérea patente e segura. Resultados: Vinte e cinco pacientes foram incluídos, com 0,5 meses a 45 anos (média de 13,5, mediana de 15) com 16 homens e nove mulheres. Dezessete pacientes (68%) eram menores de 18 anos. A maioria dos pacientes apresentava estridor, falha de decanulação ou desconforto respiratório. A maioria das estenoses era adquirida, enquanto apenas 24% apresentavam causa congênita. Trinta e dois procedimentos reconstrutores foram feitos, resultaram em decanulação de 24 pacientes (96%), com 15/17 (88%) pacientes pediátricos e 5/8 pacientes (62,5%) adultos que necessitaram de apenas um único procedimento reconstrutor. Enxertos de cartilagem foram usados principalmente em crianças (84% vs. 38%) e a maioria dos stents era feita principalmente de silicone, seguido por tubo endotraqueal. O número de endoscopias necessárias variou de um a sete (média de três). Mais comorbidades foram observadas em crianças pequenas, o que resultou em falha de decanulação em um paciente. Pacientes adultos apresentavam doenças mais complexas que requereram vários procedimentos para decanulação, com enxertos menos eficazes do que em pacientes mais jovens. Os pacientes pediátricos apresentaram o dobro da incidência de tecido de granulação em comparação com os adultos. Os pacientes decanulados permaneceram assintomáticos em um seguimento médio de 50,5 meses. Conclusão: A revisão da nossa abordagem para tratamento cirúrgico/reconstrução aberta das vias aéreas demonstrou eficácia na estenose laringotraqueal em estágio avançado. O conhecimento de uma variedade de técnicas de reconstrução é importante para conseguir bons resultados em vários grupos etários.

Anesthetic management of a large mediastinal mass for tracheal stent placement / Manejo anestésico de grande massa mediastinal para a colocação de stent traqueal

ABSTRACT The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

RESUMO O manejo anestésico de pacientes com grandes massas situadas no mediastino pode ser complicado por causa dos efeitos da pressão da massa sobre as vias aéreas ou grandes vasos. Relatamos o manejo anestésico bem-sucedido de uma paciente de 64 anos com uma grande massa mediastinal que invadiu os grandes vasos e comprimiu a traqueia. Um stent traqueal foi colocado para aliviar a compressão da traqueia, sob anestesia geral. A ventilação espontânea foi mantida durante o período perioperatório com o uso de uma máscara laríngea clássica. Discutimos a utilidade da máscara laríngea para o manejo da colocação de stent traqueal em pacientes com massas situadas no mediastino.

Reoperación en cirugía traqueal / Reoperation required in tracheal surgery

Objetivo: describir los resultados obtenidos con el tratamiento quirúrgico en pacientes con recidiva de estenosis isquémica traqueal o subglótica. Métodos: entre junio de 1985 y julio de 2009 fueron operados 28 pacientes por recidiva de estenosis traqueal y laringotraqueal. Dos de ellos se perdieron durante el seguimiento. Las variables estudiadas fueron: procedencia y localización de la lesión, causa de la recidiva, técnica quirúrgica empleada, complicaciones y resultado definitivo. Resultados: diez pacientes fueron intervenidos primariamente por los autores y 16 en otros hospitales. En 12 enfermos la lesión fue traqueal y en 14 subglótica. La principal causa demostrada de recidiva fue la tensión excesiva sobre la línea de sutura. En 15 pacientes no se pudo determinar, la mayoría de estos (14) ocurrió en enfermos remitidos de otros centros. Se realizó resección al 73,1 porciento de los casos (subglótica 11, traqueal 8) y colocación de un tubo en T al resto (tráquea 4, subglotis 3). Las complicaciones comprendieron: granulomas, infección de la herida, dehiscencia parcial de sutura, fístula traqueal y lesión recurrencial bilateral. El resultado fue excelente y satisfactorio en el 96,2 porciento y malo en el 3,8 porciento. Conclusiones: el tratamiento quirúrgico por recidiva de una estenosis traqueal o subglótica, puede producir resultados que garanticen calidad de vida adecuada sin la necesidad de prótesis o traqueostomía(AU)

Objective: to present the results achieved with the surgical treatment in patients with recurrent tracheal and subglottic ischemic stenosis. Methods: twenty eight patients were operated on from recurrent tracheal and laryngeal-tracheal stenosis from June 1985 through July 2009. Two of them were excluded because they were lost during the follow-up. The study variables were origin and location of the lesion, cause of recurrence, surgical technique, complications and final results. Results: Ten patients were operated on by the authors and 16 underwent the same procedure in other hospitals. The tracheal lesion was involved in 12 cases and the subglottic one in 14. The main cause of recurrence was excessive tension on the suture line. It was not possible to define the cause in 15 patients, 14 of whom had been referred from other hospitals. Nineteen patients (73,1 percent) underwent resection (tracheal 8, subglottic 11) and T-tube was placed in other 7 patients (tracheal 4 and subglottic 3). Morbidity comprised granulomas, wound infection, partial suture dehiscence, tracheal fistula and bilateral recurrent nerve lesion. Final results were excellent and satisfactory in 96.2 percent of cases and unsatisfactory in 3.8 percent. Conclusions: Surgical treatment in cases with tracheal or subglottic recurrent stenosis may yield positive results that guarantee adequate quality of life without requiring prosthesis or tracheostomy(AU)

role of tracheal stenting as an alternative treatment in cicatricial and non-operable tracheal stenosis

Tracheal stenosis is normally caused by trauma, infection, benign and malignant tumors, prolonged intubation or tracheostomy. The best treatment for tracheal stenosis is resection and anastomosis of trachea. Yet the major surgical complication of tracheal surgery is postoperative stenosis. The goal of this paper is to study the result of tracheal stenting as a replacement therapy for patients suffering from tracheal stenosis who are not good candidates for surgery. This study presents the results of stenting in patients with: Inoperable tumoral stenosis,Non-tumoral stenosis being complicated due to prior surgeries,Inability to undergo a major surgery. The study was performed between September 2002 and July 2011 and poly flex stents were used by means of rigid bronchoscopy. A total of 25 patients received stents during this study. Among them 15 patients suffered from benign and 10 suffered from malignant tracheal stenosis. The patients were followed up for at most 12 months after the stenting operation. The mean age of the patients was 35 years. The most common cause of stenosis was prolonged intubation [75%]. The most common indication for stenting was the history of multiple tracheal operations. The most common complication of stenting and cause of stent removal was formation of granulation tissue. 30% of patients with benign tracheal stenosis were cured and about 10% improved until they could stand a major operation. Ten patients in benign group and 2 patients in malignant group [20%] needed T-Tube insertion after stent removal but other patientcure by stenting. In benign cases stenting is associated with recurrence of symptoms which requires other therapeutic techniqus, so the stenting may not be named as a final solution in benign cases. However, this technique is the only method with approved efficacy for malignant cases with indication

Estenosis laringotraqueal: experiencia clínica / Laryngo-tracheal stenosis: our experience

Introducción: La estenosis laringotraqueal es una patología de difícil manejo y obtener un resultado que permita, al sujeto que la padece, volver a tener una función adecuada fonorrespiratoria y deglutoria, no siempre es factible de obtener. Objetivo: Presentar una serie clínica de pacientes que tienen una estenosis de la vía aérea superior (VAS) y que fueron intervenidos quirúrgicamente. Como objetivo secundario es evaluar si a técnicas similares hay o no diferencias entre los grupos etarios. Material y método: Presentamos un análisis retrospectivo de los pacientes intervenidos quirúrgicamente por los autores. En él se realiza la descripción demográfica de los casos, sitio de la estenosis, tipo de intervención según edad; porcentaje de éxito en la decanulación después de una o varias intervenciones, necesidad de reoperación, tipo de injerto y tutores utilizados. Se dividió el grupo en pediátrico (hasta los 18 años) y adulto (mayores de 19 años). Los resultados fueron analizados con las pruebas no paramétricas de x² y de Fisher. Resultados: La casuística consta de 88 pacientes intervenidos quirúrgicamente para reparar una estenosis laringotraqueal. Los menores de 18 años corresponden a 45 casos (51 por ciento). El porcentaje de éxito alcanzado en la primera cirugía es de 75,6 por ciento (34/45 casos) en los menores de 18 años y de 76,7 por ciento por ciento (33/43 casos) en los mayores de 19 años. Se reoperan 15/21 casos fracasados en primera instancia; logrando decanular a 13 de ellos aumentando el éxito a 90,9° por ciento. Fracasan a las reoperaciones y pendientes de resolver aún, 8 casos. La técnica más utilizada fue la reconstrucción laringotraqueal con injerto de cartílago costal ya sea anterior y/o posterior, por ser la estenosis subglótica el sitio de la lesión. El porcentaje de éxito para esta técnica es de 68,3 por ciento; siendo en los menores de...

Introduction: Laryngo-tracheal stenosis is a condition difficult to manage and obtain results which permit the person who suffers it recover phonorespiratory and deglutory function. This is not always possible to achieve. Aim: Present a clinical series of patients with stenosis of the VAS and underwent surgery. A secondary objective is to assess whether or not there are similar technical differences between age groups. Material and method: We present a retrospective analysis of patients surgically treated by the authors. They present demographic description cases, site of stenosis, type of intervention according to age; percentage of successful decannulation after one or more interventions; reoperation, type of graft and stents used. The group was divided into pediatric and adult. Statistical analysis was performed with x2 and Fisher. Results: The case mix consists of 88 patients who underwent surgery to repair laryngo-tracheal stenosis. Children under 18 years correspond to 45 cases (51 percent percent). The percentage of success in the first surgery is 75.6 percent percent (34/45 cases) in children under 18 and 76.7 percent percent (33/43 cases) over 19years. 15/21 failed cases were reoperated in the first instance; 13 of them were decannulated increasing success to 90.9 percent percent. Reoperation failure and still unresolved, 8 cases. Surgical technique used was laryngotracheal reconstruction with costal cartilage graft either anterior or posterior being subglottic the site of stenosis. Success rate to this technique is 68.3 percent percent. In patients under 18 years old is 71 percent percent success and over 18 years 60 percent percent. For tracheal stenosis, tracheal resection with end to end anastomosis has a success rate of over 90 percent and it is performed mostly in the age group over 18 years...

Initial experience of endobronchial silicon stents from a tertiary care centre in north India.

Background. Central airway obstruction (CAO) is defined as obstruction of trachea and principal bronchi. Therapeutic rigid bronchoscopy with tracheobronchial stenting using silicon stents is a well established procedure in the management of such conditions. However, there is limited experience with this technique in India. Methods. Between January 2010 and April 2010, Dumon stents were placed in four patients with CAO. Three patients had symptomatic tracheal stenosis while one patient had malignant obstruction at the carina. Rigid bronchoscopy under general anaesthesia was performed to relieve the CAO followed by placement of silicon stents. Pre- and post-stent placement symptom assessment was performed with a symptom-based visual analogue scale. Results. Four patients underwent silicon stent placement in the tracheobronchial tree. Three patients had benign postintubation tracheal stenosis and one had malignant tracheal obstruction at carina due to endobronchial growth. Significant improvement was achieved in all patients. There were no significant complications. Conclusions. Rigid bronchoscopy with silicon stent placement is an effective and suitable method of relieving the distressing symptoms due to benign or malignant airway obstruction.

Tracheal resection and end-to-end anastomosis for tracheal stenosis: etiology and outcome

To know the etiology of tracheal stenosis and asses outcome of tracheal resection and end-to-end anastomosis for tracheal stenosis. Descriptive prospective case series. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi and Quetta from May 2005 to March 2010. Twenty two patients were included in the study who underwent tracheal resection followed by primary tracheal reconstruction by same surgical team. Etiology was ascertained on the basis of available history and per-operative findings. End-to-end tracheal anastomosis was done using vicryl 3/0. Outcome of surgical technique was assessed using peak expiratory flow rate [PEFR] and flexible bronchoscopy. Twenty two patients were managed over a period of five years, of which 17 [77.3%] were male and 5[22.7%] female. Mean patient age was 27.31 +/- 9.61 years. Seven [31.8%] patients had New York Heart Association grade [NYHA]-III and 15 [68.2%] had NYHA grade-IV dyspnoea. Seventeen [77.3%] had stridor. All patients were already being managed by pulmonologists, ENT specialists or intensivists. Twelve [54.5%] had grade-V stenosis [91-100% luminal obstruction] and 9 [40.9%] had cervical tracheal stenosis and 3[13.6%] had mediastinal tracheal stenosis. Six [27.3%] patients had partial cricoid resection followed by thyrotracheal anastomosis, 13[59.1%] patients underwent cervical tracheal anastomosis and 3 [13.6%] patients required mediastinal tracheal anastomosis. Patients were followed up post-operatively for the development of immediate and delayed complications. The follow up was carried out for a minimum period of 6 months to a maximum period of 2 years. Postoperative complications included neck pain, lung collapse, and superficial skin infection. Tracheal resection with end-to-end anastomosis is a safe, reliable and permanent procedure for the treatment of tracheal stenosis