Post-intubation tracheal stenosis in pediatric age group: single-center experiences of 24 years.

BACKGROUND AND AIM: Post-intubation tracheal stenosis (PITS) is an iatrogenic injury that involves some patients. Given the importance of this issue and the referral of a significant number of children with tracheal stenosis to Masih Daneshvari Hospital in Tehran, Iran, the present study investigated tracheal stenosis following prolonged intubation in the pediatric age group. METHODS: In this observational retrospective study, from 1994 to 2018, the medical records of all children under 14 years of age with a history of PITS were reviewed. Demographic and clinical characteristics including signs and symptoms, the underlying condition that leads to intubation, duration of intubation, type of stenosis, and the therapeutic approach, type of surgery, and follow-up were collected and analyzed using SPSS. RESULTS: Among 161 patients with a mean age of 9.8 ± 4.2 years, 69% were male. The site of stenosis was limited to the trachea in 47% and others both trachea and subglottic area were involved. The most common cause of intubation was trauma. The most common symptoms were dyspnea and wheezing. Success rates of reconstruction were 93.75% in type I, 82.15% in type II, and 35.70% in type III. Among the 16 patients who underwent Type III surgery, decannulation was not performed in 11 patients. Traction in the anastomosis and complications were stated in 26 and 10% of the patients respectively, a mortality rate of 8.7% was also reported. CONCLUSION: In the case of endotracheal intubation, PITS should be considered in the differential diagnosis of dyspnea in children as well as adults.

Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience.

BACKGROUND: Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. METHODS: A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n = 13): 1-stage resection of both strictures, Type 2 (n = 6): 2-stage resection of both strictures, Type 3 (n = 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n = 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. RESULTS: Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P = .017). No factors predictive of recurrence or outcome were ascertained. CONCLUSIONS: Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

The Role of Systemic Steroids in Postintubation Tracheal Stenosis: A Randomized Clinical Trial.

BACKGROUND: Most patients with postintubation tracheal stenosis are not ideal candidates for airway resection at presentation and their airways must be temporarily kept open by repeated bronchoscopic dilation (RBD). Meanwhile, some sufficiently recover by RBD without further airway resection requirement. We hypothesized whether systemic corticosteroids could lengthen RBD intervals, decrease the number of patients who eventually need airway resection, and shorten the required length of airway resection. METHODS: Between February 2009 and November 2012, a randomized double-blind clinical trial with a 1:1 ratio (corticosteroids group [group C], prednisolone 15 mg/day; placebo group [group P]) was conducted on 120 patients without tracheostomy or T tube and in no ideal situation for airway resection at presentation, whose precipitating injury had occurred recently. All underwent RBD until they became asymptomatic or prepared for airway resection. Asymptomatic patients received the capsules (prednisolone or placebo) for 6 months; others discontinued them before surgery. Those requiring RBD at short intervals underwent tracheostomy or T tube placement and were then excluded. Follow-up terminated 6 months after airway resection or capsule discontinuation. RESULTS: There were 105 patients (72 male; 50 in group C), aged 15 to 64 years, who completed their follow-up. There was no significant difference between the two groups in age, sex, history of tracheostomy, intubation cause and duration, time interval between intubation and initial bronchoscopy, length of stenosis, and subglottic involvement. Our study showed a trend for RBD with longer intervals (22 days), and fewer operations, 17% (28 of 50 versus 40 of 55) in group C, although statistically insignificant. Furthermore, the required airway resection length became significantly shorter (5.3 mm) in group C. CONCLUSIONS: Early low-dose systemic corticosteroids can be beneficial in postintubation tracheal stenosis management.

Experimental replacement of esophagus with a short segment of trachea.

BACKGROUND: Segmental resection of esophagus with primary anastomosis is prohibited because of the risk of dehiscence. We previously have shown that replacement of a segment of cervical esophagus with a tracheal segment of the same length could successfully be performed in a canine model. In this study, we sought to assess the feasibility of replacement of the esophageal defect with a shorter segment of trachea. METHODS: In five mongrel dogs weighting 20-30 kg, under general anesthesia and after a cervical incision, 8 cm of the cervical esophagus was resected and replaced by a 4-cm segment of the adjacent trachea. The animals were evaluated clinically for signs and symptoms of stenosis and dehiscence and then euthanized after 2 mo of follow-up. RESULTS: All dogs recovered from surgery and started regular diet on the seventh postoperative day. No clinical or endoscopic sign of stenosis or voice change was seen. Squamous metaplasia and atrophy of mucosal glands and cartilage were detected in the histopathologic examination of the replaced segments. CONCLUSIONS: Replacement of a cervical esophageal defect with a shorter segment of trachea can be performed successfully in dogs. This procedure can be potentially used for the treatment of cervical esophageal lesions in humans.

The role of T-tubes in the management of airway stenosis.

OBJECTIVES: When the T-tube is inserted as a temporary stent, it is unclear whether keeping it longer in place has any benefit on the outcome. METHODS: Among 1738 patients with airway stenosis (1996-2011), 134 underwent T-tube placement (mean duration = 14.3 months); temporarily while waiting for an appropriate time for surgery in 53 (Group 1), as an adjunct after a complex laryngotracheal resection in 27 (Group 2), after surgical failure in 43 (Group 3) and permanently in 11 unresectable strictures (Group 4). A logistic regression model was used for statistical analysis. RESULTS: Seventy percent of patients were males (age = 33.6 ± 17 years). The main cause was postintubation/post-tracheostomy stenosis in 87% of patients. The stenosis (29.6 ± 14 mm, 5-80 mm) was located in the subglottis in 33%, trachea in 47% and both in 20% of cases. To assess the effect of T-tubes on stabilizing the airway after decannulation, 50 patients who still had a T-tube at the end of follow-up or for <1.5 months were excluded. Of the remaining 84, 31.5, 91.5 and 32.5% of patients in Groups 1, 2 and 3 were stable at least 3 months after decannulation. Moreover, 70% of those who were decannulated at or before 6 months and 53.7% of those who were decannulated after 6 months underwent another intervention (P = 0.17). The age, sex, cause, site of stenosis and even duration of T-tube insertion (P = 0.07) showed no significant effect on the decannulation outcome. CONCLUSIONS: Although it seems that keeping the T-tube in place for >6 months may increase the chance of successful decannulation, it was not confirmed in our study.

A successful third resection-anastomosis in a tracheal restenosis.

Reoperation due to recurrence after tracheal resection and reconstruction still seems challenging. Although recurrence may lead to serious morbidity, an appropriate surgical technique plays a significant role in the cure of these patients. We report our experience of a patient who successfully underwent a third resection and anastomosis of the trachea. We believe that the number of previous operations is not a contraindication by itself against reoperating on a patient with restenosis. Also the success rate might be acceptably high if a sufficiently healthy tracheal length remains.

Thyroid cancers with laryngotracheal invasion.

OBJECTIVES: Management of thyroid cancers with laryngotracheal invasion is controversial. METHODS: A retrospective analysis of our database found 69 patients (38 females, mean age 59.6 ± 11.6) between March 1995 and July 2010; of them 42 (61%) were managed by non-resectional methods due to the extensive airway or regional involvement, severe co-morbidities, diffuse metastases or patient's preference. Segmental airway resection was performed in 27 (39%) patients; concurrent with thyroidectomy in 17 (Immediate group (IG)), and as a delayed procedure in 10 referred patients (Delayed group (DG)), who had previously undergone thyroidectomy with conservative airway management, like shaving procedures. Follow-up was completed in 81% of patients with a mean duration of 30 months. RESULTS: Tracheal or laryngotracheal resection and reconstruction was performed in 18, laryngectomy in eight and pharyngolaryngectomy in one patient. There were two anastomotic dehiscence (11.1%), one resulted in mortality (3.7%). One or a combination of bronchoscopic core-out, laser, tracheostomy and stent placement was performed in 42 non-resected patients with two mortalities (4.7%). Overall 1-, 2-, 3- and 5-year survival was 85, 85, 68 and 49% in resected group, as well as 56, 46, 40 and 31% in non-resected group (P = 0.049), respectively. Among resected group, the overall 1-, 2-, 3- and 5-year survival was 92, 92, 76 and 61% in the IG as well as 75, 75, 56 and 28% in the DG (P = 0.43). CONCLUSIONS: Complete segmental airway resection during or even after thyroidectomy could be safely performed, might be curative and may be associated with improved survival.

Using tracheal segments for replacement of cervical oesophagus: an experimental study.

OBJECTIVES: Segmental resection and anastomosis of oesophageal lesions are not performed as a routine clinical practice because of complications and associated problems, whereas tracheal resection and anastomosis are a routine clinical practice. In this experimental study, we resected a segment of cervical oesophagus and replaced it with a tracheal segment. METHODS: In eight dogs (mixed races), weighing 20-30 kg, ageing 1-2 years, under general anaesthesia, through a cervical incision, 5 cm of cervical trachea was separated while preserving its attachments to surrounding fibroareolar tissues. Afterwards, 5 cm of the oesophagus was resected and replaced with a prepared segment of the trachea. Oral liquids were started at the first post-operative day; the animals were kept for 2 months and then euthanized. Quality of swallowing and voice were evaluated. After an autopsy, anastomoses were examined grossly and histopathologically. RESULTS: No complications occurred during surgery. Swallowing function and voice were normal in all eight dogs after the operation. No sign of aspiration was seen in clinical and radiographic examinations after starting oral diet. In autopsy examination, anastomoses were patent without narrowing or abnormal mucosal changes. Remarkable histopathological findings in replaced tracheal segments were squamous metaplasia, atrophy and degeneration of mucosal glands and degeneration of cartilages. CONCLUSIONS: Replacement of a segment of the oesophagus with an autogenous tracheal segment is a practical procedure with low complications and can probably be used for the treatment of cervical oesophageal lesions in human beings.

Major airways trauma, management and long term results.

PURPOSE: The number of patients with traumatic and iatrogenic tracheobronchial injuries is increasing. Early diagnosis, prompt establishment of a secure airway, and appropriate management could prevent sequelae and lead to a good outcome. METHODS: Between "1994-2007", 35 patients with major airways trauma were managed. This descriptive and retrospective study evaluates clinical findings, diagnostic approaches, initial managements, definitive surgical or nonsurgical treatments and follow-up results. SPSS was used for descriptive outcomes. RESULTS: There were 27 males (77%) and 8 females, with a mean age of 28.2. There were 16 blunt, 11 penetrating and 8 iatrogenic traumas, at the level of the larynx in 1, larynx and hypopharynx in 3, laryngotracheal in 12, tracheal in 13, tracheobronchial in 1, and main bronchi in 5 patients. Fourteen patients (40%) were initially managed, and 21 patients were referred to us after their initial managements at outside hospitals. There were 7 complications (20%); one resulted in mortality (2.9%). The overall final results were good in 57.1%, acceptable in 31.4% and poor in 5.7% of patients, (mean follow-up time, 58.2 months). The respiratory status and the phonation looked better in the initially managed than the delayed managed group. CONCLUSION: We recommend that, patients only become respiratory stable with minimum intervention and then be referred to centers with sufficient experience in airway surgery.

Primary major airway tumors; management and results.

OBJECTIVE: Primary major airway tumors are rare. A retrospective analysis of referral centers experience could be helpful for their management. METHODS: Fifty-one patients, including 44 (86%) malignant and seven (14%) benign with primary tumors of subglottis, trachea, carina, and main stem bronchi, were managed in a 14-year period. Based on computed tomography (CT) scan and rigid bronchoscopy findings, those who evaluated as resectable underwent airway resection and reconstruction. The others were managed by one or a combination of these methods: core out, laser, chemotherapy, radiotherapy, and tracheostomy. Follow-up was completed in 88.2%, mean (35.2 ± 33.2 months). RESULTS: Extraluminal extension of the tumor found in CT scan was significantly associated with unresectability (p = 0.006). Thirty-two patients underwent resection with three complications (9%) and one mortality (3%). Nineteen were managed by non-resectional methods; of these, 15 were found unresectable, because of tumor length, extensive local invasion or diffuse distant metastases, and four due to risk-benefit ratio or patient preference. Among 18 patients with adenoid cystic carcinoma 13 (72%) were resected (seven with negative margins). Overall 1-, 2-, 5-, and 8-year survival was 90.9%, 90.9%, 77.9%, and 19.5%, respectively. In unresectable tumors with adenoid cystic carcinoma, overall 1- and 2-year survival was 60% and 40%, respectively. Data analysis found significant association of long-term survival with resection (p = 0.005) but not with negative margins in adenoid cystic carcinoma. Among 15 patients with carcinoid tumors, all were alive at the end of follow-up, except one who died after surgery. CONCLUSIONS: Airway resection, if feasible, may extend survival and may even be curative, with low morbidity and mortality, in most patients with major airway tumors.

The etiological factors of recurrence after tracheal resection and reconstruction in post-intubation stenosis.

We assessed several factors which might be responsible for the recurrence of post-intubation airway stenosis in a large group of patients who underwent resection and reconstruction surgery by one surgical team. Four hundred and ninety-four patients underwent reconstruction of post-intubation airway stenosis during 1995-2006. The case group comprised patients who had developed recurrence, while controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic evaluation. The following variables were compared in both groups: age, sex, duration of intubation, reason for intubation, period of time between intubation and surgery, history of previous tracheotomy, previous therapeutic interventions, subglottic involvement, length of resection, presence of unusual tension at the site of anastomosis and anastomotic infection. Fifty-two patients (10.5%) developed recurrence. Lengthy resection, presence of tension at the site of anastomosis, anastomotic infection and subglottic involvement were significantly higher in the case group. Logistic regression model showed that the three main predictors are anastomotic infection (OR=3.44), subglottic involvement (OR=2.43), and presence of tension (OR=1.97), respectively. It is concluded that the surgeon can play an important role in avoiding recurrence by decreasing tension, preventing infection, and preserving subglottic structure.

Postintubation multisegmental tracheal stenosis: treatment and results.

BACKGROUND: A number of postintubation tracheal stenoses involve different and separate segments. Treatment of these types of strictures is complicated with obscure results, infrequently reported in literature. METHODS: A total of 648 patients underwent treatment for tracheal or subglottic stenosis from September 1993 through October 2005; of those, 26 cases had two separate stenotic segments. Four types of therapeutic approaches were considered for these 26 patients: one-stage resection of the stenotic sites; two-stage resection of the stenotic sites; resection of one stricture and treatment of the second one by nonresectional methods such as dilatation, laser, stenting, T-tube, or tracheostomy; or treatment of both lesions by nonresectional methods. The therapeutic approach for each patient was determined by the surgeon and was based on the nature and location of stenoses, length of stenoses and the distance between the two stenotic sites. RESULTS: There were 20 male patients (76.9%) and 6 female patients (23.1%), with a mean age of 23.9 years (range, 4 to 64). Fourteen patients had tracheal stenosis and 12 had both tracheal and subglottic involvement. Five patients underwent type 1 therapeutic approach whereas 4, 9, and 8 patients underwent types 2, 3, and 4, respectively. Mean length of resection was 58.9 mm in those who underwent complete resection of the stenotic sites (range, 30 to 90 mm). There were 2 complications, 1 stomal fistula and 1 wound infection. Follow-up was accomplished in all patients with a mean period of 21.5 months (range, 1 to 108). Sixteen patients achieved satisfactory results (good voice and airway), 7 are still under treatment (requiring stent, tracheostomy, or repeated dilatation), and 3 died (2 type 3 and 1 type 4). Two deaths were due to T-tube obstruction, and 1 was due to acute obstruction of the stenotic part. CONCLUSIONS: Resection of both strictures and reconstruction of airway are feasible in some patients with multisegmental tracheal stenosis with good results. When resection of both strictures is not feasible, a combination of resectional and nonresectional managements could be helpful for the vast majority of patients.