Original Article
Tracheal resection and anastomosis: An 11 year management
outcome
Hassan FH, Goh BS, Kong MH, Marina MB, Sani A
Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan
Malaysia Medical Centre, Kuala Lumpur, Malaysia
Objective: To evaluate the etiology, perioperative
management and outcome of surgery in cases of
tracheal stenosis.
Methods: This was a retrospective analysis of
patients with tracheal stenosis who underwent
tracheal resection with anastomosis from January
2000 to December 2010.
Results: Ten patients, aged between 15 to 53
years old (mean of 34.4 years) were included.
Post intubation injury was the major cause of
tracheal stenosis (n=8), followed by external
laryngeal trauma (n=2). Using the Cotton-Myer
classification, 60% of patients had Grade III
stenosis whilst 40% had Grade IV stenosis.
Intravenous corticosteroids were given 24 hours
before extubation. Four patients were well postoperatively without complications. The most
common complication in the other patients was
INTRODUCTION
In the majority of patients, acquired stenosis of the
subglottis and trachea is due to prolonged intubation
and tracheostomy.1 This is because of the increasing
use of mechanical ventilation in the intensive care
units. This may explain the increasing rate of
laryngotracheal stenosis in post-intubated patients,
2
ranging from 0.6 to 21%. Although several grading
systems have been proposed, the universally
accepted grading of laryngeal stenosis was devised
3
by Myer et al in 1994. Following the works of
Grillo and Pearson since the late 1970s, the
complete resection of the stenotic segment with
primary anastomosis has been accepted as the
procedure of choice because of its high success rate
(71-95%) and minimal morbidity.4 Currently,
excellent results have been reported in many large
series.4,5 The objective of this study was to evaluate
the etiology, perioperative management and
outcome of tracheal resection with anatomosis,
being performed in a tertiary care hospital in
Malaysia.
177
granulation tissue at the anastomosis region
(n=3), vocal cord paresis (n=2) and one
restenosis (n=1).
Four of these patients
underwent examination under anesthesia with
removal of granulation tissue and/or laser
dilatation. However, 2 cases needed Shian Lee
operation and required T-tube until present. The
success rate for tracheal resection and
anastomosis is taken as the number of patients
successfully decannulated, which was 80%.
Conclusion: Tracheal resection with end-to-end
anatomosis was a successful procedure for
cervical tracheal stenosis, with low mortality and
few complications related to it. (Rawal Med J
2013;38: 177-180).
Keywords: Tracheal stenosis, laryngostenosis,
acquired laryngeal stenosis, endotracheal
intubation.
METHODOLOGY
This retrospective analysis was carried out at the
Department of Otorhinolaryngology, Head and
Neck Surgery, Universiti Kebangsaan Malaysia
Medical Centre, Malaysia, which is a tertiary care
hospital. The study included patients who
underwent tracheal resection for tracheal stenosis
with end-to-end anastomosis between January 2000
and December 2010. All patients were referred to
our tertiary academic hospital with a tracheostomy
tube in-situ. We included tracheal stenosis only in
the cervical region. Data was compiled from the
operating theatre registry and patients' operative
notes. A total of 18 patients had undergone tracheal
resection with end-to-end anatomosis for the above
period of time. Eight cases were excluded from the
study due to incomplete data.
The demographic features including age, gender,
the grade of tracheal stenosis, length, distance and
type of stenosis, the presence of tracheomalacia and
vocal cord palsy preoperatively were collected from
the case notes. The etiology of tracheal stenosis,
perioperative procedures pertaining to tracheal
Rawal Medical Journal: Vol. 38. No. 2, April-June 2013
Tracheal resection and anastomosis: An 11 year management outcome
resection with anastomosis, surgical outcome and
complications which had occurred were also
recorded. The outcome measure for this analysis
was taken as the number of patients successfully
decannulated after the surgery. All nominal data
were analyzed using frequency (number) and ratio
(%). The numerical data were analyzed in the form
of mean and median.
The grading of the tracheal stenosis is using the
3
Cotton-Myer classification. Prior to tracheal
resection with anastomosis, all patients underwent
examination under anesthesia, with direct
laryngotracheoscopy. The surgery was performed
by the same team of surgeon in all cases. Tracheal
resection with primary anatomosis was performed
with the trachea skeletonized and then resected from
the site of anatomosis until normal mucosa was
identified. Post-operatively, all patients were nursed
in the intensive care unit for 5 days and were given
intravenous antibiotics. Intravenous corticosteroids
were given 24 hours before extubation in all cases.
RESULTS
Out of 10 patients, 4 (40%) were male and 6 (60%)
female. The age ranged from 15 to 53 years (mean
34.4). There were 6 (60%) cases of Grade III and
and 4 (40%) cases of Grade IV stenosis. The
distance of the stenosed segment from the vocal
cords varied from minimum of 2.5 cm to a
maximum of 4.0 cm, with median of 3.6 cm and
mean distance of 3.4 cm. The length of the stenosed
tracheal segment ranged from 0.5 cm to 3.4 cm.
Two patients (18%) had tracheomalacia on direct
laryngoscopy pre-operatively. Two other patients
(18%) had vocal cord paresis pre-operatively. These
two had external laryngeal trauma as the etiology of
the tracheal stenosis.
Table 1. Preoperative Procedures.
* Preoperative procedures which were performed after the
initial examination
178
under anesthesia with direct laryngotracheoscopy.
Post intubation injury was the leading cause of
tracheal stenosis (8 patients, 80%), while external
laryngeal trauma was the cause in the remaining 2
patients (20%). Prior to tracheal resection with
anastomosis, all patients underwent examination
under anesthesia, with direct laryngotracheoscopy.
Four patients (40%) were put up for tracheal
resection with anastomosis after the initial
examination under anaesthesia. The remaining 6
patients (60%) underwent few endoscopic
procedures, namely laser ablation of stenosis,
bougie dilatation or Mitomycin C application,
before decision for tracheal resection was made
(Table 1). The number of procedures required
ranges from 1 to 4 procedures, where only one
patient (10%) needing 4 endoscopic procedures
prior to tracheal resection with anastomosis (Table
1).
Table 2. Postoperative complications and surgical outcome
(n=10).
Four patients were well after tracheal resection
without complications or the need of any
intervention (Table 2).
The most common
complication in the other patients was granulation
tissue in the anastomosis region (n=3), vocal cord
paresis (n=2) and one restenosis (n=1) (Table 2).
The 2 cases complicated by vocal cord paresis,
resolved with conservative management. The
remaining complications (n=4) were dealt with
examination under anesthesia with removal and/or
laser dilatation where necessary. However, 2 cases
needed Shian Lee operation and required T-tube
Rawal Medical Journal: Vol. 38. No. 2, April-June 2013
Tracheal resection and anastomosis: An 11 year management outcome
until present. The success rate for the tracheal
resection with anastomosis was 80% (n=8), while
20% of patients (n=2) still require T-tube until
present. However, these patients are frequently
being assessed for trial of decannulation.
DISCUSSION
Tracheal stenosis remains as an iatrogenic
complication following endotracheal intubation or
tracheostomy. In our 11-year series, the most
common etiology was post intubation injury. Postintubation tracheal stenosis is a clinical problem
5
caused by regional ischemic necrosis of the airway .
Stenosis can occur anywhere from the level of the
endotracheal tube tip up to the glottic and subglottic
area, but the most common sites are where the
endotracheal tube cuff has been in contact with the
tracheal wall and at the tracheal stoma site after a
6
tracheostomy procedure. Thus, tracheal stenosis
can most commonly occur following the two types
of airway intubation: endotracheal intubation and
tracheostomy.7
The postulated causative factor for stenosis is loss of
regional blood flow due to pressure emitted through
the cuff on the tracheal wall. Fortunately the advent
of large volume, low pressure cuffs has markedly
8
reduced the occurrence of cuff injury. Endoscopic
techniques have been used in attempt to address post
intubation tracheal stenosis, such as performing
laser ablation, dilatation or stenting. However, only
thin webline stenosis can be removed definitively by
laser treatment and benefit in more extended lesions
9
is temporary. In our series, only 4 patients
underwent tracheal resection with anastomosis
without any prior endoscopic intervention. Six
patients had 1 to 4 endoscopic procedures (Table 1),
which had short-term relief of airway obstruction.
Repeated endoscopic procedures were necessary,
and all these 6 patients eventually underwent
resection with anastomosis.
Previously, tracheal stenosis was managed with
endoscopic procedures alone10 and success rate was
defined when the patients were able to wean off
from tracheostomy tubes. Recently, surgical
resection and end to end anastomosis was
considered the only definitive treatment for tracheal
stenosis.5,10 Tracheal resection with primary
179
2
anastomosis is associated with no or low (1.8 %)
mortality.11 Prior to the tracheal resection, frequent
assessment of the tracheal stenosis following
endoscopic prodecures are needed, as decision for
surgery can be made early if the grade or degree of
stenosis remains after the endoscopic intervention.
In our series, our success rate was 80%, which
means that those patients were successfully
decannulated after resection. However, 20% of our
patients still required T-tube until present. Wain5
has reported a success rate of 93.7% and Marques et
al. reported a 92% success rate, with no mortality.2
CONCLUSION
Tracheal resection with end-to-end anastomosis was
a safe procedure in management of tracheal
stenosis. However, this procedure should be carried
out by the trained surgical teams who can perform
endoscopic and open airway surgeries with a good
post operative nursing care by the intensivist.
Authorship Contribution:
Conception and design: Goh BS, Sani A
Collection and assembly of data: Hassan FH, Kong MH, Marina
MB
Analysis and interpretation of the data: Hassan FH, Kong MH,
Marina MB
Drafting of the article: Hassan FH, Goh BS, Kong MH, Marina
MB,
Critical revision of the article for important intellectual content:
Goh BS, Sani A
Statistical expertise: Hassan FH, Goh BS, Kong MH
Final approval and guarantor of the article: Goh BS
Conflict of Interest: None declared
Corresponding Author: Associate Professor Dr Bee See GOH
Telephone Number: 03-91455555 extension 6046
Fax Number: 03- 91456675 Email: [email protected]
Rec. Date: Nov 20, 2012 Accept Date: Feb 24, 2013
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