Ann Thorac Surg 2007;84:211-214
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Postintubation Multisegmental Tracheal Stenosis: Treatment and Results
Azizollah Abbasidezfouli, MD,
Mohammad Behgam Shadmehr, MD,
Mehrdad Arab, MD,
Mojtaba Javaherzadeh, MD,
Saviz Pejhan, MD,
Abolghasem Daneshvar, MD,
Roya Farzanegan, MD*
Department of General Thoracic Surgery, Masih Daneshvari Hospital, Shaheed Beheshti University of Medical Science, Tehran, Iran
Accepted for publication March 19, 2007.
* Address correspondence to Dr Farzanegan, Department of General Thoracic Surgery, Masih Daneshvari Hospital, Shaheed Beheshti University of Medical Science, Shaheed Bahonar Ave, Darabad, PO Box 19575/154, Tehran, 1956944413 Iran (Email: roya_farzanegan{at}yahoo.com).
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Abstract
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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.
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Introduction
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Postintubation tracheal stenosis mostly occurs in one segment of trachea and usually involves less than one third of the length of airway [1–5]. Therefore, most cases can be successfully managed by resection and anastomosis [6–8]. The therapeutic approach for management of postintubation tracheal stenosis is thoroughly discussed by Grillo [9, 10] and Abbasi [11]. Pearson [12] and others [13–17] have also discussed resection procedures for treatment of subglottic stenosis, however, there are few data regarding treatment of multisegmental tracheal stenosis because these types of lesions are not frequently seen by tracheal surgeons.
In this study, we present a rare group of patients with postintubation multisegmental tracheal stenosis and evaluated the incidence, types of lesions, and our therapeutic approaches.
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Material and Methods
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A retrospective review of our hospital records found 648 patients with postintubation tracheal stenosis between September 1993 and October 2005, who presented to the department of thoracic surgery at Masih Daneshvari Hospital in Tehran. Of them, 26 patients had multisegmental tracheal stenosis. All hospital and outpatients charts were reviewed, and the patients and their families were contacted for recent follow-ups. This study was approved by our Institutional Review Board, and because there was a retrospective chart review study, the patient consent was waived by the chairman of the Ethics Committee Board. All patients underwent rigid bronchoscopy under general anesthesia, and the diagnosis of postintubation stenosis was confirmed. In bronchoscopy, the site of stenosis, the length of stenosis, the distance from the carina and vocal cords, and functional status of the larynx were evaluated and recorded. For evaluation of the vocal cords and laryngeal function, a fiberoptic laryngoscopy with topical anesthesia was done in most of the patients. Twenty-six patients (4%) had two strictures in two different sites of the airway; these patients formed the study population.
Supportive therapy along with individualized procedures were performed preoperatively based on the case, including general care, stomal and wound care, protecting tracheostomy tubes and replacing them with more adequate ones, trying to decannulate the patients by repeated dilatation of strictures (if possible), psychotherapy, and speech therapy (if necessary). Resection was done when the patient’s general condition became stable and the inflammatory reactions and airway infection were treated.
Initially, the stricture that was more troublesome to the patient’s normal breathing was resected. Strictures located closer to the carina were resistant to dilatation and were more troublesome for the patients as compared with other types of strictures. A common problem encountered in treatment of these types of strictures was that the distal end of tracheostomy tube would frequently come out of the stenotic site, requiring urgent bronchoscopic intervention. Therefore, these strictures were operated on sooner than others. If the distal stricture was not a significant one, the proximal one would be operated first.
Four types of therapeutic approaches were taken, as follows:
- 1 If the distance between the two strictures was short and resection of both together was feasible, they were resected in one session. The resected part included the two stenotic sites with the intact area located between them. To make sure the two intact ends of trachea reached together, first the more significant one was resected; then if the intraoperative evaluation permitted resection of a longer segment, the second area would be resected as well.
- 2 If one-stage resection could not be performed, two-stage resection would be planned. Then, the more troublesome stricture was treated by a resection and anastomosis. The more troublesome strictures were those that required repeated dilatations, those not properly manageable by tracheostomy tubes or stents, and those responsible for continuous infective bronchial secretions distal to the stenotic site. After resection of the first stricture, periodic bronchoscopic evaluations continued; and the status of the second stricture, the treatment plan, and feasibility of the second operation were reevaluated; and the second resection was done when appropriate.
- 3 If an adequate airway after resection of the first stricture was not achieved and resection of the second stricture was not feasible as well, the second would be managed by repeated dilatation, laser therapy, stenting, T tube, or tracheostomy tube.
- 4 For patients who were not in good condition for resection of either of the two lesions, the airway was managed by nonresectional approaches as mentioned above.
Patients were actively followed up either by their regular visits to the hospital or by contacting and asking them to come for an evaluation of their phonation and airway status according to a questionnaire.
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Results
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There were 20 males (76.9%) and 6 females (23.1%) with a mean age of 23.9 years (range, 4 to 64). The patients had been intubated as a result of head injuries (21 cases, 80.8%), suicide attempts (2 cases, 7.7%), surgical procedures (2 cases, 7.7%), and cerebral stroke (1 case, 3.8%). Twenty-three (88.5%) had either a tracheostomy or a history of a previous tracheostomy on admission.
Figure 1
schematically demonstrates the characteristics of the strictures. The number of patients treated by each of the four aforementioned methods is as follows: (1) one-stage resection of two strictures: 5 patients (19.2%; patients 1 to 5 in Fig 1); (2) two-stage resection of two strictures: 4 patients (15.4%; patients 6 to 9); (3) resection of one stricture and managing the second one by nonresectional procedures including repeated dilatations, temporary stenting, T tube, or tracheostomy insertion: 9 patients (34.6%; patients 10 to 18); or (4) management of both strictures by therapeutic procedures other than resection: 8 patients (30.8%; patients 19 to 26).
A total of 22 resections and anastomoses were performed on 26 patients. Mean length of resection in those who underwent total resection of strictures (groups 1 and 2) was 58.9 mm (30 to 90 mm). The time interval between the two resections in group 2 was 1 to 13 months (mean, 6.1). A complete follow up of 1 to 108 months (mean, 21.5) was performed. In 16 patients (61.5%), the treatment was successful, and the patients had a normal airway and good voice after the treatment. Seven patients (26.9%) have not achieved good results yet. These patients still need airway management by dilatation, laser therapy, or stenting. Recurrent nerve palsy did not occur in any cases. In 1 case, a fistula persisted at the tracheostomy stoma between the trachea and skin and was repaired by surgery. Wound infection occurred in 1 case and was treated by antibiotic therapy and drainage. Three patients (11.6%) died. The characteristics of these patients have been summarized in Table 1. The complete course of therapy was not accomplished in those 3 who died. Death occurred when they were at home far from any professional help.
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Comment
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Multisegmental tracheal stenosis has been infrequently discussed. The reason might be that this complication is rare. Grillo [18] has hardly encountered this problem. He believes that multisegmental tracheal stenosis is due to stenosis at both cuff site and stoma and has stated the treatment to be staged resection of the lesions. The rate of this complication in our patients was 4% (26 of 648 patients). It means that a tracheal surgeon very infrequently confronts this problem. Therefore, there is clearly no focused experience regarding the treatment of these types of strictures. To select the treatment of choice for this problem, meticulous evaluation of strictures including their clinical course, bronchoscopy findings, and response to nonresectional methods of therapeutic approaches, namely, dilatation, laser therapy, and stenting, are the important issues to be considered. Some strictures are easily manageable by nonresectional methods, but some others are resistant, and airway preservation might be feasible only by resection and anastomosis (Fig 2). The most important issue in the treatment process is to choose which stricture should be resected and which one is manageable by therapeutic procedures other than resection (Figs 3, 4).
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Fig 2. Resected tracheal segments of a patient with postintubation stenosis. Destruction of cartilages and severe fibrosis is prominent.
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Fig 3. Computed tomography scan (three-dimensional reconstruction) of proximal tracheal postintubation stenosis in a 22-year-old male. This stricture was relieved by bronchoscopic dilatation. (Arrows indicate location of stenosis and deformity of airway.)
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Fig 4. In a patient with subglottic stenosis, the lumen of cricoid is mostly occluded by scar tissue. This type of lesion is not amenable to nonresectional treatments.
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Of the four types of therapeutic approaches mentioned above, our first choice was usually the second type. But during the first resection, if the resection and anastomosis of the second stricture was feasible, it would be done as well; and all 5 patients treated as such achieved good results. Nine patients were treated by the third type of therapeutic approaches. In these patients, after the first resection, the second stricture was managed by nonresectional methods, on the other hand, if the surgeon was uncertain about the feasibility for a second resection. Of 3 patients who died, 2 were in group 3. In both cases, we were waiting for a better condition to perform the second resection. The second stricture in these patients had been temporarily managed by T tube. But choking and death occurred as a result of T-tube obstruction before we could meet the requirements for the second operation. As a matter of fact, residing in places far from medical centers and the special living condition of these patients led to their death. Actually, preserving a good airway by T tube in these patients is associated with a greater risk as compared with use of a tracheostomy tube. The third death occurred in a patient with two strictures. He had not undergone any prior attempts of surgical resection and had been temporarily managed by repeated dilatation of strictures. We repeatedly advised this patient to come to the hospital in case of noticing any signs of dyspnea. But he disregarded the advice and did not come to the hospital in spite of gradual progression of his dyspnea until acute obstruction of one of the strictures occurred. He had choking followed by death before seeking any medical care.
The deaths of these 3 patients, although due to complexity of therapy, were preventable, however. Sixteen patients completely recovered with a normal airway and voice. Seven patients have an acceptable airway in spite of some problems. These patients either have a stent (T tube) or their living condition does not exceed normal activities as the result of residual airway stenosis. Treatment results in these patients are acceptable in our belief, because there is no other choice for treatment of these types of complicated airway lesions. Use of artificial prosthetics instead of trachea has not shown clinically successful results until now [19]. Although the reconstruction of trachea with artificial procedures as well as allograft, homograft, and genetic engineering products are in progress, they are not still of a clinical benefit for this complicated group of patients [19–23].
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Abstract
Introduction
