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Department of General Thoracic Surgery, Massih Daneshvari Hospital, Shaheed Beheshti University of Medical Science, Shaheed Bahonar Ave, Darabad, PO Box 19575/154, Tehran, 1956944413 Iran
(Email: abbasidezfouli{at}nritld.ac.ir).
Questions asked by Drs Puma and Rugasa [1] are actually good questions and are indicative of their knowledge of tracheal surgery and its technical principals. Although we assume that in the body of the article that these questions have been somewhat answered, we offer the following explanations for better understanding:
Answer to the First Question: All of our cases were patients with an intact segment of trachea between the two stenotic sites. As mentioned by Dr Puma, cases in which cuff and stoma strictures are adjacent are common. However, these patients are not the subjects of this study and we consider such cases as having one stricture as well. In our experience, 4% of all cases with postintubation tracheal stenosis had multi-segmental stenosis. This has been pointed out in the discussion of the article [2].
Answer to the Second Question: The patient we reported with a 9-cm resection was an exceptional case. It was unknown that such a long resection would be feasible. In fact, we anastomosed the remaining 2 to 3 cm of trachea to the cricoid cartilage. We do not believe that this procedure is feasible in every patient. In our study, the mean length of resection in patients who underwent complete resection of the stenotic sites was 58.9 mm. During tracheal surgery, we resect the stenotic portion segment by segment. When a segment was removed, the next segment would be resected only if the two intact ends of trachea were able to reach one another with an acceptable tension. When the two ends did not reach one another, or an unusual tension was required to make them reach each other, we avoided further resection, even if we had to perform the anastomosis on a relatively damaged segment of trachea.
Tracheal release maneuvers in our patients included anterior tracheal release in the peritracheal space down to the carina. A modified Montgomery suprahyoid laryngeal release was also used in some patients. We did not perform pericardial hilar release in any patient. The patient who underwent a 9-cm airway resection was a 25-year old man with a slim neck and a suitable anatomy for tracheal resection. When we performed such a long resection, we were surprised to know that it was possible to anastomose the distal end of trachea to the cricoid with an acceptable tension. For tracheal release in this patient, peritracheal space anterior to the trachea was dissected down to the carina and up to the suprahyoid border. Subsequently, muscles were divided from the superior border of hyoid bone. In over 507 cases of tracheal resections by our group, such a long resection was performed only in 1 other patient. In studies conducted by Grillo and colleagues [3], length of resection was reported to be between 1 and 7.5 cm. Also, in an experimental study on sheep, resection and anastomosis of 9 cm of trachea was feasible with no complication [4].
Answer to the Third Question: Difficult stenosis is defined as strictures that are not manageable by dilation or stenting of any kind. For example, some strictures were too close to the carina. Any tracheostomy tube inserted would enter into the bronchi or the end of the tracheostomy tube would come out of the stenotic site and locate proximal to the stricture. The consequence was disturbed ventilation in either of these situations. Sometimes these strictures were not manageable even by bronchoscopic dilation, and following each dilation the patient required repeated dilatation for a short period of time. Some strictures lead to complete obstruction, and no procedure other than resection was efficient for their management. However, when we resect a difficult stenosis, the simpler one is resected only if maintaining a good airway was not possible by less complicated procedures. This condition has been explained as types 2 and 3 in the article.
Answer to the Forth Question: Regarding the appropriate time for the next resection, we do not insist on a 1-month period. Often in our patients, the following operation was performed over a month after the initial operation. The average interval was 6.1 months (range, 1 to 13 months).
Answer to the Fifth Question: In the body of the article, we claimed the probability that the T-tubes had not been properly and adequately protected. Maintaining the T-tube in patients with multi-segmental stenoses is more difficult than single segmental stenoses. If the T-tube was protected adequately, risk of complications would be decreased. But the risk of T-tube obstruction is always higher than tracheostomy, especially early after its insertion. Resolving the obstruction and maintaining an airway are more difficult as well. Although long-term use of the T-tube is known as a treatment modality in benign and malignant airways stenoses, it is primarily used in patients who do not meet the requirements for resection and anastomosis [5–8]. Our experience in using the T-tube was not satisfactory. Some of our patients had an adequate airway by long-term use of the T-tube, but in the majority of them the stricture recurred after removing the T-tube. Considering the aforementioned complications and due to the problems regarding the protection of the T-tube, we do not use the T-tube for treatment of stenosis except in cases in which no other treatment choice is available.
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