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Thread: How to find info on Trach Surgery

  1. #1

    How to find info on Trach Surgery

    My husband is a C5 incomplete...he has had a trach since two weeks after he was extabated due to formation of scar tissue in his trachea. This is called tracheal stenosis. He has endured 15 or more surgeries none of which have had a long term effect..they help for a while and then the stenosis comes back.

    Anyhow...A new Dr. (ENT) we went to has suggested an operation which will solve all of his problems...I think it is called a tracheoplasty. They make a cross incision in the trachea and add a cartilage graft to make the trach bigger so if it scars you are left with a "normal size" airway and don't need the trach.

    I can't find any info on this surgery and am concerned..Can anyone suggest how to check this out. The Dr says this is a simple solution...I am worried. I like details. Maybe I am calling it the wrong thing.

    Any resources would be appreciated...

  2. #2
    Senior Member
    Join Date
    Jun 2005
    I'm not to familiar with this subjec, but maybe you can find some information here:

  3. #3

    Probably more information that you wanted to know

    How to find info on Trach Surgery

    My husband is a C5 incomplete...he has had a trach since two weeks after he was extabated due to formation of scar tissue in his trachea. This is called tracheal stenosis. He has endured 15 or more surgeries none of which have had a long term effect..they help for a while and then the stenosis comes back.

    Anyhow...A new Dr. (ENT) we went to has suggested an operation which will solve all of his problems...I think it is called a tracheoplasty. They make a cross incision in the trachea and add a cartilage graft to make the trach bigger so if it scars you are left with a "normal size" airway and don't need the trach.

    I can't find any info on this surgery and am concerned..Can anyone suggest how to check this out. The Dr says this is a simple solution...I am worried. I like details. Maybe I am calling it the wrong thing.

    Any resources would be appreciated...

    Tracheal stenosis is a much more common complication of tracheostomy than most people realize. There are several good articles on internet regarding surgery to repair tracheal stenosis. Debbie Fisher wrote a comprehensive review of the different surgical approaches to glottic stenosis (a problem that is associated with tracheal stenosis on the Emedicine web site. It gives a pretty good summary of the terminology and surgery. In December 2004, Michal Sicard at Baylor reviewed the history of tracheal stenosis and treatments in an article named Complications of Tracheostomy. A common cause of tracheal stenosis is stomal infection (infection of the opening) that spreads into the trachea. As he points out, this complication depends on the immune status of the patient but can occur in as many as 36% of patients but progresses in only 3-8% of the patients. The infection can predispose to scar formation and subsequent tracheal constriction. He points out that there is controversy concerning use of antibiotics to treat such infections and comes down on the side of using topical antibiotics. Damage to the trachea due to the compression cuff and subsequent infection may also contribute to tracheal stenosis development. Sicard cites a paper by Grillo, et al. that describes a study of 216 patients, 90% of whom had successful repair through resection and anastomoses (cutting out a portion of the trachea and bringing the two ends together).

    I did a quick review of the recent 2005 literature on the subject.

    Sarper, et al. (2005) described their experience with 45 patients who experienced tracheal stenosis over 18 years at the Texas Heart Institute. They treated 11 patients with bronchoscopic surgery (presumably just to cut scar tissue) and 34 patients with tracheal resection with 93% success rate. A second operation was required only in 3 patients.

    Morshed, et al. (2005) in Poland described their experience with using tracheostomy T-tube. A t-tube is simply a tube that is placed in the trachea with the stem of the T coming out of tracheostomy opening. It is similar to the L-tube that is commonly used in a tracheostomy. Made of silicone, the t-tube prevents stenosis. They treated 12 patients who were able to breathe through their nose with normal speech without need to occlude the opening. The patients wore the T-tubes for 1-12 years, exchanged every 2-4 years. The main complication was “granulation” tissue developing around the tracheostomy site.

    Katsarava, et al. (2005) described 28 and 61 patients with tracheal stenosis treated in 1998-2001 and 2001-2004. They point out that medical literature suggests a 25% incidence of post-ventilation tracheal stenosis. They did a circular resection and anastomoses, using a variety of plastic operations. Three of the 89 cases died, 2 from anastomotic leakage and 1 from hemorrhage after surgery.

    Littlewood (2005) cited a recent series of 1130 patients who had a late complicaton rate of about 4%. Of these complications, tracheal stenosis accounted for about half of the cases. Thus, the rate of tracheal stenosis is much lower than the 25% seen in the past, probably due to better tracheostomy management and care taken to avoid damage to the trachea.

    George, et al. (2005) evaluated the outcomes of 26 male patients in Switzerland, 20 of whom underwent resection of 1.5-6.0 cm of trachea and anastomosis. The rest had cricotracheal resection with thyrotracheal anastomoses. Of these 26 patients, 15 achieved “excellent results”, 7 had good results, and 4 died of unrelated causes. None showed restenosis. They concluded that resection lengths of up to 6 cm are “feasible”.

    While several articles described synthetic prostheses, I don’t think that any of them have reached the level of reliability to be used routinely. However, some surgeons have used cartilage and even muscle from different sources in the reconstruction. Olias, et al. (2005) made a chondromucosal tubular flap from forearm skin that repaired the trachea of a 25-year old patient with a long tracheal defect. This tube was patent at 2 and 6 months after surgery. The authors concluded that this approach may work for people with extensive laryngotracheal defects not amenable to resection and anastomoses. Hashizume, et al. (2004) used a pedicled cartilage graft (with the blood vessels still attached) from the rib to reconstruct the trachea. The patients apparently did well.

    Finally, Kocyildirim, et al. (2004) described a procedure called “slide tracheoplasty” which they used to repair the trachea of 21 patients with multiple congenital anomalies. In patients with stenosis of tracheal that extend more than 6 cm, there is not enough trachea to anastomose the two ends. So, what they did was to transect the trachea and then made longitudinal cuts on the two ends, “slid” the two V-cut ends into each other, and sewed them together. This minimized the length of trachea that had to be sacrificed.

    In summary, the general surgical approach is resection of the stenotic trachea (cut out the stenotic portion) and anastomosis (sewing the two ends together) and use of a stent (a tube placed in the trachea to prevent stenosis). When a long length of the trachea is involved, resection and anastomoses may not be effective and reconstruction of the trachea may be necessary. Although synthetic prostheses are still experimental, there has been some success creating autologous (self) mucocartilaginous tubes for extensive stensoes. In London, there is a group that has developed a “slide tracheoplasty” approach that looks very promising for repair of long stenotic segments. In general, the surgery is successful in over 90% of patients and mortality rate is typically in the range of 2%.

    I hope that this is helpful.


    References Cited

    George M, Lang F, Pasche P and Monnier P (2005). Surgical management of laryngotracheal stenosis in adults. Eur Arch Otorhinolaryngol The purpose was to evaluate the outcome following the surgical management of a consecutive series of 26 adult patients with laryngotracheal stenosis of varied etiologies in a tertiary care center. Of the 83 patients who underwent surgery for laryngotracheal stenosis in the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Lausanne, Switzerland, between 1995 and 2003, 26 patients were adults (>/=16 years) and formed the group that was the focus of this study. The stenosis involved the trachea (20), subglottis (1), subglottis and trachea (2), glottis and subglottis (1) and glottis, subglottis and trachea (2). The etiology of the stenosis was post-intubation injury ( n =20), infiltration of the trachea by thyroid tumor ( n =3), seeding from a laryngeal tumor at the site of the tracheostoma ( n =1), idiopathic progressive subglottic stenosis ( n =1) and external laryngeal trauma ( n =1). Of the patients, 20 underwent tracheal resection and end-to-end anastomosis, and 5 patients had partial cricotracheal resection and thyrotracheal anastomosis. The length of resection varied from 1.5 to 6 cm, with a median length of 3.4 cm. Eighteen patients were extubated in the operating room, and six patients were extubated during a period of 12 to 72 h after surgery. Two patients were decannulated at 12 and 18 months, respectively. One patient, who developed anastomotic dehiscence 10 days after surgery, underwent revision surgery with a good outcome. On long-term outcome assessment, 15 patients achieved excellent results, 7 patients had a good result and 4 patients died of causes unrelated to surgery (mean follow-up period of 3.6 years). No patient showed evidence of restenosis. The excellent functional results of cricotracheal/tracheal resection and primary anastomosis in this series confirm the efficacy and reliability of this approach towards the management of laryngotracheal stenosis of varied etiologies. Similar to data in the literature, post-intubation injury was the leading cause of stenosis in our series. A resection length of up to 6 cm with laryngeal release procedures (when necessary) was found to be technically feasible. Department of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 26, 1011, Lausanne, Switzerland,

    Hashizume K, Kanamori Y, Sugiyama M, Tomonaga T and Nakanishi H (2004). Vascular-pedicled costal cartilage graft for the treatment of subglottic and upper tracheal stenosis. J Pediatr Surg 39: 1769-71. BACKGROUND/PURPOSE: Free costal cartilage graft for the treatment of subglottic and tracheal stenosis is widely used, but postoperative granulation formation is a problem. To reduce the risk of granulation formation after free costal graft, a new operation of costal cartilage graft with vascular pedicle was introduced. METHODS: A vascular pedicled fifth costal cartilage graft is prepared using internal thoracic artery and vein and intercostal artery and vein as a vascular pedicle. The prepared graft is brought to the upper trachea. The anterior wall of cricoid is split, and the costal cartilage graft is implanted to the split part and tracheostomy. Extubation on the next day is possible if the general condition of the patient permits. RESULTS: In 3 cases of subglottic or upper tracheal stenosis, this operation was performed. All the patients had tracheostomy made during early infancy. The postoperative course was uneventful, and all the patients were extubated soon after the operation. No granulation tissue was observed by postoperative bronchoscopic examinations. CONCLUSIONS: Costal cartilage graft with vascular pedicle is a safe and useful new operation for the treatment of subglottic and upper tracheal stenosis. There also is a possibility of using this procedure for the treatment of long segment tracheal stenosis. Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan.

    Katsarava V, Gobechiia KN, Gobechiia RD and Katsarava LV (2005). [Treatment of sclerotic stenosis of trachea]. Georgian Med News 34-7. An evident trend towards the increase of postintubational and posttracheostomic tracheal stenoses is observed in Georgia during the past 10-12 years. For example, during the period of 1998-2001 28 patients were admitted to our center with this diagnosis, while during 2001-2004 we treated 61 similar cases. According to several international publications overall frequency of postventilatory laryngotracheal stenoses is as high as 25%. At present time surgical intervention remains as a method of choice for treatment of tracheal stenoses including circular resection, step by step reconstructive plastic operations and different methods of tracheal recanalization. 89 patients 14-68 years of age were treated in our center during 1998-2004. 61 (68,5%) cases were presented with pathology within the cervical part of trachea and larynx. 28 (31,5%) cases were with intrathoracic tracheal stenosis. In 71 (79,8%) cases stenoses were induced by pulmonary ventilation by endotracheal tube and in 18 (20,2%) cases etiologic factor was posttracheostomic tracheal injury. Duration of intubations varied from 3 to 86 days. Mortality was 3 cases out of 89. In 2 cases mortality was due to anastomotic leakage, in 1 case--bleeding from brachiocephalic vessels. Based on our experience, an accurate follow up of diagnostic and treatment algorithms allows achievement of good results in 91% cases.

    Kocyildirim E, Kanani M, Roebuck D, Wallis C, McLaren C, Noctor C, Pigott N, Mok Q, Hartley B, Dunne C, Uppal S and Elliott MJ (2004). Long-segment tracheal stenosis: slide tracheoplasty and a multidisciplinary approach improve outcomes and reduce costs. J Thorac Cardiovasc Surg 128: 876-82. OBJECTIVE: Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Management remains controversial. A multidisciplinary tracheal team was formed in 2000 to deal with a large number of children with airway problems referred for management. We review the effect of that service, comparing the era before and after the establishment of the multidisciplinary tracheal team. METHODS: From January 1998 through January 2004, 34 patients with long-segment tracheal stenosis (21 patients with cardiovascular anomalies) underwent surgical intervention. Cardiopulmonary bypass was used in all operations. Before the multidisciplinary tracheal team, pericardial patch tracheoplasty with or without an autograft technique was the preferred method of repair. After the multidisciplinary tracheal team, an integrated care plan preferring slide tracheoplasty was initiated, correcting cardiac lesions simultaneously. RESULTS: Before the establishment of the multidisciplinary tracheal team, pericardial patch tracheoplasty was performed in 15 of 19 patients. Twelve patients had a suspended pericardial patch tracheoplasty, 2 (17%) of whom died late after the operation. Of 3 patients who had had a simple unsuspended patch, 2 (67%) died early after the operation. Four patients were operated on with the tracheal autograft technique, 2 (50%) dying early in the postoperative period. After multidisciplinary tracheal team formation, in the era between 2001 and 2004, 15 patients were operated on with slide tracheoplasty, and there were 2 (13%) early postoperative deaths. A significant reduction in cost and duration of stay has been shown both in the intensive care unit and the hospital. CONCLUSION: Our data suggest that a formalized multidisciplinary team approach and a policy of primary slide tracheoplasty are beneficial in the management of children with long-segment tracheal stenosis. Tracheal Team, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK.

    Littlewood KE (2005). Evidence-based management of tracheostomies in hospitalized patients. Respir Care 50: 516-8. There is little evidence-based literature on the management of tracheostomized patients. The existing data relate to the role of tracheostomy in specific disease states, the timing of tracheostomy, and comparison of open surgical to percutaneous tracheostomy. Tracheostomy protocols are under development. A recent series of 1,130 patients who underwent tracheostomy had a combined procedural, early, and late complication rate of approximately 4%, which is an improvement from the earlier complication rate. In the recent series, tracheal stenosis overtook hemorrhage as the leading complication, by 2 to 1. Tracheal stenosis accounted for nearly half of the complications. Half of the tracheal stenoses required surgical correction. All the patients who developed tracheal stenosis had endotracheal tubes for > 12 days before tracheostomy. Department of Anesthesiology, University of Virginia Health System, Charlottesville VA 22908-0710, USA.

    Morshed K, Szymanski M and Golabek W (2005). [The use of tracheostomy T-tube in the treatment of tracheal stenosis]. Otolaryngol Pol 59: 361-4. The aim of the study was evaluation of the use of tracheostomy T-tube in patients with tracheal stenosis. The advantages of closed T-tube over open tracheotomy are: 1/ normal breathing through the nose, 2/ normal speech without necessity to close the tube with a finger, 3/ no spitting during cough. Silicone tracheostomy T-tube was used in 12 patients with tracheal stenosis. The stenosis resulted in 7 patients from prolonged intubation, in 4 patients from defective tracheostomy and in one patient from failure of tracheal resection. In all the patients rigid tracheoscopy and/or flexible bronchoscopy revealed the length of the stenosis and the distance from vocal cords. T-tube was placed under local anesthesy. The patients used to wear closed T-tube from 1-12 years. The tube was exchanged every 2-4 years. The only adverse effect was recurrent granulation around tracheostomy in two patients. 7 of 12 patients were decannulated with good result in 3 months - 5 years follow up. In two decannulated patients stenosis recurred. One patient was retracheostomized and in another patient stenosis was resected with end to end anastomosis. Three patients were not decannulated. Tracheostomy T-tube can be used temporary in patients with tracheal stenosis before planned stenosis resection or as a sole treatment with good chances for successful decannulation. When stenosis resection is not possible, T-tube can be placed for long time. Katedra i Klinika Otolaryngologii i Onkologii Laryngologicznej AM w Lublinie.

    Olias J, Millan G and da Costa D (2005). Circumferential tracheal reconstruction for the functional treatment of airway compromise. Laryngoscope 115: 159-61. OBJECTIVES/HYPOTHESIS: The objective was to describe a surgical technique for replacement of long tracheal defects with a totally autologous free prefabricated cutaneous chondromucosal forearm tubular flap, applied to humans. STUDY DESIGN: Surgical reconstruction of the trachea. METHODS: A three-stage surgery was performed in a 25-year-old patient who presented with a long tracheal defect not resolved by previous resection with primary anastomosis and laser surgery. RESULTS: The staged surgery has been well tolerated by the patient, and no problems at all were reported. The postoperative computed tomography scan and the bronchofibroscopy examination of the "neo-trachea" at 2 and 6 months revealed normal caliber, good healing of the suture lines, absence of crusts or granulation tissue, and a well-vascularized internal mucosal lining. CONCLUSION: The modified flap reconstruction technique has the potential to be considered reliable for the definitive circumferential reconstruction of extensive laryngotracheal defects not amenable to being cured by conventional techniques. Department of Otolaryngology, Instituto Portugues de Oncologia de Lisboa, Lisboa, Portugal.

    Sarper A, Ayten A, Eser I, Ozbudak O and Demircan A (2005). Tracheal stenosis after tracheostomy or intubation: review with special regard to cause and management. Tex Heart Inst J 32: 154-8. To investigate the management outcomes of patients who developed tracheal stenosis after tracheostomy or intubation, we reviewed the courses of 45 patients who had experienced tracheal stenosis at a single institution, over 19 years from February 1985 through January 2004. There were 38 tracheal and 7 infraglottic stenoses. Twenty-nine stenoses were associated with the stoma, 12 with the cuff, and 2 with the endotracheal tube resulting in infraglottic lesions; the remaining 2 were double stenoses. Eleven patients were treated by bronchoscopic surgery, and 34 patients were treated by tracheal or laryngotracheal resection. The overall success rate was 93%. The complication rate was 18%. A 2nd operation was required in 3 patients, and 1 of the 3 died of sepsis. Our management strategy of treating tracheal stenosis with resection and end-to-end anastomosis has been associated with good outcomes. Management of infraglottic stenosis is difficult, particularly when there is a large laryngeal defect or when there have been previous surgical attempts at the same site. Department of Thoracic Surgery, Akdeniz University Medical School, Antalya, Turkey.
    Last edited by Wise Young; 08-30-2005 at 07:38 PM.

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