Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study

Slide laryngotracheopexy for idiopathic subglottic stenosis

OBJECTIVES

Idiopathic subglottic stenosis (iSGS) is a rare fibroinflammatory disorder characterized by scar tissue formation in the subglottic and tracheal regions. This study evaluated the long-term outcomes of a novel, single-step surgical technique that redefines the glottic and subglottic airway using local tracheal grafts.

METHODS

Thirteen patients (2 male and 11 female) diagnosed with iSGS who underwent slide laryngotracheopexy were enrolled in this study. The diagnosis of iSGS was confirmed through endoscopic assessment, CT scanning, and autoimmune blood testing. Patients completed post-operative Voice Handicap Index (VHI), Quality of Life (QoL), and MD Anderson Dysphagia Inventory (MDADI) questionnaires, and spirometry assessments were conducted.

RESULTS

All patients were successfully extubated in the operating room following surgery. None of the patients required intensive care unit treatment. The average hospital stay was 14 days. A temporary tracheotomy was needed in one case because of excessive crusting. Adjuvant endolaryngeal laser surgery was performed in three cases. In one case, mitomycin-C therapy was administered to treat granulation. Post-operative quality of life (QoL) assessment, peak inspiratory flow (PIF), and scores from the MDADI and VHI questionnaires were 9.0 (± 2.2), 2.8 l/s (± 0.83), 95.6 (± 4.3), and 18.7 (± 13.4), respectively.

CONCLUSION

Slide laryngotracheopexy was a safe and dependable technique for cases classified as Cotton-Myers II-IV grade iSGS. The use of a tracheal flap was advantageous to ensure optimal mucosal function. Slide laryngotracheopexy may be employed following multiple endolaryngeal interventions, whereas adjuvant CO2 laser surgery or mitomycin-c therapy may be considered in cases involving granulation tissue formation.

LEVEL OF EVIDENCE: 4

STUDY DESIGN

Retrospective case series review.

Partial cricotracheal resection for treatment of subglottic stenosis: complications and outcomes

Purpose

Subglottic stenosis (SGS) is defined as an obstruction of the subglottic area, potentially extending towards the first tracheal rings. Although endoscopic procedures are frequently preferred as first-line treatment, (partial) cricotracheal resection (PCTR) offers the most durable results. This study aims at reporting and analysing complications and respiratory and vocal outcomes after PCTR.

Methods

For this retrospective cohort analysis, the files of 37 patients with SGS who underwent PCTR in a tertiary referral center were reviewed. Patient- and stenosis-characteristics along with postoperative outcomes and complications were analyzed using descriptive statistics.

Results

The majority of patients were female (95%), which reflects the high incidence of idiopathic SGS in our patient group (89.2% vs. 2.7% postintubation SGS and 8.1% SGS related to systemic inflammatory disease). Most patients presented with a Cotton grade II (35.1%) and III (54.1%) stenosis, with a mean craniocaudal stenosis length of 17.5 mm. The vast majority of patients (89.2%) had undergone previous endoscopic procedures. The most common complication after PCTR was fibrin deposit/granulation tissue formation at the anastomotic site (n = 15, 40.5%). Other complications were rare, with anastomotic dehiscence, postoperative haemorrhage and vocal cord paralysis each in 1 patient (2.7%), temporary tracheostomy in 2 patients (5.4%), and postoperative wound infection in 3 patients (8.1%). During follow-up, only 2 patients (5.4%) developed restenosis which was successfully salvaged by endoscopic procedures. No patients were long-term tracheostomy dependent. Post-operative mean peak expiratory flow (PEF) percentage showed a 43.7% increase compared to pre-operative. For the mean increase in maximum inspiratory flow (MIF) at 50% this was 1.3 L/s. VHI (voice handicap index) scores increased significantly from baseline preoperative score of 27.5 (±23.7) to a mean value of 54.9 (±18.7) (p = 0.002) 1-month postoperatively but decreased below preoperative scores after 2 years (22.2 ± 18.1, p = 0.036).

Conclusion

PCTR is an efficient treatment for SGS, with low complication rates, a low rate of long-term restenosis and good vocal outcomes.

Airway stenosis: classification, pathogenesis, and clinical management

Airway stenosis (AS) is a fibroinflammatory disease characterized by abnormal activation of fibroblasts and excessive synthesis of extracellular matrix, which has puzzled many doctors despite its relatively low prevalence. Traditional treatment such as endoscopic surgery, open surgery, and adjuvant therapy have many disadvantages and are limited in the treatment of patients with recurrent AS. Therefore, it is urgent to reveal the pathogenesis of AS and accelerate its clinical transformation. Based on the discovered pathogenesis, including fibrosis, inflammation, epithelial-mesenchymal transition, metabolic reprogramming, microbiome, genetic susceptibility, and other mechanisms, researchers have developed a series of treatments, such as drug therapy, gene therapy, stem cell therapy, growth factor therapy, protein therapy, and photodynamic therapy. This review introduces the classification of AS, explores the existing pathogenesis and preclinical treatments developed based on the pathogenesis, and finally summarizes the current clinical management. In addition, the prospect of exploring the interaction between different types of cells and between microorganisms and cells to identify the intersection of multiple mechanisms based on single-cell RNA sequencing, 16S rRNA gene sequencing and shotgun metagenomic sequencing is worth looking forward to.

Surgery for tracheal and laryngotracheal stenosis: a historical case series

OBJECTIVES

Benign (laryngo-)tracheal stenosis is a relatively rare pathology and its surgical treatment is performed only at few specialized centres. This study aims to investigate outcomes after (laryngo-)tracheal resection-anastomosis, to explore potential risk factors for postoperative complications and to assess whether, over a 33-year period, there were major changes in surgical indications, techniques or outcomes.

METHODS

Retrospective, single-centre review of all consecutive patients who underwent tracheal or laryngo-tracheal resection/anastomosis for benign pathologies from 1990 to 2023.

RESULTS

Overall, 211 patients underwent tracheal (149 patients, 70.6%) and laryngo-tracheal (62 patients, 29.4%) resection-anastomosis. Of these, 195 patients (93.8%) were affected by iatrogenic stenosis, while 13 (6.2%) suffered from idiopathic stenosis. The median length of stenosis was 25 mm (interquartile range 1-3, 20-30). The overall morbidity rate was 27.5%, while major morbidity occurred in 10.5% of cases. One patient (0.5%) died in the postoperative period. Glottic oedema (17 patients, 8.1%), granulations (12 patients, 5.7%) and restenosis (10 patients, 4.7%) were the main complications. The only independent risk factor for postoperative complications was the length of the resected airway (P = 0.019). In the latest half of the study period, an older median age was observed, and no patient with idiopathic tracheal stenosis underwent surgery. Postoperative outcomes were comparable between surgical eras.

CONCLUSIONS

Surgical treatment of (laryngo-)tracheal stenosis is challenging and should be performed by specialized centres. In our experience, morbidity and mortality rates were satisfactory, and in most cases, patients could breathe without tracheostomy. The length of the stenosis was the most significant risk factor for postoperative complications.