Treatment of Childhood High-Grade Subglottic Stenosis (SGS) Through Laryngotracheoplasty (LTP) in a Tertiary Pediatric Center from 2013 to 2020

Revision tracheal resection anastomosis for recurrent stenosis after airway surgeries: functional outcomes

OBJECTIVES

To evaluate the surgical and functional outcomes as well as the quality of life among patients who underwent revision tracheal/cricotracheal resection anastomosis for recurrent stenosis after previous unsuccessful airway surgeries.

METHODS

This prospective study was conducted on 53 patients. Circumferential resection of the stenotic airway segment was done with primary end-to-end anastomosis. All surgeries were performed by the authors of this work with the same standardized surgical techniques. To decrease the anastomotic tension, suprahyoid release was performed for all patients and trachea-hyoid detensioning stitches were placed. Surgiflo was applied over the line of the anastomosis to enhance healing. Surgical and functional outcomes were evaluated.

RESULTS

Types of anastomosis were cricotracheal anastomosis (n = 18), thyrotracheal anastomosis (n = 24), and tracheo-tracheal anastomosis (n = 11) according to the remaining proximal and distal stumps. The overall decannulation rate was 92.5% (49 out of 53 patients). No major intraoperative complications were reported. Postoperative complications were reported in 13 patients (24.5%), in the form of restenosis (n = 7), granulation tissue formation at the site of anastomosis (n = 5), surgical emphysema / minor air leak through drains (n = 4), unilateral vocal fold paralysis (n = 2), wound seroma (n = 1). Regarding functional outcomes, dyspnea was considerably alleviated both at rest and during exercise, and most patients had satisfactory voice and swallowing related functions. The majority of patients reported adequate QOL.

CONCLUSION

Revision tracheal/cricotracheal resection anastomosis presents significant surgical challenges. Nevertheless, by employing meticulous surgical techniques and implementing strategies to reduce anastomotic tension and enhance healing such as suprahyoid release, trachea-hyoid detensioning stitches, and the application of surgiflo, high success rates and satisfactory functional outcomes were achieved.

Comparative success of different graft types in pediatric laryngotracheal reconstruction: a systematic review and meta-analysis

BACKGROUND

Laryngotracheal stenosis (LTS) results from abnormal airway narrowing, primarily caused by iatrogenic injuries like prolonged intubation. It leads to respiratory distress and vocal complications, requiring interventions ranging from endoscopic procedures to open surgeries like laryngotracheal reconstruction (LTR) with autologous grafts. Pediatric patients pose unique challenges due to smaller airways but may have better healing outcomes. This review aims to synthesize evidence on the success and operative parameters of different grafts in pediatric LTR to guide clinical decision-making and improve patient outcomes.

METHODS

We retrieved relevant articles from PubMed, Scopus, Web of Science, and the Cochrane Library up to August 2024. Two independent authors extracted data from eligible studies, including baseline information, success rate, need for extra procedures, time to stent removal, and time to decannulation. All analyses were undertaken using RevMan v5.4.

RESULTS

We collected 1,201 records from four databases after excluding 788 duplicates. After screening titles and abstracts, 108 records were assessed for eligibility, resulting in 86 included articles. Of these, 64 had enough data for analysis. The overall success rate for LTR was 89% for costal grafts, 86% for thyroid grafts, and 85% for auricular grafts, with no significant differences between graft types. A third of cases required additional procedures. Time to stent removal averaged 7.85 days for single-stage LTR and 62.86 days for double-stage LTR. Decannulation took 198.29 days. Complications included respiratory issues like atelectasis and pneumonia, graft-related problems, infections, and wound complications. Donor site complications and deaths were rare but occurred due to respiratory arrest, pneumothorax, and tracheotomy tube obstruction.

CONCLUSION

Costal, thyroid, and auricular grafts are comparable and show similar success rates in pediatric LTR. Optimizing perioperative management is crucial for reducing complications. Future research should standardize postoperative care and address patient pathology heterogeneity to improve outcomes.

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty

OBJECTIVES

To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP.

METHODS

A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal.

RESULTS

Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63).

CONCLUSIONS

Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:963-967, 2024.