ARTICLE IN PRESS doi:10.1510/icvts.2009.202978
Interactive CardioVascular and Thoracic Surgery 9 (2009) 446–449 www.icvts.org
Institutional report - Thoracic non-oncologic
The etiological factors of recurrence after tracheal resection and reconstruction in post-intubation stenosis Azizollah Abbasidezfouli, Ehsan Akbarian*, Mohammad Behgam Shadmehr, Mehrdad Arab, Mojtaba Javaherzadeh, Saviz Pejhan, Golbahar Abbasi-Dezfouli, Roya Farzanegan Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih Daneshvari Hospital, Shaheed Beheshti University of Medical Sciences (SBUMS), Darabad St., Niavaran Ave, PO 19569-44413, Tehran, Iran Received 2 February 2009; received in revised form 27 May 2009; accepted 28 May 2009
Abstract We assessed several factors which might be responsible for the recurrence of post-intubation airway stenosis in a large group of patients who underwent resection and reconstruction surgery by one surgical team. Four hundred and ninety-four patients underwent reconstruction of post-intubation airway stenosis during 1995–2006. The case group comprised patients who had developed recurrence, while controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic evaluation. The following variables were compared in both groups: age, sex, duration of intubation, reason for intubation, period of time between intubation and surgery, history of previous tracheotomy, previous therapeutic interventions, subglottic involvement, length of resection, presence of unusual tension at the site of anastomosis and anastomotic infection. Fifty-two patients (10.5%) developed recurrence. Lengthy resection, presence of tension at the site of anastomosis, anastomotic infection and subglottic involvement were significantly higher in the case group. Logistic regression model showed that the three main predictors are anastomotic infection (ORs3.44), subglottic involvement (ORs2.43), and presence of tension (ORs1.97), respectively. It is concluded that the surgeon can play an important role in avoiding recurrence by decreasing tension, preventing infection, and preserving subglottic structure. 䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Tracheal stenosis; Anastomosis; Restenosis
1. Introduction Grillo w1, 2x, Pearson et al. w3x, Couard et al. w4x, Perelman and Koroleva w5x and others w6x have described technical principles and outcomes of resection-anastomosis for postintubation tracheal stenoses as follows: ‘resection of all damaged segments of the airway, approximation and anastomosis of the two intact ends by means of fine synthetic absorbable sutures with minimum tension, trying the best to protect the recurrent nerves from injury, and preserve the normal function of the larynx’. We studied the patients with post-intubation tracheal stenosis who underwent resection-anastomosis in our center by one surgical team to describe the rate of recurrent stenosis and identify etiological factors. 2. Patients and methods Patients who underwent resection-anastomosis during 1995–2006 for the treatment of post-intubation trachealy laryngotracheal stenosis were included in the study. The case group comprised the patients whose stenosis recurred after the operation, while the control group consisted of *Corresponding author. Tel.: q98 (21) 2010-9647; fax: q98 (21) 20109484. E-mail address:
[email protected] (E. Akbarian). 䊚 2009 Published by European Association for Cardio-Thoracic Surgery
the others. Variables of age, sex, duration of intubation, reason for intubation, period of time between intubation and surgery, history of previous tracheotomy, history of laser therapy, subglottic involvement, length of resection, presence of tension at the site of anastomosis as judged by the surgeon, and anastomotic infection were studied. In case we had to resect some portion of cricoid cartilage to remove the stenosis, we defined it as a subglottic involvement. A surgeon judged and defined presence of tension, in case approximating the two ends of the airway puts the suture lines under unusual tension. Peri-surgical site infection was also defined by presence of constitutional symptoms of infection including fever or leukocytosis along with at least one of the following findings: abscess formation beneath the incision site or around anastomosis, bronchopneumonia with abnormally excessive purulent sputum. Reasons for intubation were categorized into four groups: non-airway trauma, suicidal attempts, postoperative respiratory failure after major surgeries, and other reasons (e.g. Guillain–Barre syndrome, drowning, and electrical injuries). All patients underwent bronchoscopic follow-up evaluation 1–2 months after the operation. If the patient had clinical symptoms of upper respiratory tract stenosis postoperatively and the bronchoscopy confirmed the presence of stenosis, it was considered as a recurrence. Mild stricture (the narrowest part of the lumen 70% of the
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3. Results
NS NS NS NS NS NS 0.022 0.002 0.008 0.005
Nomenclature
25.9"14.6 38 (73.1%)y14 (26.9%) 16.5"10.1 6.6"6.2 32 (61.5%) 4 (7.7%) 17 (32.7%) 43.2"14.4 8 (15.4%) 19 (36.5%)
Brief Communication
25.4"11.3 329 (74.4%)y113 (25.6%) 16.2"11.2 8.2"12.9 268 (60.6%) 63 (14.2%) 85 (19.2%) 37.8"11.6 22 (4.9%) 85 (19.2%)
State-of-the-art
Case group (52)
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NS, not significant.
Control group (442)
Proposal for Bailout Procedure
Age (years) Maleyfemale Duration of intubation (days) Months between intubation and surgery History of tracheostomy History of laser therapy Presence of tension at the anastomosis Length of resection (mm) Anastomotic infection Subglottic involvement
P-value
Mean"S.D.ypositive cases (%)
Best Evidence Topic
Probable risk factors (494 patients)
Follow-up Paper
Table 1 Studied factors with probable effect on the recurrence rate
Negative Results
Four hundred and ninety-four patients (367 males and 127 females) with the mean age of 25–34 years ranging from 4 months to 83 years underwent resection-anastomosis. In 52 patients, stenosis recurred after the surgery, which means the rate of recurrence was 10.5%. The following variables were different between the case group (recurrence) and the control group (non-recurrence) with a statistical significance: length of resection (mean 43.2 mm in the case group vs. 37.8 mm in the control group), presence of tension at the site of anastomosis (32.7% vs. 19.2%), anastomotic infection (15.4% vs. 4.9%), and subglottic involvement (36.5% vs. 19.2%). It seems that these factors were influencing recurrent stenosis. Other factors like age, sex, reason for intubation, duration of intubation, period of time between the primary intubation and surgery, history of previous tracheostomy, and previous laser therapy were not significantly different between the two groups (Tables 1 and 2). As shown in Fig. 1, comparing the means of length of resection resulted in a significant difference between the two groups of tension-positive and tension-negative patients (P-0.001). Logistic regression was conducted to assess whether the three predictors, presence of tension at the site of anastomosis, anastomotic infection, and subglottic involvement, significantly predicted whether or not a recurrent stenosis would occur. When all three predictors are considered together, they significantly predict whether a recurrent stenosis would occur (x2s18.4, dfs3, P-0.001). Predicting variables entered in the stepwise model on step 1–3 were respectively infection, subglottic involvement, and presence of tension. Table 3 presents the odds ratios, which suggest that the odds of estimating correctly who will suffer recurrent stenosis improve by 244% if one developed anastomotic infection, by 143% if one had subglottic involvement, and by 97% if one had tension at the site of anastomosis.
Institutional Report
Via a cervical transverse incision, laryngotrachealy tracheal resection was performed in a similar way to the technique described by Grillo and Pearson et al. w2, 3x. In a few number of cases, we performed the supra-hyoid laryngeal release maneuver (Montgomery technique) w7x. In addition, a few patients underwent lateral thoracotomy to release the hilum of lung from the pericardium. However, division of left bronchus and re-implantation was not performed in our cases. In laryngotracheal stenosis, the tracheal part was resected first and then the resection of anterior part of cricoid cartilage was carried out anteriorly in an arcuate line from the midline of the thyroid cartilage. Subsequently, it was extended posteriorly along the lower border of the cricoid cartilage, leaving the posterior cricoid plate intact. In case subglottic lumen was still constricted, posterior cricoidotomy was done along with implanting a rib cartilage graft in the defect. Anastomosis was performed with interrupted absorbable sutures using 4-0 polyglactin (Vicryl, Ethicon, Inc.). Re-operation was carried out with the same technique of the primary reconstruction. The most notable complexity in re-operation was severe adhesion bands in the surgical site, which led to difficult dissection of mediastinal trachea from the surrounding vessels. Nonetheless, we were able to adequately proximate two ends of the trachea before the anastomosis, and anastomotic tension was not an issue in our re-operations. A chin stitch was placed in all patients to prevent cervical hyperextension and was removed within a week. Prophylactic antibiotic therapy with intravenous cefazolin (1 g, 4 times a day) was started in all cases before the surgery and continued for two days. The statistical analysis was carried out by SPSS software (Chicago, IL) with independent t-test, analysis of variance,
Protocol
2.1. Surgical technique
or Wilcoxon rank sum test as well as x2 and Fisher exact tests. Correlation between different variables was assessed before performing the logistic regression analysis. The length of resection was obviously highly correlated with presence of tension; thereafter, the length of resection was excluded from the binary logistic regression model.
Case Report
internal diameter of the intact trachea) was not considered as a recurrent stenosis if the patient had no clinical symptoms. Clinical symptoms were defined as dyspnea as well as stridor or using respiratory accessory muscles. Stricture over 30% of the internal diameter was considered a recurrence whether or not the patient had complaints or clinical symptoms. This study was approved by the hospital Ethics Committee and written consents were waived by the committee.
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Table 2 Reasons for intubation with their recurrence rates* Reasons
Total cases
Recurrence
Trauma Suicidal attempt Major surgery Others
330 93 31 40
35 11 3 3
(66.8%) (18.8%) (6.2%) (8.1%)
(67.3) (21.1) (5.8) (5.8)
*P-value, not significant.
Fig. 1. Length of resection in two groups of patients with or without unusual tension. Table 3 Independent variables which predict recurrence of stenosis as in logistic regression model*
Anastomotic infection Subglottic involvement Presence of tension
b
S.E.
Wald
Odds
95% CI
P-value
1.23 0.89 0.68
0.45 7.78 4.31
7.45 7.78 4.31
3.44 2.43 1.97
1.42–8.35 1.30–4.53 1.04–3.74
0.006 0.005 0.038
*df (degree of freedom), 1.
4. Discussion It seems that the nature of healing differs between anastomoses of the trachea and anastomoses of the gastrointestinal (GI) tract or vessels. In comparison with trachea, less stricture rate or anastomotic tension is seen in anastomosis of GI tract even in case of infected surgical site. Although anastomotic tension was subjectively defined by the surgeon and put a limitation to our study, this factor could be of help to predict results of the surgery. Surgeons may typically describe absence or presence of the tension at various anastomotic sites of the intestine, vessels, or trachea to some extent. Despite the fact that presence of tension and the length of resection are fairly related, this relationship is not merely seen in all cases. In our study, several cases with more than half of the trachea resected had less tension than those with a shorter length of resection. In our patients, bronchoscopic appearance of recurrent stenosis was an annular fibrotic ring at the anastomotic site and histopathological findings also revealed increased fibrous tissue in the restenosis. Hence, we presume that
the principal etiology of recurrence is continuity or recurrence of an inflammatory process in the anastomotic site, which results in development of fibrotic tissue. In our series, we tried to carefully resect all the strictured parts of the airway, avoid local devascularization, and reconstruct it with fine Vicryl sutures. Using the same technique and the same surgical team for all patients, along with excluding patients with any clinical situation other than post-intubation tracheal stenosis, let us focus just on the probable predicting factors evaluated in this study, under the same circumstances. Among the evaluated factors in this study, remarkable etiological factors for the recurrence were infection, subglottic involvement, tension, and lengthy resection. It was learned that the anastomotic infection was the strongest predictor for the recurrence, so the first thing to prevent the recurrence is to control the infection. Infection of the anastomosis is a complication itself; however, this complication, which could be preventable, was directly related to restenosis. We therefore came to this point that, in tracheal reconstruction, avoiding anastomotic site infection with the best efforts is the key role to reduce the recurrence rate. The other predictors were subglottic involvement and presence of tension at the anastomotic site, respectively. Inflammation is mostly induced and maintained by infection; moreover, presence of tension increases production of fibrotic tissue at the site of anastomosis by the mechanism of local ischemia. The cause of increased likelihood of recurrence in the subglottic region rather than the trachea is not clearly known yet. Nonetheless, the subglottic region may be susceptible to inflammation and fibrosis more than the trachea. The most important complications after tracheal anastomosis, according to a report by Wright et al., were reoperation, diabetes, lengthy resection, laryngotracheal resection, age 17 years or younger, and need for tracheostomy before operation w8x. The fundamental difference between their study and ours were the inclusionyexclusion criteria. Included cases in our study were post-intubation tracheal stenoses, while Wright and colleagues studied tracheal stenoses taken place due to several situations. It was stated that resection-anastomosis should be carried out at least 2 or 3 months after intubation to let the inflammatory process stop. Performing the surgery in a short time after intubation may cause recurrence of fibrotic tissue at the surgical site as a consequence of the continuity of inflammatory process. In our study, the time between intubation and the surgery did not influence the recurrence rate; nevertheless, we prefer to postpone the surgery in case observing inflammation at the site of stenosis by means of a bronchoscope, which means that most patients will go through the operation after 2 or 3 months. 5. Conclusion We suppose that a surgeon has to minimize local inflammation at the anastomotic site to reduce the recurrence rate after tracheal reconstruction; thus, it is very important to prevent infection at the surgical site. We believe that the use of enhanced methods to prevent infection and thereafter, appropriate antibiotic therapy for 1–2 weeks
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Author: Serdar Han, Department of Thoracic Surgery, Ankara Guven Hospital, Ankara, Turkey doi:10.1510/icvts.2009.202978A I read with interest the article by Abbasidezfouli et al. on the etiological factors of recurrence after tracheal resection and reconstruction in postintubation stenosis w1x. Stenosis after tracheal resection and reconstruction is an important problem. Tracheal stenosis and dehiscence of anastomosis due to excessive tension are well known problems after long segment tracheal resections. Therefore, in terms of prevention or reducing these complications, we aimed to make comparison between the standard reconstruction technique and the ‘W plasty technique’ in our experimental study. Results were good w2x. This technique could be used for human tracheal resection.
Institutional Report
References
Follow-up Paper
w1x Abbasidezfouli A, Akbarian E, Shadmehr BM, Arab M, Javaherzadeh M, Pejhan S, Abbasi-Dezfouli G, Farzanegan R. The etiological factors of recurrence after tracheal resection and reconstruction in post-intubation stenosis. Interact CardioVasc Thorac Surg 2009;9:446–449. w2x Han S, Han U, Atinkaya C, Cavusoglu T, Osmanoglu G, Dikmen E. Wplasty technique in tracheal reconstruction: A new technique? An experimental study. Eur Surg Res 2008;41:319–323.
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w1x Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis treatment and results. J Thorac Cardiovasc Surg 1995; 109:486–492. w2x Grillo HC. The management of tracheal stenosis following assisted respiration. J Thorac Cardiovasc Surg 1969;57:52–71. w3x Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;70:806– 816. w4x Couraud L, Jougon JB, Velly JF. Surgical treatment of nontumoral stenoses of the upper airway. Ann Thorac Surg 1995;60:259–260. w5x Perelman M, Koroleva N. Surgery of the trachea. World J Surg 1980; 4:583–591. w6x Ashiku SK, Mathisen DJ. Tracheal lesions. In: Sellke FW, Swanson SJ, del Nido PJ, editors. Sabiston and Spencer surgery of the chest, 7th edition. Philadelphia, PA: Elsevier Saunders, 2005:105–117. w7x Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otolaryngol 1974;99:255–260. w8x Wright CD, Grillo HC, Wain JC, Wong DR, Donahue DM, Gaissert HA, Mathisen DJ. Anastomotic complications after tracheal resection: prog-
eComment: New technique in tracheal reconstruction
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References
nostic factors and management. J Thorac Cardiovasc Surg 2004;128: 731–739. w9x Rendina EA, Venuta F, Ricci C. Effects of low-dose steroids on bronchial healing after sleeve resection. A clinical study. J Thorac Cardiovasc Surg 1992;104:888–891.
Case Report
after the surgery may improve our results. Our strategy has long been to attempt to wean patients from corticosteroids before the surgery, because of the experiences and suggestions of Grillo et al.; however, some researchers have recommended steroids as a routine after the surgery w9x. In order to inhibit the inflammatory process, perhaps we should use steroids with low doses, which we expect would not increase the rate of dehiscence at the anastomotic site.
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