Alper Toker, Serkan Kaya, Serhan Tanju, Yusufhan Süoğlu, Mustafa Ererel,

Şükrü Dilege, Göksel Kalaycı Istanbul Medical School

Interventions other than tracheostomy in subglottic and tracheal pathologies.

What did we do in the last 5 years ?

Aim

• Changing concepts in tracheal dieseases: 1990 – Resections– Endobronchial treatment modalities– Stenting– Hybride techniques

• Our approach to tracheal disease in the last 5 years.

Patients and Methods

• Jan 2002 – Jan 2007• 62 patients, subglottic-tracheal obstructions

• Postintubation tracheal stenosis: 36 patients• Secondary tracheal tumors: 16 patients• Primary tracheal tumors: 6 patients• Tracheosephageal fistula: 4 patients

Age, sex, type of operation,

reintervention, morbidity, mortality

Patients

• 48 male, 14 female,• Mean age: 48.3 years (7-84 years) • Previous tracheal intervention: 24 patients

• Trachea resections • Tracheal stenting• Tracheostomy • Intubation• TEF Division

• Primary admission 38 patients

• Operations in ENT Department:• Tracheal resections and end to end anastomosis• Tracheal reconstructions and plasty operations • Montgomary –T tube

• Interventions in Department of Pulmonary Diseases

• Endo Tracheal – Endo Bronchial treatment• Stenting

Patients before Jan 2002 8 tracheal resections and end to end anastomosis

16 tracheal stenting

Excluding Criterias

Emergency First intervention - reintervention

•Bronchoscopy in all patients

•Dilatation in BTS

•Endoluminal tumor: Cautery, argon, cryotherapy

•Stenosis that does not permit dilatation:Tracheostomy

•Dilatation – stenting: Primary – Complication treatment

•Endoluminal therapy – stenting: Primary – complication treatment

Dilatation and resection relations in BTS

• Resection: after CT and Tracheoscopy – 13 patients

• Dilatations and immediate resection– 12 patients – Technically easy, – Good risk patients,– Timing, – No inflamation.

• Dilatation – reevaluation and resection– 6 patients– Odematous trachea, – Technically difficult,– Comorbidity,– A new CT is a must,– Previous interventions.

29 tracheal resection

1 reresection

Tracheal resections

• 24 Benign tracheal -subglottic stenosis

• 1 Primary tracheal tumors• 1 Secondary tracheal tumor• 3 Benign tracheosephageal

fistulas

Laryngeal release manuever: 4 patients

(Suprahyoid release)

Length of resection: 1cm - 5 cm

Tracheal resectionImmediate postoperative and early postoperative

complications

• Immediate postoperative complications (24 hours)• 2 emergency tracheostomy -1 hemorrhage

• Early complications (24 hours – 10 days)• 4 patients with infections

Cord vocal paralysis :Unilateral (symptomatic and diagnosed 4 patients)

Bilateral (1 patient)

Late postoperative complications (10 days)

6 patients restenosis• Multiple dilatations

– Dilatation Stenting: 1 patients - removed – no problem– Montgomary T tube 1 patient,– Argon laser 3 patient – no problem– Reresection 1 patient – no problem

In tracheal resections 1 patient died: TEF – Fistula division - stenting - septic shock: Resection anastomosis- osephageal primary repair: mediastinitis - sepsis

Tracheal resections done in other centers

•1 patient: tracheal stenting

•1 patient: Montgomary T tube – Removed in the first year – no problem

•1 patient: Montgomary T tube – Multiple granulation tissue – Multiple endobronchial treatment – trachea perforasyonu - Hybrid interventions – Restenosis : Tracheostomy

Hybride interventions

Interventions other than resections employed in

other centers: 21 patients

•Tracheal stenting: 4 patients

•Tracheostomy:13 patients

•Endobronchial treatment: 2 patients

•Tracheaosephageal fistula division 2 patients

Stenting•Stenting as a primary treatment

8 patients: 4 patients with endobronchial treatment

4 patients after dilatation

• Stenting as a complication treatment

6 patients: 2 patients after endobronchial treatment

4 patients after dilatationsonrası tedavi

Complications and mortality

•Tracheostomy: 2 patients: Stenting as a primary treatment

•Postobstructif negative pressure lung edema:2 patients (12-24 hour intubation)

•1 patient died of febrile neutopenia –sepsis

Results

• After Tracheal resection – stenting: 24 patients had multiple interventions;

•Patients who had primary intervention in our hospital had a mean of 1.24 intervention.

• Patients who had primary intervention in other centers had a mean of (excluding the primary intervention) 2.14 intervention.

•Two patients died in hospital period.

•44 of the interventions were emergency, 36 were semi-emergency.

Discussion

1- Is stenting true in benign tracheal disease ? Or should it be resection ?

Stenting : Duration Type of the stentGeneral health and social condition, Literature: results (%24 Dumon 1996)(%26Martinez1996)

(%17Brichet 1999) (%27 Puma 2002)2- Could stent be a bridge to real treatment ?

3- Monodisciplinary ? Multidisciplinary airway team ?

Multidisciplinary airway team

ENT Clinics

Pulmonary Departments

Chest Surgery Clinics

Anesthesiology and intensive care unit

Speech therapists

•Laryngeal examination, •Augmentaton of vocal cords,•Laryngeal release manuevers

•Rigid Bronchoscopies•Flexible Bronchoscopies

•Endobronchial treatment

•Post operative care