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Vs Double-Stage Laryngotracheal Reconstruction ORIGINAL ARTICLE Single- vs Double-Stage Laryngotracheal Reconstruction Lee P. Smith, MD; Karen B. Zur, MD; Ian N. Jacobs, MD Objective: To compare single-stage laryngotracheal re- respectively. Patients who underwent ssLTR and dsLTR construction (ssLTR) and double-stage LTR (dsLTR). were further divided into early and late groups based on whether the posterior graft was sutured in place (early) Design: Retrospective medical record review. or not (late). Overall and operation-specific decannula- tion rates were 100% and 89%, respectively, for the early Setting: Tertiary care children’s hospital. single-stage group and 100% and 92% for the late group. Regarding the dsLTR group, overall and operation- Patients: Seventy-one patients underwent 84 proce- specific decannulation rates were 88% and 42%, respec- dures (22 ssLTRs and 62 dsLTRs). tively, for the early group and 95% and 79% for the late group. Among all groups, there was no significant differ- Intervention: Review of preoperative disease severity ence in overall decannulation rates (PϾ.05). Single- and surgical outcomes for patients who underwent ssLTR vs dsLTR. stage LTR offered an increased rate of operation-specific decannulation over dsLTR (PϽ.05). However, that dif- Main Outcome Measure: Operation-specific and over- ference was not significant between the late ssLTR and Ͼ all decannulation rates. the late dsLTR groups (P .05). Results: Regarding ssLTRs, the mean grade of subglot- Conclusion: Careful assessment of preoperative dis- tic stenosis was 2.1 and the overall and operation- ease severity and overall medical status will help sur- specific decannulation rates were 100% and 91%, geons choose between ssLTR and dsLTR, maximizing pa- respectively. The mean grade of subglottic stenosis for tient outcomes for both modalities. double-stage procedures was 2.9, and the overall and operation-specific decannulation rates were 93% and 68%, Arch Otolaryngol Head Neck Surg. 2010;136(1):60-65 ROM ITS EARLIEST DESCRIP- tage of ssLTR is immediate decannulation tions in the 1970s, expan- at the time of reconstruction (or avoid- sion laryngotracheal recon- ance of a tracheotomy altogether). This re- struction (LTR) with cartilage moves a potential source of infection and grafting was performed as a addresses the stoma site concurrent with F2-stage, or double-stage, procedure.1 By defi- LTR. In addition, prolonged stenting, with nition, in double-stage LTR (dsLTR), the tra- its potential complications, is also avoided. cheostomy tube is kept in place at the con- These advantages must be weighed against clusion of the procedure. If the procedure the potential for airway complications in the is successful, the patient is decannulated perioperative period and the complica- during a separate hospital admission, usu- tions that may result from prolonged ally several weeks or months later. In 1988, endotracheal intubation.11,12 Prescott2 presented perhaps the first de- Although good data regarding surgi- scription of single-stage LTR (ssLTR) when cal outcomes for ssLTR vs dsLTR remain he described the results of 5 children who elusive, a consensus has emerged in the had their tracheostomy tube removed at the literature regarding when to perform each time of LTR. Prescott2 advocated stenting procedure. Most researchers6,8,11 advo- with an endotracheal tube for approxi- cate dsLTR in children with complex mul- Author Affiliations: Division of mately 10 days postoperatively. Since then, tilevel stenosis, significant neurologic defi- Pediatric Otolaryngology, 3-10 The Children’s Hospital of multiple researchers have confirmed the cits, significant lung disease, or anatomy Philadelphia, Philadelphia, feasibility of ssLTR, outlining their results that makes reintubation technically diffi- Pennsylvania. and refining the indications. The advan- cult (craniofacial or vertebral anoma- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 1), JAN 2010 WWW.ARCHOTO.COM 60 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/03/2021 lies). There is also a trend toward performing dsLTR in patients with higher grades of stenosis (Cotton-Myer grade Table 1. Surgical Procedures III or IV),3,5,8 although we and others13-16 would advo- cate for partial cricotracheal resection (pCTR) in select Procedures, No. children with severe grade III or IV subglottic stenosis Type of Procedure (N=84) (SGS) whose disease is separated from the larynx by an ssLTR adequate margin. In this study, we attempt to carefully ACCG 16 APCCG 1 define our surgical results for ssLTR and dsLTR to help PCCG 3 surgeons choose between these surgical modalities. ATAG 1 AACG 1 METHODS Subtotal 22 dsLTR ACCG 8 Institutional review board approval was obtained to perform a APCCG 37 retrospective medical record review of all patients who under- PCCG 11 went LTR with cartilage grafting at a tertiary care children’s hos- ATAG 1 pital (The Children’s Hospital of Philadelphia) between Feb- ACCG-PCS 3 ruary 1, 2000, and April 15, 2008. All the operations were ACCG-PSS 2 performed by 1 of 2 senior surgeons (K.B.Z. or I.N.J.). Pa- Subtotal 62 tients who were treated endoscopically or who underwent cri- cotracheal or tracheal resection were excluded from this study. Abbreviations: A, anterior; ACG, auricular cartilage graft; CCG, costal In an effort to compare the outcomes for ssLTR vs dsLTR, de- cartilage graft; ds, double stage; LTR, laryngotracheal reconstruction; P, posterior; PCS, posterior cricoid split; PSS, posterior scar split (division of tails relating to preoperative disease severity and location, sur- scar tissue that had replaced the posterior cricoid); ss, single stage; gical procedure performed, stent type, and duration of stent- TAG, thyroid ala graft. ing or intubation were recorded. As previously defined by Hartnick et al,5 operation-specific and overall decannulation rates were recorded. Briefly, operation-specific decannulation performed (8 ssLTRs and 12 dsLTRs). Five patients who refers to the rate at which an open surgical procedure is asso- underwent revision had their first procedure performed at ciated with subsequent decannulation or extubation without another institution. One child was unavailable for fol- the need for further open airway surgery. The overall decan- low-up 3 months after reconstruction. This child was in nulation rate includes patients who subsequently receive an ad- the early dsLTR group and was considered a surgical fail- ditional open surgical reconstruction.5 The number of postop- ure (operation specific and overall). Three patients from erative endoscopic procedures and significant complications the late dsLTR group required major endoscopic proce- were also identified. dures before decannulation. Two patients required a car- A reconstruction was defined as single stage if the patient bon dioxide laser partial right arytenoidectomy, and one did not have a tracheostomy tube in place at the conclusion of the procedure. This included patients who had their tracheos- of them also received carbon dioxide laser treatment of the tomy tube removed at the time of surgery and patients who did lingual tonsils. One patient required multiple postopera- not have a tracheostomy tube present preoperatively. All pa- tive balloon dilations, with microdebrider removal of a por- tients who underwent ssLTR remained nasotracheally intu- tion of the anterior costal cartilage graft that had pro- bated after their procedure. Patients who underwent dsLTR had lapsed into the airway. These 3 patients were considered a tracheostomy tube present at the conclusion of their proce- operation-specific surgical successes. One patient was ex- dure. In all cases, these patients had a tracheostomy tube pre- cluded from the analysis. This child acutely lost her air- operatively. way and expired 1 day after dsLTR. Patients who underwent ssLTR and dsLTR were further sub- Two patients from the dsLTR group had a postopera- divided into early and late groups. In late 2003, we began in- tive pneumothorax (2.4%); one resulted from pleural in- serting and securing posterior grafts without sutures, as pre- viously described.17 Patients operated on before this technical jury at the rib graft harvest site and resolved without a advancement were included in the early group and after in the chest tube. The other patient had subcutaneous emphy- late group regardless of whether they had a posterior graft placed. sema and a pneumothorax identified on postoperative day All patients who underwent dsLTR in the early group had an 2 that required neck exploratory surgery with replace- Aboulker stent, and almost all (93%) in the late group had a ment of an extruded Penrose drain and a chest tube. Two cylindrical Silastic (Dow Corning Corp, Midland, Michigan) patients from the dsLTR group had significant postop- stent placed. As we previously described,18 this stent was fash- erative neck infections (2.4%). One of them required in- ioned by cutting one limb off of a Montgomery T-tube (Hood cision and drainage early in the postoperative period, and Laboratories, Pembroke, Massachusetts). Single-stage LTRs the other had resorption of an anterior costal cartilage and dsLTRs were otherwise performed similar to previous graft. Both of these patients failed their respective sur- descriptions.11 gical reconstructions, and one of them was decannulated after a revision procedure. The other patient remains de- RESULTS pendent on a tracheotomy tube 3 years postoperatively. One patient who underwent ssLTR required urgent rein- Eighty-four (22 single- and 62 double-stage) LTRs with car- tubation for symptomatic stridor 2 days after extubation. tilage grafting were performed on 71 patients during the This patient responded well to corticosteroid therapy and study (Table 1). Mean patient age at the time of surgery remains decannulated and asymptomatic 2 years after his was 51.6 months, and median age was 41 months (age LTR. The remainder of the patients who underwent ssLTR range, 5-212 months). Twenty revision procedures were had no significant complications. (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 1), JAN 2010 WWW.ARCHOTO.COM 61 ©2010 American Medical Association.
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