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Interact CardioVasc Thorac Surg 2008;7:227-230. doi:10.1510/icvts.2007.168054
© 2008 European Association of Cardio-Thoracic Surgery
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Institutional report - Thoracic general

Single-staged laryngotracheal resection and reconstruction for benign strictures in adults{star}

Giuseppe Marulli, Giovanna Rizzardi, Luigi Bortolotti, Monica Loy, Cristiano Breda, Abdel-Mohsen Hamad, Francesco Sartori and Federico Rea*

Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Via Giustiniani 2, 35128 Padova, Italy

Received 14 September 2007; received in revised form 20 December 2007; accepted 24 December 2007

{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.

*Corresponding author. Tel.: +39 049 8212237; fax: +39 049 8212249.

E-mail address: federico.rea{at}unipd.it (F. Rea).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Conference discussion
 References
 
Laryngotracheal stenosis (LTS) is a challenging problem, and its management is complex. This study evaluated both short- and long-term outcomes following laryngotracheal resection and anastomosis. Between 1994 and 2006, 37 patients underwent surgery for LTS. The cause of stenosis was post-intubation or post-tracheostomy injury in 28 cases and idiopathic in nine. Pearson's technique was used for anterolateral cricotracheal resection (n=23), and Grillo's technique of providing a posterior membranous tracheal flap was used in cases of circumferential stenosis (n=14). Since 1998, we have modified the techniques in 21 cases, using a continuous 4/0 polydioxanone suture for the posterior part of the anastomosis. No peri-operative mortality was recorded. Three (8.1%) patients developed major complications (two fistulae and one early stenosis) that required a second surgical look. We had 16 minor complications in 14 (37.8%) patients. The long-term results were excellent to satisfactory in 36 patients (97.3%) and unsatisfactory in one (2.7%). Single-staged laryngotracheal resection is a demanding operation, but can be performed successfully with acceptable morbidity in specialized centers. The continuous suture in the posterior part of the anastomosis simplifies the procedure without causing technique-related complications. In our experience, this procedure guaranteed excellent to satisfactory results in more than 90% of patients.

Key Words: Laryngotracheal stenosis; Tracheal surgery; Airway resection


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 Conference discussion
 References
 
Benign laryngotracheal stenosis (LTS) usually occurs as an acquired inflammatory complication following prolonged intubation and tracheostomy [1]. It causes considerable morbidity or a poor quality of life if untreated. Less frequent causes of benign LTS are radiation, Wegener's granulomatosis, inhalational injuries, and idiopathic causes. The peculiarity of the anatomical region involved, which contains delicate structures such as the vocal cords and recurrent laryngeal nerves, makes this disease difficult to manage.

Several treatment modalities have been used, ranging from less invasive procedures such as sequential airway dilatation, laser treatment, and stent placement to major airway surgical resection and reconstruction [2–4]. Although dilatation and laser treatment are safe, well-tolerated procedures, they usually provide only temporary improvement of symptoms, and recurrence is frequent, requiring repeated procedures without a definitive result.

In 1975, Pearson et al. [5] described the technique of anterolateral cricoid cartilage resection and primary thyrotracheal anastomosis with preservation of the recurrent laryngeal nerves. Subsequently, Grillo [6] proposed the use of a flap of posterior membranous trachea to cover the denuded surface of the posterior cricoid plate in the case of subglottic circumferential stenosis. Consequently, a surgical approach, although technically challenging, has become a widely used option owing to the good reported results.

Here, we report our experience with laryngotracheal resection and reconstruction for benign stenosis in adults.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 Conference discussion
 References
 
We retrospectively reviewed the charts of 37 patients who underwent surgical treatment for LTS between January 1994 and December 2006 at the Division of Thoracic Surgery, University Hospital of Padova, Italy. Table 1 presents the general characteristics of study population. Airway obstruction had been induced by prolonged intubation or long-term tracheostomy in 28 patients, and nine stenoses were idiopathic. One case was associated with a tracheo-esophageal fistula.


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  		Table 1 Characteristics of population

 
Thirty-three (89.2%) patients received one or more interventions preoperatively (all performed in other hospitals) for a total of 62 procedures.

To rate the severity of LTS the Myer–Cotton grading system [7] was used. It encompasses the following grades of stenosis: (1) 0–50% of obstruction; (2) 50–70%; (3) 70–99%; and (4) complete obstruction.

The preoperative assessment included a careful laryngotracheal endoscopic examination to rate the degree of stenosis, verify the grade of inflammation and edema of the subglottis and trachea, determine the integrity of the vocal cords, and measure the extent of laryngotracheal involvement.

Neck and chest computed tomography (CT) allowed assessment of the extent of stenosis and the remaining linear amount of normal airway and provided further information on the extraluminal region.

Laryngotracheal resection was performed following the basic surgical principles described by Grillo and Pearson. The details of our surgical technique have been described in a previous report [8]. A few technical points are presented here.

The primary anastomosis was performed with interrupted absorbable suture material for the membranous (4-0 Vicryl) and cartilaginous (3-0 Vicryl) parts. Since 1998, we have used a running 4-0 polydioxanone (PDS; Ethicon, Somerville, NJ) suture for the posterior membranous wall, taking only a few stitches to approximate the posterior membranous flap to the healthy laryngeal mucosa. The two ends were tied with the sutures at the cartilaginous–membranous angles.

A chin stitch was placed in all patients to prevent cervical hyperextension and was removed on the seventh postoperative day.

The patients were extubated within 24 h postoperatively and were kept under observation for 48 h in the intensive care unit. However, patients who had received a procedure high in the upper thorax were kept intubated for 48–72 h, because they were more susceptible to developing laryngeal edema. The criteria for extubation were based on the patency of the airway, bilateral recurrent laryngeal nerve function, and absence of laryngeal edema. Before extubation, the patients underwent fiberoptic bronchoscopy to remove any retained secretions and blood.

To reduce the risk of laryngeal edema, post-extubation management included elevating the head of the bed, limiting the use of the voice, and administering aerosolized corticosteroids and racemic epinephrine.

Surgical outcome measures, including subsequent required procedures, postoperative decannulation, speech and swallowing functions, complications, and mortality, were evaluated.

Postoperative follow-up included clinical evaluation and tracheoscopy at 1, 3 and 6 months postoperatively and when indicated after that.

The long-term outcome was classified as excellent, satisfactory, or unsatisfactory. A minimum follow-up of six months was required, and the follow-up period ranged from 7 months to 13 years (median, 6.5 years).


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 Conference discussion
 References
 
At the time of surgery, 13 (35.1%) patients had tracheostomy cannula in place.

Twenty-three patients underwent resection of the anterolateral cricoid. Fourteen of these patients with circumferential cricoid involvement underwent anterolateral resection of the cricoid cartilage and resection of the mucosa covering the posterior plate, with advancement of a posterior membranous tracheal flap. A continuous posterior suture was performed in 21 patients.

The surgical resection extended from 1.5 to 5.1 cm (median, 2.5 cm); the median number of tracheal rings removed was four (range, 1–8). Three patients, at the beginning of our experience, had a protecting tracheostomy performed on completion of the operation. One patient with post-tracheostomy stenosis underwent a long tracheal resection (5 cm) and needed a suprahyoid laryngeal release to reduce the tension at the level of the anastomosis.

In Table 2 are summarized surgical and functional results in the early and late postoperative period.


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  		Table 2 Short- and long-term results

 
No intra- or peri-operative mortality occurred. Major peri-operative complications were recorded in three (8.1%) patients: in one case, a suture dehiscence in the anterior face of the anastomosis required surgical debridement and temporary Montgomery T-tube insertion; and in another case, a small lateral dehiscence was treated with revision of the anastomosis. A third patient developed acute dyspnea and stridor on the fifth postoperative day because of airway occlusion resulting from glottic and laryngeal edema after a high surgical procedure. A protecting tracheostomy was necessary to allow time for the edema to resolve.

Fourteen (37.8%) patients had one or more minor complications. Idiopathic LTS had a high rate of complications (66.6%), which were mostly minor (83.3%).

At long-term follow-up, one (2.7%) patient had an unsatisfactory result. This patient had idiopathic LTS who needed a postoperative protecting tracheostomy after laryngeal edema. After decannulation we diagnosed a restenosis that caused dyspnea during ordinary activity. The patient underwent frequent laser ablations and dilatations, but at the last follow-up there was a stenosis of about 40% with severe hoarseness, reduction of volume of voice and episodic dyspnea.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
Conference discussion
 References
 
The management of benign LTS remains a challenge, often requiring a multidisciplinary approach by well-trained personnel. The various treatments proposed for LTS, including endoscopic dilatation, laser ablation, and cryosurgery, temporarily relieve the airway stenosis and associated respiratory distress, but repeated procedures are usually needed to treat frequent recurrences. Tracheostomy or prolonged stenting are not helpful and can extend the damaged area, making surgical repair more difficult [8, 9].

Many otolaryngologists used various techniques of laryngeal reconstruction, however, procedures that do not remove the diseased segment of the subglottis or trachea are associated with variable and unpredictable outcome [10].

To date, laryngotracheal resection with primary end-to-end anastomosis, offering a chance for immediate decannulation in a one-step procedure, is the preferred treatment modality. Although the excellent long-term results of tracheal surgery are well established [1], only a few centers have experience in laryngotracheal surgery.

Post-intubation/tracheostomy injury is the leading cause of LTS. Inflammatory stimuli affecting the mucosa and submucosa of the subglottis and trachea lead to thickening and scarring of the epithelium and submucosa, producing stenosis.

Idiopathic LTS is a rare condition of unknown cause characterized by an inflammatory cicatricial stenosis at the level of the cricoid and upper trachea. It occurs almost exclusively in women between the third and fifth decades of life. There is no consensus on the surgical indications for idiopathic LTS. Some authors [11] consider it a progressive disease that should be treated indefinitely with palliative procedures, although recent studies [12] reported good outcomes after surgery, with low or no recurrence. Nevertheless, the experience of the team, the accurate selection of patients suitable for resection and reconstruction, and the optimal timing of the surgical approach seem to be the factors that determine the results.

In our series, nine patients had idiopathic LTS. Although the rate of complications was high (66.6%), the majority were minor complications such as anastomotic edema or temporary vocal cord dysfunction as a result of a surgical procedure in the upper larynx.

Preoperative assessment is a crucial step in the surgical management of LTS. The precise definition of the injury in the subglottic area, the length of the stenosis, the degree of tracheal involvement, and the presence of active inflammation or edema should be evaluated carefully, and surgery should be delayed to allow time for the inflammation to regress and the stenosis to stabilize.

In our opinion, laryngotracheal endoscopy is the cornerstone in the preoperative setting. Spiral CT with 1- to 1.5-mm sections enables multiplanar reconstruction of the airway and gives information about the relation of the stenosis with the extraluminal structures, but does not provide information about inflammatory status or laryngeal function.

Regarding the surgical technique, a meticulous dissection preserving the tracheal blood supply and recurrent laryngeal nerves and avoiding excessive anastomotic tension are the main principles. To reconstruct the airway, we adopted the principles of the techniques of laryngotracheal anastomosis described by Pearson et al. [5] and Grillo [6]. These have been modified since 1998 by introducing the use of a running suture with 4/0 PDS for the posterior wall of the laryngotracheal anastomosis. This modification has simplified the anastomotic technique as it avoids extensive dissection to create more space for applying knots outside the laryngeal lumen and eliminates the need for knots inside the laryngeal lumen. No increase in the anastomotic complication rate has been noted with this technique.

Pearson et al. [5] considers advantageous the subperichondrial resection of the cricoid cartilage as it is less bloody and provides substantial tissue to secure the upper side of the anterior anastomosis when the anastomosis is not performed directly to the inferior border of the thyroid cartilage, but with the cricothyroid membrane.

We did not use this technique and we did not face problems intraoperatively regarding bleeding or suture technique. Moreover, we needed to resect part of the posterior cricoid plate only in one patient as the diameter of airway at the site of anastomosis was adequate in all the other cases. Preserving the posterior plate of the cricoid is of paramount importance for stability of the larynx.

It is difficult to compare the results of reported experiences, because there is no standardized definition of the success or failure rate and of the major and minor complications after surgery.

In our experience, major anastomotic complications occurred in 8.1% of our cases, with a 5.4% rate of partial anastomotic dehiscence. Macchiarini et al. [13], Wright et al. [9], Ciccone et al. [2] and Amoros et al. [14], reported anastomotic problems in 4, 11.7 and 14.2% of their cases, respectively.

Another dangerous complication that can develop during the peri-operative period is anastomotic edema, which is more frequent in laryngotracheal resection and reconstruction, especially when an anastomosis is performed close to the vocal cords. Ashiku et al. [12] reported two cases (2.7%) of postoperative glottic and laryngeal edema requiring protective tracheostomy, out of 73 laryngotracheal resections and anastomoses for idiopathic LTS. We had one patient (2.7%) who developed serious laryngeal edema five days after surgery. Maneuvers to limit or prevent postoperative laryngeal edema, such as reducing fluid administration, elevating the head of the bed, using racemic epinephrine or aerosolized corticosteroids, and limiting the use of the voice in the immediate postoperative period, are standard practices for us.

Our functional results were remarkable and in accordance with the best reported results (Table 3), with an excellent to satisfactory outcome in a high percentage (97.3%) of patients. These patients returned to a normal life and, despite the partial laryngeal resection, did not show marked changes in their voice characteristics, with a slight deepening of the tone of voice, a reduced maximum volume, or a slight hoarseness being the most common findings.


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  		Table 3 Long-term functional results after laryngotracheal resection and anastomosis in larger reported experiences

 
In conclusion, the high success rate and good functional results of single-staged laryngotracheal resection with primary end-to-end anastomosis make this an effective and reliable approach for the management of benign LTS, keeping in mind that meticulous preoperative assessment and selection of patients, an experienced and skillful surgical team, and careful postoperative management are mandatory to avoid disastrous complications.


   Conference discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Conference discussion
References
 
Dr. R. Santosham (Chennai, India): Just two points I want to clarify. In your presentation you said that 23 patients were laserized preoperatively. In our observation in India what we have seen is once the laser is used, the wall of the trachea gets much thicker and calcified. And did you have that in those patients with preoperative laser?

Dr. Marulli: We didn't find in this observation, but usually after laser the amount that is scarred is increased.

Dr. Santosham: The second point is about your continuous suture in the posterior wall. What we have found is sometimes there is a disparity in the upper and the lower area. In such a situation we find that the use of interrupted sutures helps much more than continuous sutures. Because we have a good vascularity. When you do a continuous suture, you are interfering with the wall of the trachea, the blood supply of the edge of the trachea, that has been our observation. And we have learned all these techniques. We have had a very high incidence in India because of the red rubber tubes, and we have learned all these techniques from Dr. Grillo and Dr. Mathisen, and what has been your observation? This is my observation about the continuous suture in the posterior wall.

Dr. Marulli: We didn't find a problem in the cases in which we had a difference in caliber. Usually you can put easily continuous suture by using a few stitches and you can adapt the anterolateral anastomosis to have a good anastomosis.

Dr. J. Anton-Pacheco (Madrid, Spain): How do you deal with granulation tissue in the postoperative course? Do you dilate? Do you put a stent?

Dr. Marulli: We treat the granulation tissue with the laser. We didn't have granulation with the stenosis, but only small granulation that we treated successfully with the laser.

Dr. W. Klepetko (Vienna, Austria): I want to ask you whether you have excluded cases with a more proximal narrowing of the airway. Those cases where you find the narrowing also in the cricoid area, because in our experience we had three patients where we had to add to the resection procedure with a cricoid or with an anterior splint to the thyroid and an enlargement by bringing in the distal trachea in a V-shaped fashion.

So, did you by purpose exclude those cases, or did you just by chance not observe those cases?

Dr. Marulli: We had one case in which we used the same technique, but no other experience.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 Conference discussion
 References
 

  1. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486–493.[Abstract/Free Full Text]
  2. Ciccone AM, De Giacomo T, Venuta F, Ibrahim M, Diso D, Coloni GF, Rendina EA. Operative and non-operative treatment of benign subglottic laryngotracheal stenosis. Eur J Cardiothorac Surg 2004;26:818–822.[Abstract/Free Full Text]
  3. Macchiarini P, Chapelier A, Lenot B, Cerrina J, Dartevelle P. Laryngotracheal resection and reconstruction for post-intubation subglottic stenosis. Eur J Cardiothorac Surg 1993;7:300–305.[Abstract]
  4. Pearson FG, Brito-Filomeno L, Cooper JD. Experience with partial cricoid resection and thyrotracheal anastomosis. Ann Otol Rhinol Laryngol 1986;95:582–585.[Medline]
  5. Pearson FG, Cooper JD, Nelems JM, Van Nostrand AWP. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;70:806–816.[Abstract]
  6. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33:3–18.[Abstract]
  7. Myer CM, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol 1994;103:319–323.[Medline]
  8. Rea F, Callegaro D, Loy M, Zuin A, Narne S, Gobbi T, Grapeggia M, Sartori F. Benign tracheal and laryngotracheal stenosis: surgical treatment and results. Eur J Cardiothorac Surg 2002;22:352–356.[Abstract/Free Full Text]
  9. Wright CD, Grillo HC, Wain JC, Wong DR, Donahue DM, Gaissert HA, Mathisen DJ. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128:731–739.[Abstract/Free Full Text]
  10. Koltai PJ, Ellis B, Chan J, Calabro A. Anterior and posterior cartilage graft dimensions in successful laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg 2006;132:631–634.[Abstract/Free Full Text]
  11. Dedo HH, Catten MD. Idiopathic progressive subglottic stenosis: finding and treatment in 52 patients. Ann Otol Rhinol Laryngol 2000;110:305–311.
  12. Ashiku SK, Kuzucu A, Grillo HC, Wright CD, Wain JC, Lo B, Mathisen DJ. Idiopathic laryngotracheal stenosis: effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 2004;127:99–107.[Abstract/Free Full Text]
  13. Macchiarini P, Verhoye JP, Chapelier A, Fadel E, Dartevelle P. Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis. J Thorac Cardiovasc Surg 2001;121:68–76.[CrossRef][Medline]
  14. Amorós JM, Ramos R, Villalonga R, Morera R, Ferrer G, Díaz P. Tracheal and cricotracheal resection for laryngotracheal stenosis: experience in 54 consecutive cases. Eur J Cardiothorac Surg 2006;29:35–39.[Abstract/Free Full Text]
  15. Grillo HC, Mathisen DJ, Wain JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 1992;53:54–63.[Abstract]




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