Pitfalls in laryngotracheal reconstruction

Objective: To determine the causes of laryngotracheal reconstruction (LTR) failures. Design: Retrospective chart review. Setting: Tertiary care children's hospital. Patients: Seventeen pediatric patients who underwent revision LTR from Octo ber 1, 1986, to December 31, 1998. Intervention: Laryngotracheal reconstruction. Main Outcome Measure: Decannulation. Results: Seventeen patients required a total of 42 LTRs for decannulation. There were 17 primary LTRs and 25 revision LTRs. The primary LTRs were done either at our or other institutions. Two patients died after initial LTR f ailed, one because of tracheotomy tube plugging and the other because of a severe respiratory syncytial virus pneumonia. All 15 remaining patients hav e been decannulated. There were 27 failed LTRs with 17 being primary and 10 revision LTR failures. In 3 of the 27 failed procedures, no obvious causes for failure could be found. In the remaining 24 procedures, 1 or more fact ors that contributed to LTR failure could be found. Poor preoperative evalu ation with subsequent failure to address the airway lesion was seen in 6 pr ocedures. Intraoperative reasons for LTR failure included inappropriate cho ice of graft in 2 procedures; inappropriate stent in 7; inappropriate stent length in 1; and inappropriate duration of stent in 8. In 6 procedures, th e airway abnormalities identified at endoscopy were not adequately addresse d at LTR. Postoperative factors for failure were poor follow-up in 2, anter ior suprastomal collapse in 2, and slipped or broken stent in 2. Other fact ors that contributed to LTR failures included intractable gastroesophageal reflux disease in 1 procedure and keloid formation in 5. Conclusions: Although some LTRs may fail secondary to factors that are not under the surgeon's control, many LTR failures can be avoided by accurate p reoperative and intraoperative assessment of the stenosis, correct choice o f surgical procedure, and close postoperative monitoring.