Laryngotracheal anastomosis: Primary and revised procedures

Objectives: Acquired upper airway stenosis is usually associated with a com plex of pathological conditions at the high tracheal and the subglottic lev els. Reported reconstructive techniques include widening by incorporation o f grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major ch allenge and has rarely been discussed in the literature. The purposes of th e present study are to compare the clinical course of primary versus revise d reconstructive procedures and to analyze the effect of age, diabetes, chr onic lung disease, grading of stenosis, extent of resection, and revised pr ocedures on the operative rate of success. Study Design: A cohort study in a tertiary referral medical center. Methods: The clinical course of 23 cons ecutive patients undergoing laryngotracheal anastomosis was studied compari ng a group of 13 primary with 10 revision procedures. Seventeen patients un derwent cricotracheal and six patients thyrotracheal anastomoses. Ad patien ts but one were tracheotomized before the definitive reconstructive procedu re. Supra-hyoid release was routinely performed except for two cases, and o nly one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postopera tive success (i.e., airway patency). Results: Twenty-two of 23 patients (95 .6%) had successful decannulation. Four patients required a revision proced ure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-act ivity exertion. There was no associated mortality. Complications included s ubcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had rev ision surgery. Age wits the only parameter that correlated nit h postoperat ive airway patency (P <.07), whereas the presence of chronic obstructive lu ng disease and diabetes, grade of stenosis, type of surgery, and revision s urgery were found to be insignificant. Conclusions: The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar i n our group of patients. The operation can be performed safety with an expe cted high rate of success and acceptable morbidity.