Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children

Abstract

ImportancePeristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. ObjectiveWe evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. MethodsThe medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. ResultsIn total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. ConclusionCombined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.