Estenosis laringotraqueales: Resección y reconstrucción primaria

Abstract

A review is made of patients with stenosis involving the larynx and trachea, treated in the thoracic surgery service of the Hospital de San Jose with resection and reconstruction techniques with primary anastomosis, during the period between 1996 and 2005. The histories were reviewed Clinical data and the information collected retrospectively were recorded in a database with: sex, age, origin, cause of the stenosis, location, severity, length, previous interventions related to the current problem, history of intubation, cause and duration of the same, time elapsed between extubation and the appearance of stenosis, stay in the ICU, history of tracheostomy, symptoms, management of acute airway obstruction, diagnostic images, endoscopic findings, surgical procedure performed, mortality, complications, time of hospitalization and functional results. Thirty patients, 16 men and 14 women were intervened. The age range varied between 12 and 80 years, with an average of 44. Twenty-seven patients had stenosis after intubation (25 orotracheal and 2 tracheostomy). The symptoms of obstruction occurred between 30 and 90 days after the procedure and the duration ranged between 3 and 45 days. In one patient an idiopathic stenosis was diagnosed, in another an inflammatory pseudotumor of the body of the trachea and in a third after trauma by firearm. In eight the narrowness compromised the laryngotracheal region, four in the subglottic space and four in the glottic in the posterior commissure. Seven of them secondary to orotracheal intubation and one idiopathic. In 22 patients it was located in the body of the trachea. The length of the narrow segment varied between 2 and 6 cm. The severity of the obstruction ranged between 70% and 90%. In two cases there was a combination of stenosis and tracheomalacia. The symptoms consisted of dyspnea of ​​effort and laryngeal stridor. There was acute obstruction of the airway in 18 and it was treated with tracheostomy in 16 and dilatations in two. Twelve patients had a tracheostomy tube when they visited the hospital. Three patients had undergone different procedures of resection and reconstruction in other institutions. In all cases, laryngeal and trachea CT and fibrobronchoscopy were performed. Three brought magnetic nuclear resonance at the time they were first evaluated in our service. Two patients were assessed in other institutions with linear tomography. In 14 patients with a clinical picture of airway obstruction, a volume flow curve was performed that showed a pattern of fixed obstruction of the upper airway. They were studied with arterial gases that showed mild to severe hypoxemia in ten and retention of CO in five. All the patients underwent resection and reconstruction by end-to-end anastomosis of the airway. In 26, a cervical approach was made and four required a combined cervical and sternal approach. In four patients with subglottic stenosis, resections were made of the anterior plate of the cartilage and the diseased mucosa, covering the defect with a membranous tracheal flap and anastomosis between the thyroid cartilage and the trachea. In one a tracheostomy cannula was left; in another, a plastic T tube was placed as a mold, which was maintained for seven months. The others were extubated at the end of the procedure. Four patients who presented lesions that compromised the glottis required a complex reconstruction consisting of a laryngofisura and resection of the entire anterior portion of the cricoid cartilage. In two, one T-tube was left for six months and in another a temporary tracheostomy cannula was placed. Twenty-two with stenosis of the body of the trachea were treated with resection and primary anastomosis of trachea segments whose length varied between 3 and 6 cm. Fifteen with resections larger than 3 cm required laryngeal release maneuvers. Three with stenosis greater than 5 cm required a median sternotomy for mobilization of the pulmonary hilum. In a patient with stenosis and tracheomalacia caused by compression by a goiter, the procedure was combined with a total thyroidectomy. One patient presented a new obstruction after the resection of a subglottic stenosis and was reoperated at six months. Hospitalization time varied between 8 and 20 days with an average of 9. There were two deaths due to tracheal fistulas with massive hemorrhage and seven complications in 30 resection and reconstruction procedures. The results obtained in 26 patients were excellent, with restoration of patency of the airway and recovery of the normal voice. To the extent that surgical reconstruction techniques have been perfected and experience with them is greater, We are increasingly convinced that resection and early reconstruction of these lesions is widely justified and that conservative treatment does not represent an appropriate alternative. Abbreviations: ICU, intensive care unit; CT scan, computerized axial tomography.