Double-stage Laryngotracheal Reconstruction Research Articles

Factors affecting graft healing in laryngotracheal reconstruction: a retrospective single-center experience.

To examine the factors that affect graft healing after laryngotracheal reconstruction (LTR). We conducted a retrospective chart review at King Abdulaziz University Hospital, Riyadh, Saudi Arabia, between January-2008 and October-2023. We included all patients who underwent LTR and required anterior and/or posterior graft placement, while those who underwent procedures without graft placement and those with incomplete information were excluded. Forty-nine patients were analyzed. Most patients were pediatric (65.3%), male (65.3%), had no coexisting comorbidities (55.1%), and harbored grade 3-4 stenosis (59.2%). Thirty patients (61.2%) underwent open surgery. Various graft complications occurred including infection (n = 1, 2%), dehiscence (n = 3, 6.1%), scar (n = 6, 12.2%), and granulation (n = 29, 59.2%). Only 15 patients (30.65%) achieved the composite status of "healthy" graft. Among 43 patients who had postoperative cultures, positive results for Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were observed in 10 and four patients, respectively. Open surgery and double-stage procedure were significantly associated with higher rates of granulation tissue formation. Pediatric-age group had significantly higher rate of complete epithelization compared to adult-age group. A significantly greater proportion of patients who had unhealthy grafts had open surgery. The rate of double-stage LTR was significantly higher in unhealthy grafts compared to healthy grafts. Prolonged stent duration was linked to various graft-related complications. Multivariate logistic regression analyses showed no statistically significant correlations between various factors and postoperative graft-related complications. Open surgery, double-stage procedure, pediatric age group, and stent duration were not significant risk factors associated with postoperative graft-related complications during LTR in multivariate analysis.

The surgical treatment of acquired subglottic stenosis in children with double-stage laryngotracheal reconstruction

The aim of this study is to report our experience with double-stage laryngotracheal reconstruction with anterior or antero-posterior cartilage grafting in the management of acquired laryngotracheal stenosis in children. Patients were treated by the same surgeon at the UMC National Research Center for Maternal and Child Health of Astana (Kazakhstan), and Sfendiyarov Kazakh National Medical University, Almaty (Kazakhstan). From November 2011 to September 2019, 9 children underwent surgery for grade III and IV laryngotracheal stenosis according to the European Laryngological Society classification (mean age of 6 years, range of 2-12 years). Six patients underwent double-stage laryngotracheal reconstruction with anterior and posterior cartilage graft, and 3 patients underwent double-stage laryngotracheal reconstruction with single anterior cartilage graft. In all patients, a T-tube was used to stabilize the airway (mean time of 5.8 months, range of 5-9 months). One patient required additional dilation with bougies to obtain a viable laryngotracheal diameter. No postoperative complications were observed. One patient experienced recurrence of the stenosis 5 months after double-stage laryngotracheal reconstruction with double anterior and posterior cartilage grafts and is waiting for revision surgery. After a mean follow-up of 14 months (range of 4-36 months), 8 patients are tracheostomy-free, and all patients are feeding tube-free. Double-stage laryngotracheal reconstruction with a single or double cartilage grafting represents a safe and effective option in the management of complete or severe laryngotracheal stenosis.

Estimating perioperative outcomes after pediatric laryngotracheal reconstruction surgery in accordance with ACS-NSQIP-P reporting

The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P) database monitors quality outcomes in pediatric surgery. However, the registry might underreport low-volume procedures. This review describes complications after laryngotracheal reconstruction (LTR) based on ACS-NSQIP-P reporting standards. A case series with chart review at a tertiary children's hospital included consecutive LTR procedures between 2010 and 2018. Surgical procedures were grouped into single- or double-stage for comparison of thirty-day complication rates. Eighty-four procedures were reviewed with 70% (59/84) double-stage and 30% (25/84) single-stage. Children requiring double-stage procedures were younger (3.3vs. 6.0 years, P= .002) and more often Black or African American (51% vs. 24%, P=.03). Double-stage LTR was frequently performed on children with grade 3 or 4 subglottic stenosis (90% vs. 52%, P < 001), with a tracheostomy (97% vs. 68%, P= .001) and with gastroesophageal reflux disease (93% vs. 67%, P=.004). Airway-related complications occurred in 19% (16/84) of children and non-airway complications occurred in 16% (13/84) with similar rates between groups. Unplanned reintubation (20% vs. 0%, P= .002), ventilator support longer than 48hours (12% vs. 0%, P=.02), and total hospitalization lengths (15.6vs. 6.5 days, P< .001) were increased after single-stage LTR. Children with non-airway complications had more central nervous system disorders (46% vs. 10%, P= .004). Postoperative complications after pediatric LTR occur in nearly 20% of children and single-stage procedures have higher unplanned reintubations, prolonged ventilator support and hospitalization lengths. Surgeons should recognize that these typically minor events should be consistently monitored and reported after surgical expansion of the pediatric airway. IV.

Complications and outcomes following open laryngotracheal reconstruction: A 15 year experience at an Australian paediatric tertiary referral centre

To report on our experience with open pediatric laryngotracheal reconstruction (LTR) with cartilage interposition grafts over the past 15 years and document setbacks and factors that affect postoperative outcomes. A retrospective chart review was performed on all pediatric patients who underwent single and double-stage LTR at The Children's Hospital in Westmead between August 2004 and July 2019. The outcomes measured include the overall decannulation rate, rates of postoperative complications, need for subsequent procedures and postoperative functional results (dyspnea, stridor, voice impairment). Between August 2004 and July 2019, a total of 51 open LTRs were performed on 46 patients, with mean age 3.9 years (range 1 month to 12.1 years), including 11 revision operations (11.8%). The most common indication for surgery was subglottic stenosis, followed by bilateral vocal cord motion impairment followed by anterior glottic web. 13 cases (25.5%) were complicated by ventilator associated pneumonia in the postoperative period and 11 patients (21.6%) experienced wound complications ranging from localised wound abscess to wound dehiscence and graft failure. Patients with viral infections had an increased risk of wound dehiscence and graft failure (OR 1.8, 95% CI 1.01 - 3.23). Patients with a greater decrease in albumin in the postoperative period were more likely to have wound complications (OR 1.8; 95% CI 1.17 -2.83). Ten patients failed extubation and required a subsequent tracheostomy. Severity of stenosis, age at time of surgery, history of prematurity and revision LTR were not predictors for need for reintubation and/or tracheostomy after surgery. 23 cases (45.1%) underwent subsequent endoscopic procedures such a balloon dilatation to manage restenosis following LTR. Though 45.7% had a very good outcome, a significant group of 21% had ongoing voice issues. Good outcomes were achieved following open LTR for pediatric laryngotracheal stenosis despite postoperative complications. At final follow up, 33 patients (71.7%) had good exercise tolerance with no or mild stridor. Forty-one of the forty-six patients (89.1%) were successfully decannulated.

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction.

Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction. A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019. A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy (P = .86), age at decannulation (P = .97), duration of tracheostomy (P = .43), or gestational age (P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter (P = .02) and stent size (P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up. Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making.

The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.

Double Stage Laryngotracheal Reconstruction with Anterior and Posterior Rib Graft

Double Stage Laryngotracheal Reconstruction with Anterior and Posterior Rib Graft

Systematic review/meta-analysis comparing successful outcomes after single vs. double-stage laryngotracheal reconstruction

To compare operation-specific decannulation rates between single-stage (SSLTR) and double-stage laryngotracheal reconstruction (DSLTR) when controlling for grade of airway stenosis. A systematic review and meta-analysis were performed using PubMed, EMBASE and Cochrane databases from 1970 to 2015 to examine primary SSLTR and DSLTR for subglottic stenosis in patients 18 years or younger. Primary outcome was decannulation or extubation after LTR. Failures included patients not decannulated or requiring additional open airway procedures prior to decannulation. Only studies providing outcomes delineated by airway stenosis grade were included. Non-English language studies and case reports were excluded. There were 712 abstracts reviewed and 16 studies with 663 pooled patients included in the systematic review analysis. The metaanalysis included 5 studies. Overall, the operation-specific decannulation success was statistically significantly different between SSLTR [93.2% (N = 221)] and DSLTR [83.7% (N = 442)] (P<0.001). When controlling for stenosis severity, however, no difference was found in decannulation success between SS- or DSLTR except in the grade 3 group: Grade 1-100% (N = 6) vs. 100% (N = 6), (P = 1); Grade 2 - 84.9% (N = 106) vs. 83.3% (N = 138), (P = 0.72); Grade 3-80.2% (N = 101) vs. 69.7% (N = 238), (P = 0.03); Grade 4-33.3% (N = 6) vs. 50% (N = 58), (P = 0.67). No difference in decannulation rates was seen between SSLTR and DSLTR when comparing similar grades of stenosis except in grade 3 stenosis. With worsening stenosis, the success rate declines with both methods. Prospective studies with standardized enrollment criteria and reported outcomes are needed to better understand the advantages and disadvantages of each approach.

Short- versus Long-term Stenting in Children with Subglottic Stenosis Undergoing Laryngotracheal Reconstruction.

Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term ( P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents ( P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single‐ and Double‐Stage Laryngotracheal Reconstruction

(1) To describe outcomes from and modifications to the hybrid laryngotracheal reconstruction (LTR) technique and (2) to compare this technique to traditional single- and double-stage LTR (ssLTR/dsLTR). Chart review with case series. Tertiary care otolaryngology specialty hospital. All patients under 18 years of age who underwent LTR by a single surgeon from July 1, 2009, to December 31, 2013. Charts were assessed for age, gender, etiology of stenosis, type of reconstruction, comorbidities, length of stay, complications, and tracheostomy status. Analysis was performed using Kruskal-Wallis and Wilcoxon rank sum analysis. Forty-four patients were identified, with 13 hybrid LTRs, 27 ssLTRs, and 4 dsLTRs. Of the hybrid LTRs, an overall decannulation rate of 76.9% was noted, comparable to those for dsLTR. The hybrid LTR technique offered a significantly shorter period of narcotic use when compared to ssLTR (median 15 vs 21 days, P<.01). No patients in the hybrid LTR group developed supraglottic granulation tissue. There was no statistically significant difference in median length of stay for ssLTRs, dsLTRs, and hybrid LTRs (P=.38). The hybrid LTR technique is well tolerated and useful in patients of all ages. Narcotics can be weaned more quickly due to the presence of a secure airway at all times via the existing tracheostomy. Use of a long stent prevents formation of granulation tissue that may be seen with a suprastomal stent. This technique should be considered in patients with high-grade stenosis with a preexisting tracheostomy.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single and Double‐Stage Laryngotracheal Reconstruction

Objectives: (1) Describe outcomes from and modifications to the hybrid, also known as the one-and-a-half stage, laryngotracheal reconstruction (LTR) technique. (2) Compare this technique to traditional single and double-stage LTR (ssLTR/dsLTR). Methods: Retrospective review of patients under 18 years of age who underwent LTR by a single surgeon at a tertiary care otolaryngology specialty hospital from July 1, 2009, to December 31, 2013, was performed. Charts were assessed for age, sex, etiology of stenosis, type of reconstruction, comorbidities, length of stay, complications, and tracheostomy status. Results: Forty-four patients were identified, with 13 one-and-a-half stage LTRs, 27 ssLTRs, and 4 dsLTRs. Of the one-and-a-half stage LTRs, an operation-specific decannulation rate of 77% was noted, comparable with those for ssLTR and dsLTR. The one-and-a-half stage LTR technique offered a significantly shorter period of narcotic use when compared with ssLTR (16 vs 23 days, P &lt; .01). Average length of stay for ssLTRs and hybrid LTRs was identical at 16 days; difference in length of stay between hybrid and dsLTRs was not statistically significant (16 vs 12.5 days, P = .16). Conclusions: The hybrid LTR technique is well-tolerated and useful in patients of all ages. Narcotics are able to be weaned more quickly because of the presence of a secure airway at all times via the existing tracheostomy. Use of a long stent prevents formation of granulation tissue that may be seen with a suprastomal stent. This technique should be considered in patients with high-grade stenosis with a pre-existing tracheostomy.

Laryngotracheal reconstruction in children with subglottic stenosis

To study the effect of laryngotracheal reconstruction (LTR) in children with subglottic stenosis (SGS), and to discuss the indications and the risks of intraoperative and postoperative treatment of LTR. From September 2008 to February 2010, 5 children (4 girls and 1 boy, aged 4 to 6 years) were treated by LTR. Among the 5 children, there were 2 congenital SGS and 3 acquired SGS. One had mild grade III SGS, 3 had severe grade III SGS, and one had grade IV SGS. One child with mild III SGS was treated by single-stage LTR, and the rest four children were treated by double-stage LTR. The surgical technique consisted of cricoid lamina midline vertical incision, rib cartilage graft interposition and endotracheal tube (ETT) stenting for 2 to 3 weeks. Four children with grade III SGS were de-cannulated 3 months after operation, and the child with grade IV SGS got de-cannulated 6 months after operation. Of all children, rib cartilage graft grower well, and the size of subglottis were amplified by grade III SGS to grade I SGS, and grade IV SGS to grade II SGS. All children obtained stable airway. One child with grade IV SGS who had hoarseness got effective phonation during follow-up 2 years after operation. LTR is a safe and effective treatment for pediatric subglottic stenosis. The important factors of successful operation are correct assessment and evaluation of the severity and overall medical status and selection of suitable surgical techniques.

Laryngotracheal reconstruction with resorbable microplate buttressing

In patients undergoing laryngotracheal reconstruction (LTR), malacic segments of trachea can pose challenges to successful reconstruction. Malacic segments may inadequately support cartilage grafts used in augmentation surgery, sometimes requiring cricotracheal or tracheal resections. We describe a novel technique of LTR with resorbable microplate buttressing of malacic lateral tracheal segments. Retrospective case series. Review of technique, treatment outcomes, and complications of seven children with subglottic stenosis and tracheomalacia requiring a microplate-augmented LTR technique. Seven infants ranging from 26 months to 9 years of age successfully underwent LTR for subglottic stenosis. Six children had a grade III subglottic stenosis. The seventh child had grade II subglottic stenosis, bilateral vocal fold paralysis, an elliptical cricoid, and an obstructing giant suprastomal fibroma. Five children underwent a double-stage LTR with resorbable microplates sutured bilaterally to support severely malacic lateral tracheal segments. A cricotracheal resection would not have been feasible in one child due to the resection length and inadequate tracheal mobilization. Two children underwent a single-stage LTR with unilateral application of a microplate. Six children were decannulated within 3 months and continue without airway symptoms or complications. One child, who is just over 2 months from reconstructive surgery, is being setup for decannulation. No complications were encountered. LTR with resorbable microplate buttressing of malacic lateral tracheal segments is technically feasible, safe, and can avoid more extensive surgery requiring tracheal resection. Further experience may support the use of this technique in challenging airway reconstructions.

Surgery for Pediatric Subglottic Stenosis: Disease-Specific Outcomes

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care children's hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (chi2 analysis, p = .0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (chi2 analysis, p = .04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (chi2 analysis, p = .63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (chi2 analysis, p = .03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.