LTR 13 Abridged

REVISION
PEDIATRIC LARYNGOTRACHEAL
SURGERY
Upon completion of this course, participants will be
able to:
1) Understand factors and pitfalls which contribute to
failure in pediatric laryngotracheal reconstruction
2) Delineate patient selection and surgical timing criteria
for revision pediatric laryngotracheal reconstruction
3) Be familiar with revision surgical techniques which are
specifically tailored to difficult cases
GEORGE H. ZALZAL M.D. FACS, FAAP.
DIEGO PRECIADO M.D. Ph.D.
CHILDREN’S NATIONAL MEDICAL CENTER
WASHINGTON D.C.
GEORGE WASHINGTON UNIVERSITY
HIGH RATE OF SUCCESS
NOT A SINGLE UNIFORM PROCEDURE
– SEVERITY, LENGTH AND SITE OF
STENOSIS DETERMINE PROCEDURE
REVISION/DIFFICULT
AIRWAY CASES
DECANULATION
95.24%
Published material - please refrain from copying
OUTCOME
RECONSTRUCTIVE SURGERY
EDUCATIONAL OBJECTIVES
DEAD
FAIL
LATE FAILURE
TRACH DEATH
DECANULATED
PATHOLOGIES THAT ARE ASSOCIATED
WITH FAILED LTR
– SUPRAGLOTTIC STENOSIS
– LARYNGEAL ATRESIA
– POSTERIOR GLOTTIC STENOSIS
– GRADE III/GRADE IV SUBGLOTTIC
STENOSIS
– COMBINED LESIONS
» ZALZAL:1993,1996,1997,1999,2000
GENERAL PRINCIPLES
GENERAL PRINCIPLES
EXPANSION SURGERY
GRADES 1,2,3,SOME 4
GRADE 4
– CRICOTRACHEAL RESECTION
– FOUR QUADRANT CRICOID SPLIT
GENERAL PRINCIPLES
CRICOTRACHEAL RESECTION WITH GRAFTING
CRICOTRACHEAL RESECTION
Grade IV or SEVERE
GRADE III SUBGLOTTIC
STENOSIS WITH A CLEAR
MARGIN (> 3 mm)
BETWEEN THE STENOSIS
AND THE VOCAL FOLDS
» MOBILITY
STAGE 4 WITH
PROXIMITY TO VOCAL
CORDS WITH OR
WITHOUT POSTERIOR
GLOTTIC STENOSIS
1
GRAFTING
WHY STENT?
HYALINE COSTAL
CARTILAGE
– RIB
– THYROID
– SEPTUM
ELASTIC CARTILAGE
– EAR
HYOID BONE
Maintain cartilage grafts in position
Lend support to reconstructed area
Provide rigid luminal framework around which
healing and scar contracture can occur
In revision surgery, prolonged stenting often
required given vascularity compromise
Double Stage Suprastomal stentsSHORT TERM
Aboulker
ACUTE FAILURE
ET TUBE
FINGER COT
SILASTIC SHEET ROLL
MONTGOMERY
– LARYNGEAL STENT
– T - TUBE
ABOULKER STENT
» ZALZAL:1988,1990,1991,1993
ENDOTRACHEAL INTUBATION
SINGLE STAGE
vs. Soft-silastic CUT T-tube
TECHNICAL
– STENT MIGRATION AND BREAKAGE
POOR FOLLOWUP AND NURSING CARE
BEYOND CONTROL
– KELOID
– GER
– UNKNOWN
DURATION OF STENTING:
– MINIMUM : TISSEAL GLUE
– MAXIMUM
AWAKE VS SEDATION VS PARALYSIS
POSTOPERATIVE MANAGEMENT
RISKS AND FAILURES
SALVAGE
– DILATION
– REPEAT SURGERY
– TRACHEOTOMY
RESULTS
Randomized dsLTR Study(Aboulker vs. Soft-Silastic Cut T-tube)
POSTOPERATVE FACTORS
T-Tube
– > 4 y/o only
– Long term (months)
– Supraglottic
problems
– FLACCID long
segment
– Older patient
multiple revisions
STENTING
Grade 3 SGS—Jan 2008-July 2011
Double stage indications (glottic, pulmonary,
tongue base, syndromic, neurologic
comorbidities, “difficult”)
Short-term stenting planned
Randomized: N=31
– Open Aboulker stent, suprastomal
– Closed Cut Soft Silastic stent, suprastomal
Aboulker Cut T-tube
Operation
specific
decannulati
on
11/12
(91.6%)
8/13 (61.5%)
p-value
0.07
2
LATE SUPRAGLOTTIC FAILURE
Learning Points
Acute Failures
log-rank, p=0.02
23 year old with a history of 153 endoscopic procedures.
LTR: A-P grafts and long Aboulker stent at age 7
Stridor at age 22 with increased exercise intolerance.
Limited initial post op intervention
Cut soft silastic Montgomery T-tubes can
induce significant granulation tissue
formation (non-machined end)
– Ideal stent has not been defined (in these 2
cases Aboulker seemed to outperform soft
silastic tube)
Timing of second surgery should be delayed
at least 6-9 months to allow for maturation of
scar
WHAT WOULD YOU DO?
IMMEDIATE AND 1 WEEK LATER
ABLATION SURGERY
– ARYTENOIDECTOMY
– PARTIAL CORDECTOMY
– VOCAL PROCESS RESECTION
3
ANTERIOR GLOTTIC WEBS,
ATRESIA AND STENOSIS
6 months later
Post single stageA-P grafts
ENDOSCOPIC CRICOID SPLIT
WHAT WOULD YOU DO?
Intra--op
Intra
Scarred
mucosal
airway
is lifted
offscar
offrom
posterior
Lateral
Trachea
cutsand
made
cricoid
superior
split
vertically
to the
andstoma
anterior
crioid
plate
to the
through
cricothyroid
stenosis
joints
Intra-op
Post-op 1 week
10 year old failed 2 consecutive single stages LTRs at age 1 year.
Underwent tracheotomy, referred and had A-P grafts LTR.
Progressive exercise intolerance for past 6 - 7 months.
4
Single stage anterior graft
Trachea collapsed
21 year old female with acquired neonatal SGS
Failed cricoid split
Treated successfully with LTR A-P grafts and
long aboulker at 1 year of age.
Presents now with increased shortness of
breath during sleep and with exercise
Trachea incised and dissected
Cricoid spared
Intra-op
Lateral stitches to approximate ends
Posterior anastomosis vicryl buried (knot esophageal side)
Anterior anastomosis prolene (mattress)
Specimen
Post-op 1 week
Anastomosis assessed endoscopically
Since cricoid spared, pt is extubated on the table at
conclusion of procedure
5
Post-op 1 month
11 year old male with Downs syndrome
Grade 3 SGS
Double stage LTR at 2 y/o and 4 y/o; both
times with A/P rib cartilage grafts
Difficulty decannulating because of microaspiration and sleep desaturation
Co-morbidities: AV canal repair at 1 y/o;
moderate asthma; obese; hypothyroidism
INTRA--OP
INTRA
Pre--op
Pre
LATE FAILURE
Post--op 1 month
Post
Post--op 2 months (1 month after T
Post
T-tube removal)
Cricotracheal Resection
Double stage
12 mm Montgomery T-tube placed for one
month
T-tube removed at 1 months, replaced with 4.5 Ped Shiley
Started on Passy Muir speaking valve
Post--op 6 months
Post
Learning Points Late Failures
Many late failures are charcterized by severe
problems at the old stoma site
Associated comorbidities must be considered
when planning single vs. double stage
Montgomery T-tube plays an important
adjuvant role in revision double-staged
cricotracheal resections, especially with multilevel stenoses
1 month after T-tube removal
Airway well healed, capping started
Capped Sleep study ordered
CONCLUSION
ACCURATE ASSESSMENT
METICULOUS SURGERY DIRECTED AT SITE
OF STENOSIS
HIGH RISK DISEASE
Sleep study AHI 5.0, no desaturations
No symptoms while awake and capping
Decannulated
6