2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta- Analyses 45,46 flowchart showing the incorporation of inclusion and exclu- sion criteria. LTR 5 laryngotracheal reconstruction. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

studies. 47 Each article was assigned a score based on the level of bias. A value of > 11 was considered to have low level of bias, where a value of < 11 was considered to have a higher level of bias. Synthesis of Results Statistical analyses were done using a random effects meta-analysis. 48 Studies with missing data were excluded from the analysis. Studies with missing data for patients were assumed to have negative outcomes for patients with missing data (more surgery, failed decannulation). Heterogeneity was assessed and reported using I 2 where 25% is low, 50% is moder- ate, and 75% is a high level of heterogeneity among studies. 49 RESULTS There were 297 abstracts reviewed. One hundred four articles were selected for full-text review, and 39 articles were included in the analysis (Fig. 1). 45,46 There were two studies 8,32 that did not specify patients who received additional surgery. For studies that discussed decannulation success, seven patients had missing data, 1,7,10,36 and these were assumed to have a negative outcome. The 39 articles included in the analysis are seen in Table I. This includes the 834 total cases, the number of patients who received additional surgery, decannulation success rate if the patient had a previous tracheostomy, and MINORS criteria. Supporting Tables I to III in the

online version of this article show the patients who received additional surgery and decannulation success, MINORS criteria for the three categories of surgical treatment options, LTR, laryngoplasty, and endoscopic procedures. Supporting Tables IV to VI show the etiology of stenosis: traumatic, intubation/tracheostomy, and idio- pathic, and those receiving further surgery and decan- nulation success for each etiology. The pooled outcomes of surgical technique on addi- tional surgery received/performed and decannulation rates (Table II) were as follows: 466 patients underwent laryngotracheal resection with anastomosis, of which 32% (95% confidence interval (CI): 26%-38%) received additional surgery, and 89% (95% CI: 83%-93%) 1–9 had decannulation success. Two hundred sixty-seven patients had open LTR with expansion grafting, of which 38% (95% CI: 31%-46%) received additional surgery, and 83% (95% CI: 77%-88%) 10–26 were decannulated. One hun- dred one patients had endoscopic procedures, of which 44% (95% CI: 32%-56%) received additional surgery, and 63% (95% CI: 47%-77%) 27–39 had decannulation success. There was a significant difference found between receipt of additional surgery and for decannulation rates in endoscopic procedures and laryngotracheal resection with anastomosis (44% vs. 32%, P < .001; 63% vs. 89%, P < .001). For open LTR with expansion grafting and endo- scopic surgeries, there was no difference between addi- tional surgery, but there was for decannulation (44% vs.

Laryngoscope 127: January 2017

Lewis et al.: Surgical Treatment of Adult LTS

275