2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

TABLE III. Pooled Outcomes of Additional Surgery and Decannulation Success for Etiology of Stenosis.

Additional Surgery, % (95% CI); I 2 %

Decannulation Success, % (95% CI); I 2 %

Etiology

Studies

Patients

Traumatic

8

33

54% (35%-73%); 85%

78% (61%-89%); 0%

Intubation/tracheotomy

12

106 109

35% (25%-47%); 58% 25% (16%-36%); 25%

88% (79%-94%); 0%

Idiopathic

4

63% (40%-81%); 67%

CI 5 confidence interval.

stenosis, yet also have the lowest decannulation rate. Two primary endpoints were chosen for this study: absence of additional surgery and decannulation, following either an open or endoscopic procedure. Lack of additional surgery is commonly considered the ultimate goal of treatment for LTS, though patients with complex or multilevel stenosis fre- quently receive multiple surgeries over many years. In a large retrospective review of pediatric subglottic stenosis, Hartnick et al. used a similar approach to define success in single and double stage LTR. 44 Decannulation was also used as an endpoint, because removal of a tracheostomy is an important goal for both clinicians and patients. We found insufficient numbers to compare which surgical procedure was more successful in outcomes with the presence of tracheostomy. Since Rethi 50 first described open surgical procedures for subglottic stenosis in the 1950s, surgical management options have greatly expanded. Open surgeries have evolved into either resection or augmentation procedures, and more recently, as superior fiberoptic imaging, balloon dilators, and lasers have developed, endoscopic treatment has become a common alternative to open surgery. Endo- scopic treatment may be less morbid and offers the patient less total operative and anesthesia time. 27–39 These same

factors may be one reason why we found endoscopic proce- dures to have less success compared to open procedures; patients with more comorbid conditions may not be able to tolerate longer anesthesia time or more invasive surgery, dictating an endoscopic approach. These patients may have diseases such as diabetes, obesity, or other medical prob- lems that may prevent adequate wound healing. The litera- ture currently lacks descriptions of patients’ comorbidities, thus confusing whether endoscopic procedures are per- formed on those with worse disease or are truly less effec- tive. In addition, endoscopic procedures do not routinely remove all granulation tissue, which may predispose a patient to recurrence requiring additional surgery. 27–40 One variable complicating the calculation for receipt of additional surgery is surveillance endoscopy. Though routine in the pediatric population after open airway pro- cedures, 44 repeat bronchoscopy is not routinely reported in adult patients who have had LTR or resection. In our experience with adult patients who have undergone open airway procedures, multiple endoscopic debridements have been necessary for granulation tissue that develops at the site of previous stenosis. It is unclear whether there is bias against inclusion of surveillance endoscopic proce- dures after open airway surgery, or if these patients are

Fig. 3. Subgroup analysis by etiology. Blue indicates additional surgery, and red indicates decannulation success. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Laryngoscope 127: January 2017

Lewis et al.: Surgical Treatment of Adult LTS

278