2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

SHADMEHR ET AL

Ann Thorac Surg 2017;103:246 – 53

SYSTEMIC STEROIDS IN TRACHEAL STENOSIS

After airway resection and anastomosis, all patients underwent at least one follow-up bronchoscopy at 1 month after surgery, or more in the case of any postoperative complication. All morbidity and mortality data, as well as the outcome of surgical procedures, were recorded and entered into the database. Follow-up of all patients who underwent surgery were continued for 6 months after the procedure. The rest of patients were followed for 6 months after discontinuation of the capsules. Statistical Analysis The data were transferred to SPSS for Windows (version 16.0; SPSS, Chicago, IL) software. The c 2 test, Fisher ’ s exact test, and independent samples Student ’ s t test were used to compare the baseline data and primary and sec- ondary outcomes between group C and group P. In addition, multivariate logistic regression was applied to predict factors affecting the outcome of interest. All p values less than 0.05 were considered signi fi cant. Results Of 60 patients in each group, 7 in group C and 3 in group P were either excluded after randomization or lost at follow-up. Moreover, 3 patients in group C and 2 patients in group P died before completion of the follow-up owing to car accident, pulmonary emboli, tracheal rupture during bronchoscopy, asphyxia due to tracheal stenosis, and an unknown reason ( Fig 1 ). In all, 105 patients (50 in group C; 72 male [68.6%]; aged 15 to 64 years [mean 27.54 10.73]) completed their follow-up for at least 6 months. There was no signi fi cant difference between the two groups in terms of de- mographics and intubation characteristics ( Table 4 ). Furthermore, there was no signi fi cant difference between the two groups in terms of their fi rst bronchoscopic fi ndings ( Table 5 ). The answers to our three hypothetical questions (our main goals for this study) are summarized in Table 6 and Figure 2 . Our study showed a trend toward longer in- tervals between bronchoscopic procedures (approxi- mately 22 days) and fewer airway operations (approximately 17%) for group C than for group P, although statistically insigni fi cant. It was also shown that the required length of airway resection became signi fi - cantly shorter (5.3 mm) for group C patients (38 9.5 mm, versus 43.6 11.3 mm for group P). The mean intervals between the fi rst bronchoscopy and surgery in group C and group P were 51.2 and 58.4 days, respectively ( p ¼ 0.546). To predict the factors that could potentially affect the length of resection, variables such as patient group C and group P, age, sex, cause and duration of intubation, his- tory of tracheostomy, interval between intubation and fi rst bronchoscopy, site of stenosis, and length of stenosis were all entered in a linear regression model. Among those variables, only patient group C was independently (after adjusting length of resection due to other variables) associated with smaller length of resection ( p ¼ 0.036).

were prepared for airway resection and anastomosis ( Table 3 ). After randomization, group C patients were given an orange-colored capsule containing 15 mg pred- nisolone, and group P patients received the same color and size capsules with no prednisolone, as placebo. Pa- tients with a history of acid peptic disease were also given proton-pump inhibitors. Weights of patients were measured, and they were checked for hypertension. A fasting blood sugar test and chest radiography were performed for all patients, and if indicated, were completed by other tests to rule out diabetes mellitus and tuberculosis. All patients were asked to restrict their salt intake and check their body weight and blood pressure weekly. All patients were provided with information regarding all potential side effects of prednisolone as well as the heralding symptoms and signs of airway stenosis on discharge, and were asked to come back as soon as they were symptomatic, or at most, after 1 month, for an of fi ce visit even if they were completely asymptomatic. On each of fi ce visit, the patients were checked not only for airway restenosis and the need for rigid bronchoscopy but also for possible side effects of corticosteroids. The capsules were continued for 6 months even if the surgeons decided to stop the follow-up bronchoscopy (based on the bron- choscopic fi ndings) sooner for asymptomatic patients. All patients underwent several bronchoscopic pro- cedures (at least twice — one at their fi rst presentation, another for the fi nal decision) until their respiratory status stabilized or was prepared for airway resection. For each patient, the interval between the bronchoscopies equaled the mean of all intervals (in days) between the performed bronchoscopic procedures for that patient. Patients who required frequent bronchoscopic procedures at short in- tervals underwent tracheostomy or T-tube placement and were then excluded from the study, because after trache- ostomy or T-tube insertion, they did not require further bronchoscopic dilation during the time they needed to become prepared for airway resection. Whenever the decision for airway resection had been made, the capsules were discontinued for at least 1 week before the procedure. The length of the resected segment of the airway was measured and recorded by both the surgeons and the pathologists. We considered the time between bronchoscopies and the decision for airway surgery as the primary outcomes and the length of the resected trachea as the secondary outcome of this study. Table 3. Criteria for Resectional Airway Surgery No gross tracheal infection No or minimal laryngotracheal mucosal edema/in fl ammation No or minimal granulation tissue Patent glottis Patient compliance, for example, able to obey surgeon commands, ability to cough All associated injuries such as fractures and underlying diseases such as cerebrovascular accidents or myocardial infarction treated or stabilized

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