HSC Section 6 Nov2016 Green Book

The American Journal of Surgery, Vol 208, No 5, November 2014

Table 2 Comparison of complication, disposition, and death data for patients who received a tracheostomy through an open or percutaneous procedure

Open procedure

Percutaneous procedure

Parameter

Number (%)

Number (%)

P value

Complication

7 (2.6%) 5 (1.9%) 2 (.8%)

8 (2.3%) 4 (1.1%) 4 (1.1%)

.773 .509 .704 .007

Tracheal stenosis

Other major complications

Disposition

Home/home with home health care/jail/mental health facility Rehabilitation center/select specialty hospital acute care/other acute hospitals

44 (16.6%) 165 (62.3%)

35 (10.0%) 262 (75.1%)

Skilled nursing unit/nursing home

14 (5.3%) 42 (15.8%) 41 (15.5%)

14 (4.0%) 38 (10.9%) 34 (9.7%)

Hospice/death

Death

.030

difference in ISS between the 2 groups with the percuta- neous group having a higher median score than the open group (24 vs 26, P 5 .007). The overall complication rate was similar between the OT and PT groups ( Table 2 ). The incidence of tracheal ste- nosis was also similar when comparing the open group with the percutaneous group (1.9% vs 1.1%, P 5 .509). The open group had an incidence of major complications other than tracheal stenosis of .8%. These complications involved scar and excess granulation tissue requiring surgical scar revision ( n 5 2). The percutaneous group had an incidence of other major complications of 1.1% ( n 5 4). These included tracheo-innominate artery fistula ( n 5 1), loss of airway requiring conversion to open ( n 5 2), and bleeding requiring conversion to open ( n 5 1). The patient with a tracheo-innominate artery fistula hemorrhaged while on the floor. The hemorrhage was occluded manually while the patient was taken to the operating room for repair, but the patient exsanguinated before repair could be accom- plished. All conversions to an open procedure occurred dur- ing the initial hospitalization. Four of the 9 patients were immediately diagnosed with tracheal stenosis after a failed decannulation attempt; how- ever, the other 5 patients presented in a delayed fashion after being decannulated. The delay ranged from 3 to 12 months, with patients presenting with shortness of breath with exertion ( n 5 4) and with trouble extubating after elective laparoscopic cholecystectomy ( n 5 1). All of the 9 patients underwent some form of treatment for their stenosis. Five of these 9 patients underwent bronchoscopy with tracheal balloon dilation, while 4 of the 9 patients underwent tracheal resection. In our study, the risk of tracheal stenosis requiring invasive intervention following tracheostomy was 1.5%. There was a significant difference in patient disposition between the 2 groups ( Table 2 ). The open group was dis- charged home more often and to a rehabilitation center less often when compared with the percutaneous group ( P 5 .007); however, mortality rate was higher in the open group (15.5% vs 9.7%, P 5 .030). We also conducted analyses comparing those patients with tracheal stenosis with those with no tracheal stenosis,

independent of which method of tracheostomy was per- formed ( Table 3 ). Patients who developed tracheal stenosis were younger (29.8 vs 45.2 years of age, P 5 .021), had a longer ICU LOS (28.3 vs 18.9 days, P 5 .036), and tended to require mechanical ventilation for a longer interval (26.7 vs 16.1 days, P 5 .055) compared with those who did not develop tracheal stenosis. There were, however, no differ- ences between the groups in regard to sex, ISS, GCS score, mechanism of injury, interval between admission and tracheostomy formation, hospital LOS, disposition, or mortality. While there is support in the literature of equivalent early complication rates between open and percutaneous techniques, 8,9 there is less evidence about their equivalency with regard to late complications such as tracheal stenosis. For this reason, there is still debate about which method provides superior patient outcomes. The incidence of symp- tomatic tracheal stenosis following OT or PT ranges in the literature from 0% to 10%. 4–6 The true incidence of tracheal stenosis is difficult to ascertain because it is often subclinical in nature. In our study, tracheal stenosis was identified based on clinical symptoms. Our study was similar to these published results, demonstrating equivalent symptomatic tracheal stenosis rates for OT and PT (1.9% vs 1.1%, respectively). As stated earlier, several studies demonstrate complica- tion rates that are equivalent for PT and OT. Our study supports the literature in this regard with an overall complication rate of 2.3% and 3.3%, respectively. The types of complications encountered during tracheostomy creation have been described in the literature and include peristomal bleeding, peristomal infection, loss of airway during procedure, surgical scar contracture, and tracheo- innominate artery fistula. 2,10 The complications reported in our study are in line with those previously described. Major complications in our study were defined as need for surgi- cal intervention or death. Both of the reoperations in the Comments

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