Predictors for Postoperative Complications After Tracheal Resection Benoit Jacques Bibas, MD, Ricardo Mingarini Terra, MD, PhD, Antonio Lopes Oliveira Junior, MD, Mauro Federico Luis Tamagno, MD, Helio Minamoto, MD, PhD, Paulo Francisco Guerreiro Cardoso, MD, PhD, and Paulo Manuel Pego-Fernandes, MD, PhD ˇ

Thoracic Surgery Department, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de S~ao Paulo, S~ ao Paulo, Brazil

Background. Tracheal resection and anastomosis is the gold standard for the treatment of tracheal stenosis. The objective of this study is to evaluate the complications after tracheal resection for benign stenosis and the predicting factors for such complications. Methods. A retrospective study was made involving patients with benign tracheal or laryngotracheal stenosis who underwent surgical resection and reconstruction between February 2002 and January 2009. Complications related and unrelated to the anastomosis were studied. Categorical variables were presented as percentage and continuous variables as mean and standard deviation. Predicting factors were determined by univariate analysis. Factors with p less than 0.05 were used for multivariate regression. Logistic regression models were also employed for dependent variables. Statistical significance was set for p less than 0.05. Results. Ninety-four patients (18 female, 76 male) were included. Complications occurred in 42 (44.6%). Twentyone percent had anastomotic complications. The most

common complication was restenosis (16%). Nonanastomotic complications occurred in 23.2%. Wound infection occurred in 10.6%. Clinical comorbidities, previous tracheal resection, and the length of tracheal resection were statistically significant factors for complications. Previous tracheal resection was the most significant factor and was highly associated with anastomotic complications (odds ratio 49.965, p [ 0.012). The greatest number of complications was found in the laryngotracheal reconstruction group, and in resections more than 4 cm. Mean follow-up was 19 ± 14 months. At the end of the study, 86 patients (91.4%) were breathing normally. There was no mortality in this series. Conclusions. Comorbidities, previous tracheal resection, and the length of tracheal resection more than 4 cm were statistically significant factors for the onset of complications.

T

Nevertheless, only a few of these studies have a significant number of patients to allow an adequate multivariate analysis to identify predictors. Therefore, more information regarding the most frequent complications after tracheoplasty as well as their predictors is still necessary. The objective of the present study was to evaluate the complications after tracheal resection for benign stenosis and the predictive factors for such complications.

racheal resection and primary anastomosis remain the standard of care for the definitive treatment of tracheal stenosis. In spite of being very effective, with success rates greater than 90%, complications are an issue. Not only might these complications be lifethreatening once they compromise the airway, but also they are quite frequent. Some studies have already addressed this issue and observed complications rates as high as 50%; consequently, adequate patient selection is paramount [1]. To improve tracheal resection outcomes, some researchers tried to identify predictors for the occurrence of postoperative complications [1, 2]. Laryngeal involvement is frequently cited as a relevant factor for anastomotic complications [3]. Other commonly mentioned factors are the need for suprahyoid release, redo tracheoplasty, diabetes mellitus, and long-segment stenosis [3, 4].

Accepted for publication March 20, 2014. Address correspondence to Dr Bibas, Secretaria do Servic¸o de Cirurgia Tor acica, Av Dr En eas de Carvalho Aguiar 44, Bloco II, 2o Andar, Sala 9, S~ ao Paulo, SP 05403-900, Brazil; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

(Ann Thorac Surg 2014;-:-–-) Ó 2014 by The Society of Thoracic Surgeons

Material and Methods This retrospective study included patients who underwent tracheal or laryngotracheal resection with primary reconstruction at our division of thoracic surgery between February 2002 and January 2009. Our institution is a tertiary teaching hospital and a national referral center for tracheal diseases. Data were collected from medical records, and all patients were assigned a code number to ascertain confidentiality of information. This project was submitted and approved by the hospital’s Ethics Committee. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.03.019

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BIBAS ET AL TRACHEAL RESECTION COMPLICATIONS

We included all patients diagnosed with postintubation tracheal or laryngotracheal stenosis who underwent surgical resection and reconstruction during the study period. The exclusion criteria were patients who underwent laryngeal split and cartilaginous grafting; patients who underwent carinal resection; patients with incomplete records; and resection due to conditions other than postintubation tracheal stenosis (eg, airway tumors, idiopathic stenosis, infectious diseases, trauma, Wegener’s granulomatosis, chronic relapsing polychondritis). Preoperative workup of all patients selected for surgical treatment included a computed tomography scan of the larynx and trachea and a flexible bronchoscopy to classify the severity of the stenosis. All surgical procedures began with an endoscopic assessment of the airway, using rigid bronchoscopy or suspension laryngoscopy, as it allows the surgeon to identify and measure the segment to be resected, and if necessary, dilate the airway [5]. Airway resection and reconstruction followed the standard procedures published previously by Grillo and associates [3] and Pearson and colleagues [6]. Operations were performed by one of the three surgeons with experience in tracheal diseases (B.J.B, H.M, P.F.G.C). The anastomosis was performed with a continuous running suture of polydioxanone 4-0 (PDS II; Ethicon, Bridgewater, NJ) in the membranous wall and separated sutures of polyglactin 3-0 (Vicryl, Ethicon) in the cartilaginous wall. The technique used was similar for both laryngotracheal reconstruction and tracheal reconstruction. Suprahyoid laryngeal release maneuvers were used judiciously according to the surgeon’s preference to reduce anastomosis tension in addition to mediastinal dissection and neck flexion during the procedure. Patients were instructed to avoid neck hyperextension in the postoperative period, and we did not routinely use the “guardian stitch.” Patients were seen at the outpatient thoracic surgery clinic at 1, 3, and 6 months after hospital discharge and twice yearly thereafter. In the event of any complaints related to the operation or clinical signs or symptoms of complications, imaging studies and flexible bronchoscopy were performed. We defined complications as those related (anastomotic) or unrelated to the anastomosis (nonanastomotic). Overall complication was a binary (yes/no) variable. By definition, anastomotic and nonanastomotic complications comprised overall complications. Complications related to the anastomosis were anastomosis dehiscence and restenosis or granulation tissue in the anastomotic line. Only events that required reintervention or led to prolonged admission were counted as complication for the current study analysis purposes. Complications unrelated to the anastomosis were wound infection requiring intravenous antibiotics, hematomas requiring drainage, tracheoinnominate fistula, dysphagia, dysphonia, and tracheoesophageal fistula. Both dysphagia and dysphonia were not analyzed quantitatively because we do not perform these tests routinely in the postoperative period. These complications were analyzed on a clinical basis, through a binary variable (yes/no).

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Other variables were also analyzed: sex, age, body mass index, comorbidities, intubation time, interval between intubation and surgery, previous treatments (such as tracheal stenting and dilation), operative technique, postoperative complications, reoperation, follow-up length, mortality, and cause of death. Telephone contact was made with patients to retrieve information that was unavailable in the medical records. If the patient had any difficulty answering the questions by phone, a return visit was scheduled in the outpatient clinic. Likewise, patients with less than 6 months of follow-up were contacted by phone, and a return visit to the clinic was scheduled. To ensure data quality, all the data inserted were checked for every 20 new patients included in the database, and the auditing was performed by at least two different investigators. Data were collected and inserted in the software EpiData version 3.0 (EpiData Association, Odense, Denmark). Statistical analysis was performed with the Statistical Package for Social Sciences, version 13.0 for Windows (SPSS, Chicago, IL). Categorical variables were presented as percentage and continuous variables as mean and standard deviation. To determine the predicting factors, we used univariate analysis for all variables collected. Factors that had a p less than 0.05 were used for the multivariate regression model. Logistic regression models were also employed for dependent variables. Statistical significance was set for p less than 0.05.

Results The flow of the patients is depicted in Figure 1. During the study period, 138 patients with laryngotracheal stenosis underwent operation. Forty-four patients were excluded from the study (10 patients had incomplete medical records; 28 underwent laryngeal split and cartilaginous grafting; and 6 had miscellaneous etiologies). Ninety-four patients (18 women and 76 men) were eventually included in the study. Patient demographics and the characteristics of the study group are depicted in Table 1. Of the 94 patients who underwent surgery during the study period, 42 (44.6%) had some sort of complication. Twenty patients (21%) had anastomotic complications. The most common complication was restenosis, which occurred in 16% of the patients. Those patients were treated endoscopically (n ¼ 12), with tracheal T tube (n ¼ 6), or tracheostomy (n ¼ 2). One patient had an anastomosis dehiscence that required reoperation. A tracheostomy was initially performed, and the patient was later treated with a T tube. Four patients had granulation tissue at the anastomosis site, and were treated with laser therapy. Nonanastomotic complications occurred in 23.2%, with superficial wound infection occurring in 10.6% of the patients. All infections were treated with local debridement or intravenous broad-spectrum antibiotics or both. No reoperation was needed. The complications related and unrelated to the anastomosis are described in Table 2. Dysphonia was clinically evaluated and treated

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Fig 1. Flowchart of the study.

with phonoaudiology, but no invasive tests were performed. One patient had a postoperative tracheoesophageal fistula. He was initially treated with a tracheostomy and a T tube; 6 months later the fistula was surgically closed. Data from univariate analysis for overall complications are presented in Table 3, and the data from multivariate Table 1. Demographics Sex Male Female Age, years Body mass index, mean Tracheostomy Comorbidities Diabetes mellitus Epilepsy Heart failure Rheumatic fever Amyloidosis Scleroderma Asthma Type of surgery End-to-end tracheal anastomosis Cricotracheal anastomosis Laryngotracheal anastomosis Length of resection, cm Follow-up, months Values are n (%) or mean  SD.

76 (81) 18 (19) 31.2  14 24.01  3.13 68 (72.3) 05 03 02 02 01 01 01

(5.32) (3.20) (2.13) (2.13) (1.06) (1.06) (1.06)

52 (55.32) 24 (25.53) 18 (19.15) 2.9  0.83 19  14

analysis are shown in Table 4. The presence of comorbidities, previous tracheal resection, and the length of tracheal resection were the statistically significant factors for the onset of anastomotic complications. Previous tracheal resection was the most significant factor, and was highly associated with the development of anastomotic complications (odds ratio [OR] 49.965, p ¼ 0.012). The greatest number of complications was found in the laryngotracheal reconstruction group, and in resections more than 4 cm in length. The mean follow-up was 19  14 months. At the end of data collection, 86 patients (91.4%) were breathing normally without stridor. There was no mortality in this series.

Comment In the present study, the overall complication rate was 44.6%, with no mortality. Restenosis was the most frequent complication, occurring in 16% of the patients. The factors associated with anastomotic complications were the presence of comorbidities, previous tracheal resection, and the extent of the resection. The overall morbidity after tracheal resection varies from 17% to 45% [3, 7–11], and mortality ranges from 0% to 2.4% [3, 7–10]. The high variability rates of complications after airway resection are probably multifactorial, but some issues should be discussed. The definition of complication is certainly a key point. Some researchers define complications as early or late [8], others describe simply overall complications [4, 10], and some choose to divide complications into major or minor [9]. We defined

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Table 2. Complications Unrelated and Related to the Anastomosis Complications

In the present study, we had 21% anastomotic problems. Those included restenosis in 16%, granulation tissue at the anastomosis in 4%, and dehiscence in 1%. This percentage, although higher than the rate reported by Wright and colleagues [7], is still similar to the reports of other groups [8–11]. Macchiarini and colleagues [8] reported 41% early complications (4 cm length Perioperative tracheostomy Body mass index >30 Comorbidities Previous tracheostomy Previous T tube Previous resection Time until surgeryb

No Complications n ¼ 76 (80.9%)

Complications n ¼ 18 (19.1%)

47 (61.8) 18 (23.6) 11 (14.4) 2.76  0.74 7 (9.2) 7 (9.2) 3 (3.9) 9 (11.8) 51 (67.1) 10 (13.1) 1 (1.3) 506.05  475.32

5 (27.7) 6 (33.3) 7 (38.8) 3.63  0.83 7 (38.8) 6 (33.3) 4 (22.2) 6 (33.3) 17 (94.4) 7 (38.8) 2 (11.1) 861.50  779.85

OR

95% CI

.

.

4.366 6.273 4.929 6.952 3.722 8.333 4.200 9.375 1.001

1.922–9.917 1.841–21.369 1.411–17.218 1.400–34.520 1.119–12.382 1.049–66.224 1.320–13.367 0.801–109.775 1.000–1.002

p Value 0.017a

4 cm

OR

95% CI

p Value

7.041 49.965 5.162

1.510–32.840 2.403–1038.985 1.935–13.772

0.013 0.012 0.001

Outcome variable is overall complications. CI ¼ confidence interval;

OR ¼ odds ratio.

referred to us from other institutions. One of them had a failed 1-cm tracheal resection and was using a tracheostomy. A 3-cm resection was performed, with no complications. The other 2 patients had failed tracheal resections that further required a laryngotracheal anastomosis and a cricotracheal anastomosis. Both resections measured 5 cm. Tracheostomy was done in both patients, and they are both still using T tubes. The patient who underwent a laryngotracheal anastomosis is using a supraglottic T tube. Donahue and associates [4] reported a 39% complication rate in patients with a previous resection and a 15% complication in patients without it. Wright and associates [7] reported that, for patients undergoing reoperation, not only did the rate of complications increase with length of resection but also the failure rate at all lengths except for the smallest was more than double that for primary resections. The increased morbidity after reoperation can be explained by the dense surrounding peritracheal fibrosis from previous operation; it impairs tracheal mobility and thus may increase tension in the anastomosis, leading to restenosis and failure [4, 7]. However, despite the elevated risk, reoperation may still be successful if patients are well selected [7]. The greatest number of complications in this study was found in the laryngotracheal reconstruction group, and in resections more than 4 cm in length (OR 5.1, 95% CI: 1.9 to 13.7; p ¼ 0.001). Indeed, when analyzing patients who had a resection more than 4 cm, 9.2% had no complications, whereas the majority, 38%, had some sort of complication (OR 6.2, 95% CI: 1.8 to 21.3; p ¼ 0.005). This finding has been reported by several other groups [2–4, 7, 11], and it is clear that resections greater than 4 cm are associated with a dramatic increase in the rate of failure [7]. Therefore, prudence dictates that patients undergoing resections longer than 4 cm should be considered for a release procedure or stent treatment [7, 8]. Clinical comorbidities were an important risk factor in multivariate analysis, in our study (OR 7.04, CI: 1.5 to 32.84, p ¼ 0.013). Among our patients, 45% were diabetic. This finding echoes other reports and can be explained by the poor circulation of the tracheal mucosa in such patients [7]. Diabetes is notorious for damaging the microcirculation, resulting in deleterious effects on wound healing. The main weakness of this study is its retrospective nature; nevertheless, we selected very objective endpoints, and we had few missing data, making our

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conclusions stronger. Still, our population was very homogeneous, as we included only patients with benign postintubation tracheal stenosis. Tracheal tumors and tracheoesophageal fistulas were not taken into consideration. Another important weakness of the study was our definition of success. Like most series [2, 4, 7–10], we defined success as a condition in which patients require no further treatment, but does not specify laryngeal function or quality of life . We believe that this simple outcome is not sufficient. Gonfiotti and associates [15] proposed a new disease-specific outcome measure, in which endoscopy, laryngeal function, and voice were evaluated. The main goal for the treatment of benign stenosis should be not only anatomic but must also take into consideration the quality of life of the patients, including all laryngeal functions. In conclusion, tracheal resection for benign tracheal stenosis has a high success rate. Nevertheless, it may have morbidity rates as high as 45%. The presence of comorbidities, previous tracheal resection, and the length of tracheal resection greater than 4 cm were the statistically significant factors for the onset of complications in this study.

References 1. Grillo HC, Mathisen DJ, Wain JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 1992;53:54–63. 2. Macchiarini P, Chapelier A, Lenot B, Cerrina J, Dartevelle P. Laryngotracheal resection and reconstruction for postintubation subglottic stenosis. Lessons learned. Eur J Cardiothorac Surg 1993;7:300–5. 3. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486–92. 4. Donahue DM, Grillo HC, Wain JC, Wright CD, Mathisen DJ. Reoperative tracheal resection and reconstruction for unsuccessful repair of postintubation stenosis. J Thorac Cardiovasc Surg 1997;114:934–8. 5. Dos Santos AO, Minamoto H, Cardoso PF, de Nadai TR, Mota RT, Jatene FB. Suspension laryngoscopy for the thoracic surgeon: when and how to use it. J Bras Pneumol 2011;37:238–41. 6. Pearson FG, Brito-Filomeno L, Cooper JD. Experience with partial cricoid resection and thyrotracheal anastomosis. Ann Otol Rhinol Laryngol 1986;95:582–5. 7. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128: 731–9. 8. Macchiarini P, Verhoye JP, Chapelier A, Fadel E, Dartevelle P. Partial cricoidectomy with primary thyrotracheal anastomosis for postintubation subglottic stenosis. J Thorac Cardiovasc Surg 2001;121:68–76. 9. Marulli G, Rizzardi G, Bortolotti L, et al. Single-staged laryngotracheal resection and reconstruction for benign strictures in adults. Interact Cardiovasc Thorac Surg 2008;7: 227–30. 10. Mutrie CJ, Eldaif SM, Rutledge CW, et al. Cervical tracheal resection: new lessons learned. Ann Thorac Surg 2011;91: 1101–6. 11. Terra RM, Minamoto H, Carneiro F, Pego-Fernandes PM, Jatene FB. Laryngeal split and rib cartilage interpositional

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grafting: treatment option for glottic/subglottic stenosis in adults. J Thorac Cardiovasc Surg 2009;137:818–23. 12. Terra RM, Bibas BJ, Minamoto H, et al. Decannulation in tracheal stenosis deemed inoperable is possible after longterm airway stenting. Ann Thorac Surg 2013;95:440–4. 13. Terra RM, Minamoto H, Tedde ML, Almeida JL, Jatene FB. Self-expanding stent made of polyester mesh with silicon coating (Polyflex) in the treatment of

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inoperable tracheal stenoses. J Bras Pneumol 2007;33: 241–7. 14. Bibas BJ, Bibas RA. A new technique for T-tube insertion in tracheal stenosis located above the tracheal stoma. Ann Thorac Surg 2005;80:2387–9. 15. Gonfiotti A, Jaus MO, Barale D, et al. Development and validation of a new outcome score in subglottic stenosis. Ann Thorac Surg 2012;94:1065–72.

Predictors for postoperative complications after tracheal resection.

Tracheal resection and anastomosis is the gold standard for the treatment of tracheal stenosis. The objective of this study is to evaluate the complic...
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