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Published on: January 20, 2010
Decreasing morbidity following laryngotracheal reconstruction in children
R F Yellon1, M Parameswaran, B W Brandom
1Department of Otolaryngology, University of Pittsburgh School of Medicine, PA, USA.
Insights
This study shows that prophylactic antibiotics and improved postoperative care, including gastroesophageal reflux treatment, significantly reduce complications and weakness after laryngotracheal reconstruction (LTR). These methods led to a 92% overall success rate for LTR procedures.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Critical Care Medicine
Background:
- Subglottic stenosis (SGS) and posterior glottic stenosis are challenging airway conditions requiring surgical intervention.
- Laryngotracheal reconstruction (LTR) can be associated with significant infectious complications and postoperative weakness, particularly following single-stage procedures (SSLTR).
- Gastroesophageal reflux (GER) is frequently observed in patients with SGS and may impact surgical outcomes.
Purpose of the Study:
- To report methods for reducing infectious complications and weakness after SSLTR.
- To investigate the association between GER and SGS.
- To present the outcomes of SSLTR and two-stage LTR (TSLTR).
Main Methods:
- Retrospective chart review of 36 patients undergoing 38 LTRs between 1990 and 1995.
- Implementation of a multimodal postoperative protocol including prophylactic antimicrobials (clindamycin + antipseudomonal agents), GER treatment, titrated neuromuscular blockade (NMB) with daily recovery, and avoidance of simultaneous NMB and corticosteroids.
- Assessment of infectious complications, patient weakness, GER status, and LTR success rates.
Main Results:
- Prophylactic antimicrobials (C + A) significantly reduced infectious complications (8% vs. 50%, P < 0.05).
- Optimized NMB management and avoidance of prolonged corticosteroid use decreased postoperative weakness (0% vs. 66%, P < 0.002).
- A significant association between GER and SGS was identified (81% of tested patients positive, P < 0.05).
Conclusions:
- A comprehensive postoperative protocol, including prophylactic antimicrobials and GER management, is effective in minimizing complications and weakness after LTR.
- Successful LTR outcomes (92% overall, 95% SSLTR, 87% TSLTR) can be achieved with improved perioperative strategies.
- GER is a significant factor in SGS, necessitating its treatment for successful LTR outcomes.
Abstract:
Our objectives are to report (1) methods for decreasing infectious complications and excessive weakness associated with the period of sedation and neuromuscular blockade (NMB) following single-stage laryngotracheal reconstruction (SSLTR); (2) an association between gastroesophageal reflux (GER) and subglottic stenosis (SGS); (3) results of 21 SSLTRs and 15 two-stage LTRs (TSLTRs). A retrospective chart review was performed for the period January, 1990-August, 1995, including 36 patients who had 38 LTRs for SGS and/or posterior glottic stenosis at a tertiary care center. Our most recent post-SSLTR protocol included: (1) prophylactic antimicrobials (clindamycin plus antipseudomonal agents = C + A); (2) GER treatment; (3) titrated infusion NMB with daily recovery of neuromuscular function; (4) avoidance of prolonged simultaneous administration of NMB and corticosteroids. Patients who had prophylactic antimicrobials (C + A) during intubation following SSLTR had fewer (1/13, 8%) postoperative infectious complications than patients who received other/no antibiotics (4/8, 50%) (P < 0.05). Avoidance of prolonged simultaneous administration of NMB and corticosteroids and use of titrated infusion of NMB with daily recovery of neuromuscular function was associated with less weakness following extubation (0/11, 0% vs. 4/6, 66%) (P < 0.002). Of 26 patients tested for GER, 21 (81%) had at least one positive test, suggesting a significant association between GER and SGS (P < 0.05). The overall success rate for LTR was 33/36 or 92%. SSLTR had a 95% success rate while two-stage LTR had an 87% success rate, although two revisions were required. Prophylactic antimicrobials, improved postoperative management and GER treatment allowed successful LTRs with decreased infectious complications and less weakness.
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