Single-Staged Laryngotracheal Reconstruction for Idiopathic Tracheal Stenosis

Transcription

1 Single-Staged Laryngotracheal Reconstruction for Idiopathic Tracheal Stenosis Alfonso Morcillo, PhD, Richard Wins, MD, Abel Gómez-Caro, PhD, Marina Paradela, MD, Laureano Molins, PhD, and Vicente Tarrazona, PhD General Thoracic Surgery Department, Hospital Clínico, Universidad de Valencia, Valencia; and General Thoracic Surgery Department Hospital Clínic, Universitat de Barcelona (UB), Barcelona, Spain Background. This study retrospectively evaluated the results of surgically treated idiopathic tracheal stenosis. Methods. Of the 220 patients surgically treated for idiopathic subglottic and tracheal stenosis in the participating hospitals, we reviewed the surgical records of all patients with idiopathic tracheal stenosis. This subgroup required resection of all of the involved mucosa but frequently had undergone more conservative treatments that damaged the tracheal mucosa and cartilage and complicated the definitive surgical treatment. Results. During the study period, 60 women (93.8%) and 4 men (6.2%), who were a mean age of 50 years (range, 19 to 77 years), were surgically treated for idiopathic tracheal stenosis, with no operative deaths. Of these 64 patients, 38 (59.3%) had undergone previous treatments in other centers: dilation, 26 (40.6%); laser only, 19 (31%); laser plus tracheal prosthesis, 5 (7.8%); tracheostomy, 7 (11.6%); T tube, 2 (3%); and laryngotracheal operations, 5 (7.8%). All patients were treated with a single-staged tracheal or laryngotracheal operation, of which 59 (98%) successful. Four of the most complex stenoses, with vocal cords and cricoid plate involvement, underwent reoperation for restenosis or larynx inconsistency. One patient was considered biologically unfit for reoperation and required a permanent T tube for restenosis. Half of the operations were temporary tracheostomies with T tube for larynx modelling. The most frequent postoperative complications were dysphonic voice in 10 patients (although in 7 instances this began months or years before the operation), granulation tissue in 10, aspiration in 3, and wound infections in 2. Conclusions. Idiopathic stenosis occurred predominantly (90% of cases) in women. Single-staged laryngotracheal correction was successful in 97%. Technique selection, with or without temporary laryngeal stenting, must be individualized with respect to the vocal cords mobility, function, and distance from the stenosis. (Ann Thorac Surg 2013;95:433 9) 2013 by The Society of Thoracic Surgeons Accepted for publication Sept 4, Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 Feb 1, Address correspondence to Dr Morcillo, General Thoracic Surgery Department, Hospital Clínico, Universidad de Valencia, Avenida Blasco Ibañez, 17, Valencia, Spain; morcillo.alf@gmail.com. Idiopathic laryngotracheal stenosis (ILTS) occurs infrequently, is not well known, and surgical treatment remains controversial. It predominantly affects mature women (90% of cases) without previous tracheal instrumentation. The laryngotracheal or tracheal mucosa typically becomes thick and inflamed, and the airway is affected circumferentially [1 3].In patients not previously treated by another specialist, the characteristic lesion type reveals undamaged cartilage and progressive narrowing of a short segment of the airway, typically in the subglottic area. Diagnosis requires the exclusion of other more frequent causes of tracheal stenosis, such as intubation, infections, physical agents, collagen vascular diseases, and congenital factors [1 4]. Some authors have applied conservative endoluminal therapies (laser, dilation, prostheses or a combination) with good short-term results at best, but late recurrences are frequent [1]. These therapies may cause harm, extending the affected area and damaging previously healthy laryngotracheal cartilages. The surgical approach to glottic and subglottic spaces is one of the challenges of laryngotracheal reconstruction. Surgical treatments are conditioned by proximity or involvement of the vocal cords and the status of the larynx cartilages. Operative techniques described by Couraud and colleagues [6 9], Pearson [10], and Grillo and coworkers [2, 11, 12] led us to face this challenge by using combined procedures that include resection of the affected mucosa and resurfacing the area with membranous flaps of the remaining trachea, with or without plastic procedures involving the larynx, essentially over the cricoid plate for airway enlargement. We present our retrospective experience in the singlestage surgical reconstruction of 60 ILTS patients during the past 33 years, considering the characteristics of the treated stenosis, surgical procedures performed, and postoperative outcomes and complications. Patients and Methods This retrospective study was approved by the Institutional Review Board and Ethics Commission. Written informed consent was obtained for all patients by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 434 MORCILLO ET AL Ann Thorac Surg IDIOPATHIC TRACHEAL STENOSIS 2013;95:433 9 Study Design, Data Collection, and Settings We reviewed 64 consecutive patients with the diagnosis of ILTS treated between January 1986 and November 2011 in two surgical units: Hospital Clínico Universitario in Valencia and Hospital Clínic in Barcelona, Spain. We retrospectively collected all demographic and clinical data. Clinical preoperative evaluation included detailed history and physical examination. Data on previous treatments (eg, successive dilatation, laser, tracheostomy, stents, surgeries, corticoids doses) were carefully collected. Pulmonary function tests and pulmonary ventilation were performed to assess obstruction, perfusion scans and echocardiography to evaluate surgical risk, and chest multidetector computed tomography (CT) or simple CT scan to assess the stenosis, including length, location, and vocal cords involvement. Flexible bronchoscopy assessed the need for initial therapeutic procedures and essential information about tracheal mucosa, vocal cords (paralysis, cords fixation, distance to the stenosis), stenosis length, and assessment of the stomas. In patients with critical stenosis, a rigid bronchoscope was used to assess the stenosis and airway dilation. All patients were treated preoperatively with warm humidification and proper antibiotic coverage, depending on the samples obtained during bronchoscopy, and patients with acute inflammatory changes received systemic steroids. Surgical Approach and Anesthetic Management Orotracheal intubation or trough tracheostomy was performed according to each patient s airway status. The surgical approach was by cervical incision (collar incision, U-shaped) with the patient s neck hyperextended. During the 33-year study period, small changes occurred in surgical techniques. In general, absorbable sutures, such as multifilament Vicryl (Ethicon Inc, Somerville, NJ) or monofilament polydioxanone (Ethicon Inc), were used to construct anastomoses, using interrupted stitches with extraluminal knots in both the cartilaginous and membranous face of the airway; running sutures were used for the membranous face at the surgeon s discretion [1, 13]. Tracheal anastomoses were routinely covered with local pedicle tissue. Laryngeal (thyrohyoid and suprahyoid) release maneuvers for trachea mobilization were performed to resolve the excess tension in the anastomosis. Surgical Procedures The appropriate surgical procedure was selected after analysis of the characteristics of the stenosis, including involvement of larynx cartilage and of the vocal cords, as well as their mobility and distance from the stenosis (Fig 1). Exceptionally, when ILTS larynx was not involved, an end-to-end anastomosis was performed. A Pearson-type operation [10] was performed when the stenosis involved tracheal mucosa at the cricoid cartilage level with a normal laryngeal ventricle and mobile vocal cords (distance 2 cm to the vocal cords): the anterior and lateral cricoid arch is removed, preserving the cricoid plate to Fig 1. Idiopathic laryngotracheal stenosis schemes are shown. (A) Typical lesion, which can be corrected by the Pearson operation. Lesion is at cricoid ring level. (B) Lesion amenable to Grillo-type operation, 0.5 to 1 cm below the vocal cords. A tailored flap is needed for cricoid plate resurfacing. (C) Maddaus-type lesion: stenosis is closer to the vocal cords, with little space for anastomosis. A laryngofissure is needed for total removal of affected mucosa and a more accurate thyroid-tracheal anastomosis. (D) Couraud techniques for typical stenosis. Impaired mobility or fixed vocal cords, most often with cricoid or upper trachea cartilage damage. Midline cricoid incision and temporary T tube is mandatory. protect recurrent laryngeal nerves. The anastomosis can be performed without laryngofissure or further action over larynx cartilages, telescoping the trachea for thyroid-tracheal anastomosis. A Grillo-type operation [2, 11, 14] was performed (Fig 2) when subglottic mucosa was circumferentially affected and required replacement. After the cricoid ring was resected, a membranous flap tailored from the remaining trachea was used to resurface the cricoid plate. Thyroid-tracheal anastomosis can be safely performed as described above. Careful healthy mucosa confrontation in the anastomosis is essential to avoid restenosis or excessive granulation tissue. A Maddaus-type [12] operation (Fig 3A and C) was selected for patients with a stenosis located even higher and closer ( 0.5 cm) to the vocal cords when these remained mobile and functional. Once the anterior cricoid arch is removed, the thyroid cartilage must be incised vertically in the midline to protect the vocal cords. Afterward, the affected mucosa is removed easily by incising the upper limit of the stenosis with a scalpel and resurfacing with the remnant trachea flap. A Couraud-type operation [6 9] (Fig 3B and C) was performed when the stenosis paralyzed both vocal cords

3 Ann Thorac Surg MORCILLO ET AL 2013;95:433 9 IDIOPATHIC TRACHEAL STENOSIS 435 All patients underwent postoperative bronchoscopy to clear secretions and blood clots and to endoscopically assess the anastomosis. In patients with a T tube, we cleaned the distal trachea through the prostheses and reassessed the correct position of the stent and its appropriate length in hyperflexion. In simple, nonstented anastomosis patients, weaning was performed in the intensive care unit under endoscopic surveillance to evaluate glottic edema and possible reintubation. A sentinel stitch (chin to sternum suture) can be avoided using an orthopedic corset individually designed and custom made for cervical flexion [13]. Flexible bronchoscopy was scheduled for every patient between the second and third postoperative week, in absence of complications. T-tube recipients had a bronchoscopy every 2 weeks until T-tube removal, allowing proper prosthesis cleaning to prevent obstruction and permit granuloma tissue treatment in both larynx and trachea. Temporary T-tube removal was performed under endoscopic view. Fig 2. Schema of the Grillo technique is shown. In stenosis affecting the mucosa at the cricoid ring level, the removal of the anterior cricoid ring is performed extraperichondrically, allowing preservation of a healthy layer for anastomotic coverage. The anterior ring is removed, completing the lateral excision with a fine rongeurs forceps. Posterior mucosa that is circumferentially affected is replaced using a Grillo flap tailored from the remnant trachea. Thyroid trachea anastomosis is performed using absorbable running sutures in the membranous face anchored by 2 stitches placed in the corners. The posterior stitches, picking up all the cricoids, layer (perichondrium and cartilage) to achieve a solid anastomosis. Covering the cricoids plate with healthy mucosa allows a proper confrontation with superior edge for healing. The anterior face is completed using interrupted concentric stitches in the cartilaginous face. or the larynx cartilages were damaged by previous procedures (eg, laser, tracheostomy, definitive T tubes, operations). In this operation, after laryngofissure, the cricoid plate is incised and divided at the midline (with or without interposition of free grafts) to increase the larynx lumen. A laryngofissure increases the chances of significant vocal cords edema and a temporary T tube (above the vocal cords and tamponaded for proper feeding) is mandatory for a few weeks or months if the cricoid plate has been excised or divided. A tracheostomy window for the temporary stent should be done at least 2 rings below the thyroid tracheal anastomosis. These endoluminal stents were used routinely in these last two groups for larynx modeling (Fig 3C). In general, the last group kept the T tube for at least 2 to 3 months due to the midline cricotomy. Long-Term Follow-Up All 64 patients had a postoperative follow-up of at least 1 year. Assessment included airway patency, vocal cords mobility and paradoxic movements during normal breathing, presence of granulation tissue, position of the arytenoids, and anastomotic status. We collected data about voice characteristics and quality of life. All patients underwent a laryngeal procedure, and, especially when thyroid or cricoid plates were sectioned, followed with logopedic and phoniatric rehabilitation for 3 to 12 months, depending on vocal impairment. Results were classified as excellent, good, fair, poor, and failure. A result was considered excellent if there were only mild changes in the voice and no dyspnea even on exertion. A good result reflected major changes in voice with maintenance of high-quality speech by phone with no dyspnea. A result was considered fair if there was dyspnea upon major exertion, with or without major changes in voice. A poor result was dyspnea upon minor exertion, and failure required reoperation or definitive T tube [1]. Statistical Analyses Statistical analyses were done SPSS 11 software (SPSS Inc, Chicago, IL). Death was defined as any death occurring during the hospital stay. Data are presented as mean standard deviation, median (range), absolute numbers, or percentages, as appropriate. Qualitative variables were compared with the 2 statistical test or the Fisher exact test as appropriate, with a significance level of p Results The final analysis excluded 4 of the 64 patients due to systemic disease diagnosed years after laryngotracheal reconstruction. There were 55 women (91%) and 5 men (9%). Patients were aged years (range, 19 to 77

4 436 MORCILLO ET AL Ann Thorac Surg IDIOPATHIC TRACHEAL STENOSIS 2013;95:433 9 Fig 3. (A) Initial Maddaus technique: Laryngofissure and posterior face of the anastomosis. An optimal exposure of affected mucosa and the lower limits of the vocal cords make consistent anastomosis easier to achieve. At least 4 stitches, picking up all the tracheal layers, are placed in the posterior face. These stitches give the real strength of the posterior part of the anastomosis. The Grillo flap resurfaces the cricoids plate, approaching both healthy mucosa edges by a running suture anchored with the corner stitches. (B) The Couraud technique: A midline cricoids plate split using a scalpel is the best option to widen the subglottic space. This preserves the recurrent laryngeal nerves and opens the larynx to achieve a normal airway caliber at this level. Sometimes free grafts (clavicle or ribs bone) are interposed into the cricoids edges or, very infrequently, between the split thyroids cartilage. These grafts are also covered with the membranous flap and with buccal or cheek mucosa in the anterior face. (C) Laryngofissure and cricoids division requires an endoluminal stent (T tube) for larynx modeling and vocal cords edema. The superior branch is placed immediately above the vocal cords and is tamponaded for correct feeding. The tracheotomy for the anterior branch is usually done 2 rings below the thyroid tracheal anastomosis and comes out to the skin through a contraincision. years). Thirty-eight patients (59.3%) had undergone previous treatments in other centers (Table 1). All patients were treated with a single-staged tracheal or laryngotracheal operation. Techniques and general results are detailed in Table 2. With the exception of one median sternotomy, the surgical approach was cervical incision in all patients. The average tracheal resection was mm (range, 23 to 45 mm). A temporary T tube, when needed, remained in place for days (range, 25 to 180 days). The average hospital stay was days. Treatment was successful in 59 patients (98%). One patient was considered biologically unfit for reoperation and needed a permanent T tube for restenosis. The most frequent postoperative complications were dysphonic voice in 10 patients (although in 7 instances this began months or years before the operation), granulation tissue in 10, aspiration in 3, wound infections in 2, temporary laryngomalacia in 1, and previous swallow disorders aggravated after the operation in 1 patient. Postsurgical new recurrent definitive paralysis occurred in only 1 patient. Four patients in the group with Couraud-type procedures underwent reoperations due to restenosis (n 2), laryngomalacia (n 1), and anastomosis dehiscence (n 1). These patients were decannulated, with good airway caliber. Postoperative major or minor complications occurred in 17 patients (28.3%). Dysphonic voice, swallowing disorders (including broncoaspiration), and reoperations were significantly more frequent when the cricoid plate was divided (p 0.03). Laser therapy for granulomas removal was more frequent in patients who received a T tube for more than 60 days (p 0.04). No other risk factors for complications were identified. Pearson-Type Operation Results were considered excellent in 17 of these 18 patients (94%). One patient had well- tolerated laryn-

5 Ann Thorac Surg MORCILLO ET AL 2013;95:433 9 IDIOPATHIC TRACHEAL STENOSIS Table 1. Previous Treatment Operation No. (%) Preoperative Treatments End-to-end 1... Pearson operation 18 (30) 4 Balloon dilation 3 Prosthesis (Dumon type) Grillo operation 11 (18) 4 Repetitive laser 2 Laser plus prosthesis (Dumon type) Maddaus operation 10 (17) 8 Dilation and repetitive laser 1 Operated-on in another center (failure) 2 Definitive tracheostomy Couraud techniques 20 (33) 10 Laser and/or dilation (mechanical or balloon) 4 Operated on in other centers (failure) 4 Definitive tracheostomy 3 Permanent T tube 7 No voice gomalacia that did not require reoperation, although a T tube was inserted for 3 months. The patient progressed to normal breathing but with a dysphonic voice despite logopedic and phoniatric rehabilitation. One patient was considered biologically unfit for reoperation and required a permanent T tube for restenosis. Grillo-Type Operation Infrahyoid release maneuvers were required in 2 of 11 patients treated with a Grillo technique. One of these patients sustained limited broncoaspiration, and percutaneous endoscopic gastrostomy for feeding was used for 3 months, after which the patient could eat without difficulty. Another patient had a postoperative anastomotic dehiscence, treated conservatively, and wound infection. Maddaus-Type Operation The ILTSs in 10 patients were sited very close ( 0.5 cm) to the lower limit of the vocal cords, with normal or very slightly impaired mobility. Eight patients had been treated previously in other centers with laser and dilation, and 1 patient was operated on and recurred. Two patients had undergone definitive tracheostomy. One patient required infrahyoids laryngeal release and another required a suprahyoids release. Average T-tube duration was days (range, 13 to 48 days). One patient experienced mild dysphonia, with excellent rehabilitation. Couraud-Type Operations The 20 patients in this group underwent cricoid plate division after anterior laryngofissure. Four patients had a recurrence after an operation in another center. At the beginning of our series, some free grafts, consisting of rib cartilage in 5, plus mucosa in 2, were interposed to widen the cricoid plate division. Currently, simple cricoid division and larynx modeling with a temporary T tube achieves excellent results. Only 4 patients (among the most complex stenoses, with vocal cords and cricoid plate involvement) required a reoperation for restenosis or larynx inconsistency. A temporary T tube was maintained for a mean of days (range, 28 to 180 days). One patient presented with temporary swallowing disorders and mild or severe dysphonic voice. Comment 437 Although ILTS is an infrequent disease with an unknown cause, several physiopathologic hypotheses have been proposed, including gastroesophageal reflux [15], chronic cough, and abnormal response to estrogen. Unlike iatrogenic tracheal stenosis, the natural history and extension of these lesions is not known, and their future course cannot be predicted [1, 3]. Some authors do not advocate for surgical treatment, considering ILTS as a progressive entity without a definitive cure and therefore more appropriate for palliative treatment sine die [4]. Techniques reported for ILTS treatment range from endoluminal palliative therapies [5] to definitive surgical procedures [1, 2, 7] involving resection of the affected tissue and its replacement with healthy tracheal mucosa tailored from the remnant trachea. Nonsurgical treatments are palliative at best [5]. Repetitive endoluminal treatments may cause new tracheal damage, making definitive surgical treatment more difficult and sometimes impossible [1, 13, 16]. Table 2. Type of Procedure and General Results Procedure No. (%) Distance to Vocal Cords Dysphonic Voice Result No. (%) No. (%) End-to-end anastomosis 1 2 cm 0 1 (100) Excellent Pearson operation 18 (30) cm 1 17 (94) Excellent 1 (6) T tube Grillo operation 11 (18) cm 1 11 (100) Excellent Maddaus operation 10 (17) 0.5 cm 1 10 (100) Excellent Couraud techniques 20 (33) Vocal cords or cricoid plate involved a 7 (35) 19 (95) Excellent or good 4 (20) Reoperation a Previous treatment caused laryngeal cartilage damage or vocal cord fixation.

6 438 MORCILLO ET AL Ann Thorac Surg IDIOPATHIC TRACHEAL STENOSIS 2013;95:433 9 The surgical approach has several advantages over other treatments: First, it is definitive and associated with good long-term results when the appropriate reconstruction technique is selected. Second, patients are freed from repetitive treatments for life (laser, balloon dilation, etc) and from prostheses complications (halitosis, granulation tissue, prosthesis migration, etc) [5]. Furthermore, these endoscopic treatments are particularly complex when laryngotracheal stenosis is sited very close to the vocal cords, and granuloma tissue formation and prothesis migration are frequent. Finally, some patients with a definitive T tube or tracheostomy can be successfully treated, opening the door to definitive decannulation. Airway operations are not risk-free, however. Major complications and death are linked to resections longer than 4 cm, diabetes, previous radiotherapy, and associated laryngotracheal reconstruction [17]. Optimal timing of the surgical approach is crucial to the success and safety of the operation. Inflammation or a stenosis close to the vocal cords demands maneuvers, such as dilation or corticoid treatments to maintain the airway, avoiding tracheostomy [1, 6]. Corticoids should be discontinued before the operation [10, 12]. The operation should be scheduled only when acute inflammatory changes have disappeared and only chronic cold stenosis remains [6]. The surgeon s perspective leads us to seek a definitive resolution of the problem even in the most complex, multiply treated, and previously operated-on patients. In our 3 decades of experience, we have treated ILTS with different surgical techniques depending on the stenosis location, vocal cords mobility and distance from the stenosis, and associated injuries caused almost exclusively by previous treatments. These surgical techniques all attempt to achieve aggressive and complete removal of the diseased mucosa as a primary and very important step. To widen the subglottic space, the anterior cricoid ring is routinely removed, preserving the cricoid plate to protect recurrent laryngeal nerves. This allows transfer of healthy, nonaffected mucosa to perform the mucosal confrontation in the anastomosis. In the Grillo [1, 2] technique, tailoring the flap requires the removal of several rings, mixing this plastic technique with tracheal and partial larynx resection. This cricoid plate resurfacing avoids excessive granulation tissue and restenosis caused by widely separated mucosal edges. In our opinion, appropriate handling of disease-free mucosa is essential to good results. A healthy mucosa anastomosis reduces technical complications, even though the anastomotic strength essentially depends on the cartilaginous (corner and anterior face) stitches. When the stenosis is so close to the vocal cords that there is little space for anastomosis, Maddaus and colleagues [12] proposed laryngofissure for total removal of affected mucosa and a more accurate thyroid-tracheal anastomosis. When damaged larynx cartilages narrow the glottic and subglottic space, resection of the anterior cricoid arch may be insufficient to achieve a normal laryngotracheal caliber. In these more complex cases, a midline incision over the cricoid plate is useful and may preserve any mobility that exists in the patient s vocal cords. Free grafts (rib cartilage, clavicle bone, and others) were interposed in some early operations to widen the cricoid plate division [18]. Currently, we achieve excellent results with a simple division and a temporary stent to keep the section open until the larynx is healed. These stents are mandatory for several weeks or months if the cricoid plate is divided. The timing of T-tube removal is controversial. Apart from personal preferences or limited experiences [12, 18], the literature lacks solid evidence. We usually leave T tubes for at least 30 days in case of laryngofissure and 2 months if the cricoid plate is divided. One patient with posterior cricotomy required T-tube reinsertion for 6 months after a removal failure. Nonetheless, the mean time in our series is 2 months. The most frequent complication was dysphonia, which is rarely seen in end-to-end tracheal operations. The likelihood and severity of dysphonia are greater when the stenosis is closer to the vocal cords. Seven patients had been unable to speak, some of them for years, for various reasons. In these patients, even a severely dysphonic voice was considered a very successful result. In patients with cricoid division, a severely or moderately dysphonic voice can be explained by the new, more separated position of the vocal cords, which impairs loud voice. This division also modifies the arytenoids position and the tension of tyro-arytenoids and cricothyroid muscles, affecting tonality. Laryngofissure and cricoid ring resection may cause voice changes but tend not to be very disturbing for the patient. After the operation, only 1 patient in our series acquired recurrent laryngeal nerve paralysis. Phoniatric and logopedic rehabilitation achieves excellent results, and even patients with a very hoarse or weak voice usually present remarkable improvement. The anterior laryngofissure and surgical action over the cricoid plate might also disturb swallowing and cause bronchoaspiration. Infrahyoid release maneuvers may have a role in this complication, although the limited clinical symptoms are very uncommon. Only 1 patient in our series suffered severe swallowing problems, which were treated with temporary gastrostomy. Grillo and colleagues [1, 2] have been considered the reference for ILTS treatment. However, their standard technique may be insufficient in glottic stenosis affecting the vocal cords. The Maddaus-type and Couraud-type operations are an excellent solution for these complex patients. We have established a surgical ILTS treatment based on an individualized selection technique, with excellent global results (98%) even in very complex patients. In conclusion, the ILTS surgical approach can be performed with low operative risk and high success rates as a standard curative treatment. The specific technique selection, with or without a temporary stent, must be individualized to achieve long-term good results. Location of the stenosis, larynx cartilages involvement, and vocal cords mobility are among the most important

7 Ann Thorac Surg MORCILLO ET AL 2013;95:433 9 IDIOPATHIC TRACHEAL STENOSIS factors to consider in technique selection. In the most challenging cases, an experienced surgeon with access to multiple surgical resources can offer safe reconstructive possibilities with excellent results. References 1. Ashiku SK, Kuzucu A, Grillo HC, Wright CD, Wain JC, Lo B, et al. Idiopathic laryngotracheal stenosis: effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 2004;127: Grillo HC, Mark EJ, Mathisen DJ, Wain JC. Idiopathic laryngotracheal stenosis and its management. Ann Thorac Surg 1993;56: Liberman M, Mathisen DJ. Treatment of idiopathic laryngotracheal stenosis. Semin Thorac Cardiovasc Surg 2009;21: Dedo HH, Catten MD. Idiopathic progressive subglottic stenosis: findings and treatment in 52 patients. Ann Otol Rhinol Laryngol 2001;110: Perotin JM, Jeanfaivre T, Thibout Y, Jouneau S, Lena H, Dutau H, et al. Endoscopic management of idiopathic tracheal stenosis. Ann Thorac Surg 2011;92: Couraud L, Chevalier P, Bruneteau A, Dupont P. Treatment of tracheal stenosis after tracheotomy. Therapeutic indications, preparation for the intervention. Apropos of 9 resections in 15 cases of acute respiratory insufficiency. Ann Chir Thorac Cardiovasc 1969;8: Couraud L, Jougon JB, Ballester M. Techniques of management of subglottic stenoses with glottic and supraglottic problems. Chest Surg Clin N Am 1996;6: Couraud L, Martigne C, Houdelette P, Dumas PJ, Morales F. Value of cricoid resection in cricotracheal stenosis following intubation. Ann Chir 1979;33: Couraud L, Martigue C, Dumas PJ, Houdelette P. The surgical treatment of stenosis of the airway following intensive care. The value of cricoid resection in cases of cricotracheal stenosis. Chirurgie 1978;104: Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;70: Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33: Maddaus MA, Toth JL, Gullane PJ, Pearson FG. Subglottic tracheal resection and synchronous laryngeal reconstruction. J Thorac Cardiovasc Surg 1992;104: Gomez-Caro A, Morcillo A, Wins R, Molins L, Galan G, Tarrazona V. Surgical management of benign tracheal stenosis. MMCTS doi: /mmcts Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486 92; discussion Walner DL, Stern Y, Gerber ME, Rudolph C, Baldwin CY, Cotton RT. Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg 1998;124: 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: Wright CD, Grillo HC, Wain JC, Wong DR, Donahue DM, Gaissert HA, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128: Terra RM, Minamoto H, Carneiro F, Pego-Fernandes PM, Jatene FB. Laryngeal split and rib cartilage interpositional grafting: treatment option for glottic/subglottic stenosis in adults. J Thorac Cardiovasc Surg 2009;137: DISCUSSION DR M. BLAIR MARSHALL (Washington, DC): Did you notice that those patients with dysphasia or laryngotracheal dysfunction were also those patients who had a release maneuver? DR GOMEZ-CARO: We thought that would be the rule; but in the 3 patients in whom we did a release, we did not have a big problem. The 1 patient in whom we had a very big problem was because he had some brain problems. I don t know exactly how to explain that, but it was not due to the operation.