Alper Toker, Serkan Kaya, Serhan Tanju, Yusufhan Süoğlu, Mustafa Ererel,

1. Interventions other than tracheostomy in subglottic and tracheal pathologies. What did we do in the last 5 years? Alper Toker, Serkan Kaya, Serhan Tanju, Yusufhan Süoğlu, Mustafa Ererel, Şükrü Dilege, Göksel Kalaycı Istanbul Medical School

2. Aim • Changing concepts in tracheal dieseases: 1990 • Resections • Endobronchial treatment modalities • Stenting • Hybride techniques • Our approach to tracheal disease in the last 5 years.

3. Patients and Methods • Jan 2002 – Jan 2007 • 62 patients, subglottic-tracheal obstructions • Postintubation tracheal stenosis: 36 patients • Secondary tracheal tumors: 16 patients • Primary tracheal tumors: 6 patients • Tracheosephageal fistula: 4 patients Age, sex, type of operation, reintervention, morbidity, mortality

4. Patients • 48 male, 14 female, • Mean age: 48.3 years (7-84 years) • Previous tracheal intervention: 24 patients • Trachea resections • Tracheal stenting • Tracheostomy • Intubation • TEF Division • Primary admission 38 patients

5. Patients before Jan 2002 8 tracheal resections and end to end anastomosis16 tracheal stenting Excluding Criterias • Operations in ENT Department: • Tracheal resections and end to end anastomosis • Tracheal reconstructions and plasty operations • Montgomary –T tube • Interventions in Department of Pulmonary Diseases • Endo Tracheal – Endo Bronchial treatment • Stenting

6. Emergency First intervention - reintervention • Bronchoscopy in all patients • Dilatation in BTS • Endoluminal tumor: Cautery, argon, cryotherapy • Stenosis that does not permit dilatation:Tracheostomy • Dilatation – stenting: Primary – Complication treatment • Endoluminal therapy – stenting: Primary – complication treatment

7. Dilatation and resection relations in BTS • Resection: after CT and Tracheoscopy • 13 patients • Dilatations and immediate resection • 12 patients • Technically easy, • Good risk patients, • Timing, • No inflamation. • Dilatation – reevaluation and resection • 6 patients • Odematous trachea, • Technically difficult, • Comorbidity, • A new CT is a must, • Previous interventions. 29 tracheal resection 1 reresection

8. Tracheal resections • 24 Benign tracheal -subglottic stenosis • 1 Primary tracheal tumors • 1 Secondary tracheal tumor • 3 Benign tracheosephageal fistulas Laryngeal release manuever: 4 patients (Suprahyoid release) Length of resection: 1cm - 5 cm

9. Tracheal resectionImmediate postoperative and early postoperative complications • Immediate postoperative complications (24 hours) • 2 emergency tracheostomy -1 hemorrhage • Early complications (24 hours – 10 days) • 4 patients with infections Cord vocal paralysis :Unilateral (symptomatic and diagnosed 4 patients) Bilateral (1 patient)

10. Late postoperative complications (10 days) 6 patients restenosis • Multiple dilatations • Dilatation Stenting: 1 patients - removed – no problem • Montgomary T tube 1 patient, • Argon laser 3 patient – no problem • Reresection 1 patient – no problem In tracheal resections 1 patient died: TEF – Fistula division - stenting - septic shock: Resection anastomosis- osephageal primary repair: mediastinitis - sepsis

11. Tracheal resections done in other centers • 1 patient: tracheal stenting • 1 patient: Montgomary T tube – Removed in the first year – no problem • 1 patient: Montgomary T tube – Multiple granulation tissue – Multiple endobronchial treatment – trachea perforasyonu - Hybrid interventions – Restenosis : Tracheostomy

12. Hybride interventions

13. Interventions other than resections employed in other centers: 21 patients • Tracheal stenting: 4 patients • Tracheostomy:13 patients • Endobronchial treatment: 2 patients • Tracheaosephageal fistula division 2 patients

14. Stenting • Stenting as a primary treatment • 8 patients: 4 patients with endobronchial treatment • 4 patients after dilatation • Stenting as a complication treatment • 6 patients: 2 patients after endobronchial treatment • 4 patients after dilatationsonrası tedavi • Complications and mortality • Tracheostomy: 2 patients: Stenting as a primary treatment • Postobstructif negative pressure lung edema:2 patients (12-24 hour intubation) • 1 patient died of febrile neutopenia –sepsis

15. Results • After Tracheal resection – stenting: 24 patients had multiple interventions; • Patients who had primary intervention in our hospital had a mean of 1.24 intervention. • Patients who had primary intervention in other centers had a mean of (excluding the primary intervention) 2.14 intervention. • Two patients died in hospital period. • 44 of the interventions were emergency, 36 were semi-emergency.

16. Discussion 1- Is stenting true in benign tracheal disease ? Or should it be resection ? Stenting : Duration Type of the stent General health and social condition, Literature: results (%24 Dumon 1996)(%26Martinez1996) (%17Brichet 1999) (%27 Puma 2002) 2- Could stent be a bridge to real treatment ? 3- Monodisciplinary ? Multidisciplinary airway team ?

17. Multidisciplinary airway team • Laryngeal examination, • Augmentaton of vocal cords, • Laryngeal release manuevers • Rigid Bronchoscopies • Flexible Bronchoscopies • Endobronchial treatment • Post operative care ENT Clinics Pulmonary Departments Chest Surgery Clinics Anesthesiology and intensive care unit Speech therapists