Papillary squamotransitional cell carcinoma of the uterine cervix: an advanced stage disease despite superficial location: report of two cases and review of the literature

Percutaneous dilatational tracheostomy (PDT) is becoming an accepted cost-effective alternative to surgical tracheostomy. PDT is performed by progressive dilatation of a tracheal opening placed under bronchoscopic guidance. Case reports of hypoventilation with associated hypercarbia during the performance of PDT have raised concerns about the utility of this procedure in patients in whom hypercarbia is problematic (e.g., patients with closed head injury). In a prospective cohort analysis of 11 critically ill patients, we evaluated the effect of PDT on ventilation during and after the procedure using end tidal capnography. We found that hypercarbia does not occur during or after the performance of PDT as compared to baseline levels.     

Effects of blood transfusion on left ventricular output in premature babies

Tracheostomy tube insertion is periodically performed when patients with acquired immunodeficiency syndrome (AIDS) require prolonged mechanical ventilation. In this population, bedside percutaneous tracheostomy may be a better technique than conventional operating room tracheostomy because it reduces procedural cost, requires no patient transport, and requires few sharp instruments, thereby potentially decreasing risk to surgical staff. A retrospective review was conducted in the Department of Medical Records at St. Vincents Hospital and Medical Center of New York City. Nine consecutive patients diagnosed with AIDS and undergoing percutaneous tracheostomy from January 1, 1992, to December 31, 1996, were identified. All patients were males (mean age 32.1 +/- 4 years, CD4 count average 145) and were ventilator-dependent for mean of 24 +/- 3 days. The procedure was successful and without complications in all patients. Follow-up was 27 months (range 1-42 months) and in-hospital mortality was 77 per cent. The average length of survival for those patients who died in the hospital was 29 days (range, 3-120). Two patients survived the hospitalization after undergoing decannulation on postoperative days 29 and 52, respectively. Despite the poor prognosis after tracheostomy in patients with AIDS this procedure allows better oral care and may improve patient comfort. Bedside percutaneous tracheostomy can be performed with less risk to surgical personnel and patient when compared to conventional surgery. This minimally invasive procedure safely and efficiently provides prolonged tracheal access in patients with AIDS.     

Differential cellular response within the rabbit tendon unit following tendon injury

Since 1975, 340 patients were treated by tracheal sleeve resection for tracheal or subglottic laryngeal iatrogenic stenoses in our unit. Preoperative iterative Nd YAG laser sessions have usually been performed, without success. The length of the sleeve specimen was an average of 3 1/4 cm. Twelve patients died on the post operative course (3.5%), 3 more patients died later after failure of the procedure (0.9%) and nineteen had recurrent stenoses treated with use of a tracheostomy tube, a permanent Montgomery tube, or an endotracheal stent (5.6%). Three hundred and six patients are definitely cured (90%), at the first attempt for 265 patients, after a laser session for granulomas for 20 patients, after a second tracheal resection for 6 patients and after a temporary Montgomery tube for 15 patients. Providing there is a good selection of the patients, tracheal sleeve resection is the best treatment for iatrogenic stenosis.     

Bedside tracheostomy in the intensive care unit

OBJECTIVE: To prove that tracheostomy performed at the bedside in the intensive care unit is a safe, cost-effective procedure. DESIGN: Retrospective review of all adult patients undergoing elective bedside tracheostomy in the intensive care unit between January 1983 and December 1988. Two hundred four patients were identified. SETTING: A private 1200-bed tertiary care center with a 120-bed critical care facility. MAIN OUTCOME MEASURES: Major and minor perioperative complications, cost savings, and comparison of risk between bedside tracheostomy and that performed in the operating room. RESULTS: There were six major complications (2.9%): one death due to tube obstruction, two bleeding episodes requiring reoperation, one tube entrapment requiring operative removal, one nonfatal respiratory arrest, and one bilateral pneumothorax; and seven minor complications (3.4%): five episodes of minor bleeding, one tube dislodgement in a tracheostomy with a well-developed tract, and one episode of mucus plugging. One late complication (tracheal stenosis) was identified. CONCLUSIONS: Bedside tracheostomy in the intensive care unit can be performed with morbidity and mortality rates comparable to operative tracheostomy. In addition, it provides a significant cost savings for the patient.     

The inferior thyroid veins--the ultimate guardians of the trachea

The inferior thyroid veins and their multiple tributaries are the ultimate guardians of the cervical trachea. Deeply embedded in the pretracheal fat pad, this plexus of veins is consistently encountered during low tracheostomy that accompanies conservation laryngral procedures as well as in tracheal reconstruction. In a high tracheotomy, the handling of the thyroid isthmus is simplified by an appreciation of these veins. Even cricothyrotomy is potentially complicated by hemorrhage sebsequent to a tear in a tributary of the inferior thyroid venous system. A cadaver study, employing 10 embalmed head and neck specimens, was performed to elucidate the tributary patterns of these veins. In every dissection there was at least one and as many as five veins overlying the trachea just below the thyroid isthmus. In 7 of 10 dissections a confluence of right and left inferior thyroid veins formed a large thyroid ima vein draining into the left innominate vein, and in 1 of 10 cases the thyroid ima vein drained into the right innominate. This confluence was present at a level which would be encountered in low tracheostomy or tracheal repair procedures. Six of 10 dissections presented large tributaries of the inferior thyroid veins overlying the cricothyroid membrane. An awareness of such anatomical considerations should result in safer surgical procedure performed in a dry operative field.     

Binding of mutated Ras- and p53-derived peptides to HLA-DR molecules

We investigated retrospectively 132 cases of open wedge high tibial osteotomy using an external fixation device, concentrating on the rate of neurological complications. One group of patients underwent surgery according to the conventional technique (n = 89). The rate of transient neurological complications was 15.7%; 7 months after surgery the rate of persistent deficits was 12.4%. For the second group (n = 43) a modified surgical technique was used that lowered the complication rate significantly (transient deficits 14%, persistent deficits 4.7%). In the modified technique the osteotomy is not performed in the conventional way using an oscillating saw but through consecutive drill holes of increasing diameter followed by osteoclasis. The lower complication rate in the second group is mainly due to the less extensive approach that leads to a smaller number of postoperative tibialis anterior syndromes (type B lesion). No differences were found with type C lesions (extension deficit of D1). No complete peroneal nerve palsy (type A) occurred in either group. We conclude that the reduction of neurological complications in group 2 is related to the less extensive approach of the proposed technique.     

Third angioplasty, and after that?

The authors studied retrospectively a series of 39 patients with a documented second restenosis after coronary angioplasty between January 1987 and November 1992, 33 of whom (31 men, 2 women) underwent a third procedure. The artery dilated was the left anterior descending (n = 17 including 9 proximal stenoses), the right coronary (n = 10), the left circumflex or its branches (n = 5) and the left main stem (n = 1). The lesions were confirmed to one vessel in 25 cases (75%) and affected two vessels in 8 cases (25%). The third angioplasty procedure was performed on a single artery in all cases. The average left ventricular ejection fraction was 60% (43%-75%). The diameter of the dilated artery was over 3.25 mm in 24% of cases (8/33). The primary success rate was 100% without any complications. The average period between the first and second angioplasties was 16 +/- 10 weeks, and between the second and third angioplasties 19 +/- 12 weeks. Angioplastic controls of the 3rd angioplasty were performed in 25 cases (75%). A third restenosis (n = 7) was treated by surgical bypass (n = 1), repeat angioplasty (n = 4), endocoronary stenting (n = 1) or medically (n = 1), with a global follow-up of 22 months (2-56 months), 2 patients underwent coronary bypass grafting, 2 have residual angina (contralateral lesion which could not be dilated), 1 had an infarct in the territory of an undilated artery, and 28 (85%) were asymptomatic. The restenosis rate after the third angioplasty procedure was 28% (7/25).(ABSTRACT TRUNCATED AT 250 WORDS)     

A Monte Carlo model for bone mineral measurement using dual energy X-ray absorptiometry

We discuss the surgical approach used for and outcome in 11 infants (< or =3 years) who were treated at our institution for ependymomas arising in the cerebellar-pontine (C-P) angle. The median age of the group was 19 months (range: 6-26 months). Of these 11 patients, the initial surgery for 8 was performed at our center and achieved a gross total resection (GTR) in 4 patients and a subtotal resection (STR) in the remaining 4. The 3 patients who had tumor debulking performed elsewhere were subsequently referred to our institution and had definitive surgery after receiving 3-4 courses of chemotherapy; one of these children had a GTR, whereas the remaining 2 had an STR. During the immediate postoperative period, 9 patients had cranial nerve deficits that necessitated placement of a tracheostomy and a gastrostomy feeding tube; these were discontinued in 6 of the 9 patients as the deficits resolved. The majority of the permanent cranial nerve deficits involved the sixth and seventh cranial nerves. Of the 11 patients, 4 have died (progressive disease, n = 1; accidental death, n = 2; withdrawal of life support, n = 1); the remaining 7 patients are alive, with a median follow-up of 37 months (range: 20-73 months). Aggressive surgical resection for tumors arising in the C-P region is associated with postoperative deficits, which resolve over time with appropriate supportive care. This approach may increase the number of children in whom GTR is achieved, thereby potentially increasing the cure rate for these patients.     

Our experience in treating obstructive lesions of the main airway by Nd-Yag laser resection

We performed 164 laser resections with a neodymiumyttrium-aluminum-garnet (Nd-Yag) laser in 116 patients between January 1992 and December 1997. Seventy-eight patients had malignant neoplasms, 5 had neoplasms of intermediate malignancy and 33 had inflammatory tracheal lesions. Eighteen resections were emergency procedures. All resections were performed with the patient under general anesthesia and preferably breathing spontaneously. Immediate results varied according to the nature and location of the lesion. Treatment was palliative for tumors showing intraluminal proliferation, providing successful reopening of the airway as shown endoscopically in 70% of patients. Mean survival of the 44 patients with malignant lesions who could be followed was 29 weeks, with a median of 15.19 (range, 1-120). The tracheas of patients with inflammatory stenosis were reopened rapidly and emergency tracheostomy was avoided in all cases. One patient with malignant tracheal tumors died during the procedure due to asphyxia related to tracheal hemorrhage.     

Application of the laryngeal mask for elective percutaneous dilatation tracheotomy

Percutaneous dilatational tracheostomy is an increasingly accepted procedure for bed-side tracheostomy. The exact positioning of the endotracheal tube, the localization of the point for puncturing the trachea and damage to the endotracheal tube and the cuff as well as to the bronchoscope due to the puncturing process are technical problems which can endanger the course of the operation. In a prospective randomized study, we examined whether use of the laryngeal mask airway (LMA) is a real alternative to the endotracheal tube during tracheostomy. Of 48 consecutive patients only 43 fulfilled all criteria for this study: PaO2 > 100 mmHg, PaCO2 < 45 mmHg (in patients with head injury < 35 mmHg) under intermittent positive pressure ventilation (IPPV) with a mean ventilation pressure of < 25 mmHg and an FiO2 of 1.0. Patients with intestinal obstruction, hemorrhages of the mouth and nose and unfavourable anatomic conditions were not included in this study. Three more patients had to be excluded from the study because of technical problems. In 21 patients tracheostomy was performed using an endotracheal tube (ET group) and in 19 patients using a LMA (LM group). After positioning of the endotracheal tube or the LMA, tracheostomy was performed in the usual way. Arterial blood gases (PaO2 and PaCO2) were investigated before positioning of the endotracheal tube or the LMA, five minutes after this procedure and five minutes after the end of tracheostomy. Mean arterial pressure (MAP), heart frequency (HF) and peripheral oxygen saturation (SpO2), endexpiratory CO2 partial pressure (PetCO2) and minute ventilation volume (MVV) were registered every 60 seconds. The ET group and LM group did not differ regarding basic diseases, age and severity of illness. Before the beginning of tracheostomy, there were no differences in MAP, HF, SpO2, PetCO2 and PaCO2 between the two groups. Before tracheostomy, only PaO2 was significantly higher in the LM group than in the ET group. Immediately before the insertion of the tracheal cannula and five minutes after the end of tracheostomy, there were no differences in the measured parameters of the two groups. An increase in PetCO2 and a decrease in minute ventilation volume were observed in both groups. Regarding technical complications, the LMA is a safe alternative to the endotracheal tube. The choice of method should depend on the basic disease and the patient's ventilation requirements at the time of tracheostomy, while there is still a call for safe instruments guaranteeing sufficient sealing of the respiratory tract during the dilatational tracheostomy and simultaneous avoidance of technical problems during puncturing of the trachea and widening of the point of puncturing.     

Early tracheostomy tube change in children

OBJECTIVE: To review the safety of early tracheostomy tube change in children. DESIGN: Retrospective case series. SETTING: Pediatric tertiary care hospital. PATIENTS: Twenty-one consecutive pediatric patients undergoing routine tracheotomy. INTERVENTION: First tracheostomy tube change performed at patient's bedside at 3 (n = 15) or 4 (n = 5) days after surgery. OUTCOME MEASURE: The ability to safely change a tracheostomy tube at the patient's bedside 3 or 4 days after surgery. RESULTS: The first tracheostomy tube change was safely performed at 3 or 4 days after surgery in 20 patients. All changes were accomplished without complication or difficulty on the first attempt. The patients' ages ranged from 4 days to 16 years. The smallest child weighed 1.6 kg. Early tracheostomy tube change was not attempted in one obese 10-year-old girl whose pediatric tracheostomy tube became dislodged and formed a false tract 2 days after surgery. CONCLUSIONS: Most pediatric tracheostomy tubes can be safely changed at the patient's bedside approximately 3 days after surgery. Clinical applications of early tracheostomy tube change may include facilitating better hygiene, earlier completion of family caregiver tracheotomy education, and shorter hospital stays. It appears safe and advantageous for surgeons to consider early initial tracheostomy tube change for pediatric patients.     

Doctoral education in nursing for practitioner knowledge and for academic knowledge: the University of Adelaide, Australia

A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU. Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3 +/- 2.8 (mean (SD) for Gp I vs 7.8 +/- 2.7 for Gp II (P = n.s.) and at elective tracheostomy (Gp III) was 5.4 +/- 2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P < 0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8 +/- 7.1 days in Gp II vs 11.7 +/- 2.9 days in Gp III (P < 0.05). In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.     

Operating on placental support: the ex utero intrapartum treatment procedure

While treating eight fetuses with predictable airway obstruction, the authors developed a systematic approach, the ex utero intrapartum treatment procedure, to secure the airway during delivery. Six patients had their trachea plugged or clipped in utero for treatment of congenital diaphragmatic hernia, and two patients had prenatally diagnosed cystic hygroma of the neck and oropharynx. The ex utero intrapartum treatment procedure was performed by using high doses of inhaled halogenated agents to facilitate uterine relaxation during cesarean section, securing the fetal airway while feto-placental circulation remained intact, and then dividing the umbilical cord. A variety of procedures were performed during the ex utero intrapartum treatment procedure including bronchoscopy, orotracheal intubation, tracheostomy, tracheostomy with retrograde orotracheal intubation, tracheoplasty, removal of internal tracheal plug, removal of external tracheal clip, central line placement, and instillation of surfactant. There were minimal maternal or fetal complications during the procedure. This approach requires the coordinated efforts of pediatric surgeons, obstetricians, anesthesiologists, sonographers, and neonatologists. The combination of intensive maternal-fetal monitoring, cesarean section with maximal uterine relaxation, and maintenance of intact feto-placental circulation provides a controlled environment for securing the airway in babies with prenatally diagnosed airway obstruction.     

Delayed complications after extrapleural pneumonolysis for lung tuberculosis

The epidemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculotic drugs led to a renaissance of surgical procedure such as plombage thoracoplasty, initiated in 1891 by Tuffier. Especially in Germany the insertion of paraffin and polyethylene was used in order to achieve an extrapleural pneumothorax in order to collapse the tuberculous cavities in the upper lobes. Due to a high rate of early complications and the assumed cancerogenicity, in a considerable number of cases the material was removed soon after its deployment. In some cases with the filling remaining in place, 30-40 years later infections and/or neoplasms occurred. From 1985 to 1996 in two centers of thoracic surgery 13 patients underwent procedures for removal of filling material. The patients suffered from infections (n = 11), malignant lymphoma associated with infection of the plombage (n = 1) and bronchial carcinoma (n = 1). Technically, we performed the thoracoplasty described by Schede (n = 9). Schede's thoracoplasty in combination with a muscle flap repair (n = 1) or partial resection of the thoracic wall (n = 1), an empyemectomy (n = 1), and an en-bloc pleuropneumonectomy (n = 1). All patients suffered from multiple underlying diseases (COPD, coronary heart disease, diabetes mellitus). However, apart from beside two procedure related deaths (pulmonary embolism n = 1, pneumonia complicated by multi-organ failure n = 1) no other major complications were observed. The plombage material in the case of malignant lymphoma is probably carcinogenic in relation to the time of exposure and should be removed in all cases.     

Nonparasitic cysts of the liver: results and options of surgical treatment

Nonparasitic cysts of the liver (NPHC) are highly variable in respect to appearance and therapeutic approach. The treatment of these cysts varies according to the nature and appearance of the disease. Based on the variable nature of disease and the various therapeutic options, all of which were attempted in our patients, the most suitable mode of treatment for different forms of NPHC are discussed. Ninety-one patients with NPHC who had been treated surgically from 1977 through 1995 were examined retrospectively. Asymptomatic peripheral cysts measuring up to 10 cm do not require further treatment. Computed tomography (CT)-guided aspiration (n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically (n = 10) or by the conventional surgical mode (n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver (n = 9) was successfully performed in cases of polycystic disease (n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver (n = 4). In patients in whom we found that the cysts communicated with the ductal system (n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.     

Long-term follow-up of immunosuppressive treatment for obstructive airways disease after allogeneic bone marrow transplantation

BACKGROUND: Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. METHODS: A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. RESULTS: Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. CONCLUSIONS: These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.     

Extensive indication of mitral valvuloplasty for non-rheumatic mitral regurgitation and postoperative QOL

Between January 1993 and June 1996, 108 patients with non-rheumatic mitral regurgitation (MR) underwent surgical treatment. Mitral valvuloplasty (MVP) was performed in 94 patients (87%) and mitral valve replacement (MVR) was performed in 14 patients. The patients were reviewed based on the location of the prolapse, active endocarditis, and re-valvuloplasty. The proportion of MVP patients to the total number of cases was 92%, 96% and 94% for prolapse of the anterior mitral leaflet (MVP: n = 22), the posterior mitral leaflet (n = 47) and of both leaflets (n = 15), respectively; it was 60% and 33% in the patients with active infective endocarditis (n = 3) and in reoperation cases (n = 3). Reoperation was required in 2 patients. Other than reoperation cases, 3/4 grade MR was detected by color Doppler echocardiography in 6 patients although they were asymptomatic. Thromboembolism occurred in 3 patients. The event-free rate at 42 months was 80.4%. Concomitant maze procedure was performed in 36 of 39 patients with atrial fibrillation and normal sinus rhythm was obtained in 25 of the 36 patients. Only 6 patients received warfarin anticoagulation after MVP. In current cases with non-rheumatic MR, the MVP could be performed in 87% of all patients and in 94% of the patients with simple prolapse, regardless of the prolapse area. Concomitant maze procedure might provide a better quality of life after MVP.     

Effects of organophosphorus, carbamate, pyrethroid and organochlorine pesticides, and a heavy metal on survival and cholinesterase activity of Chironomus riparius Meigen

BACKGROUND & AIMS: The first therapeutic experiences with the conventional photosensitizer dihematoporphyrinester in the treatment of Barrett's esophagus show the curative potential of photodynamic therapy (PDT). The aim of this study was to test 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX, a photosensitizer with a high mucosa specificity without phototoxic side effects on the skin, as a new form of PDT. METHODS: Thirty-two patients (mean age, 68.5 years) with histologically proven high-grade dysplasia (n = 10) and mucosal cancer (n = 22) in Barrett's esophagus were treated. Four to 6 hours after oral ingestion of 5-ALA (dose, 60 mg/kg body wt), irradiation was conducted with a dye laser system (635 nm) with a light dose of 150 J/cm2. The patients received 20-80 mg omeprazole daily after PDT. RESULTS: High-grade dysplasia was eradicated in all patients (10 of 10), and mucosal cancer was eliminated in 17 of 22 patients (77%) at a mean follow-up of 9.9 months (range, 1-30 months). All tumors < or = 2 mm in thickness were completely ablated (17 of 17). The method-related mortality and morbidity was 0%. CONCLUSIONS: Severe dysplasia and thin (< or = 2 mm) mucosal cancer of Barrett's esophagus can be completely ablated. PDT might offer a minimally invasive treatment modality as an alternative to esophagectomy.     

Ciaglia's percutaneous dilatative tracheostomy in intensive care. Perioperative complications and long-term results

BACKGROUND AND AIM: The introduction of percutaneous tracheostomic techniques using dilatation (PDT) has led to the gradual disuse of conventional methods of surgery. The aim of this study was to evaluate ventilatory function in critical patients during the execution of PDT using Ciaglia's method as well as, in the postoperative phase, the long-term results, namely endotracheal lesions and cosmetic deformities of the stoma. EXPERIMENTAL DESIGN: A prospective study was carried out on a consecutive series of adult patients. SETTING: The intensive care ward of a 600-bed teaching hospital. PATIENTS: A group of 50 critical patients undergoing PDT from 1993 to 1996. Valuations of ventilatory function: expiratory volume (EV), PaO2 and PaCO2, were calculated in 40 patients undergoing PDT. Endoscopic controls of the trachea were performed in 21 surviving patients 60 days after the removal of the tracheostomic tube and a cosmetic evaluation of the tube insertion site was also made in the same patients. RESULTS: During PDT a mean reduction of EV was observed of 1.41/min and PaO2 values also diminished 15% accompanied by a 14.2% increase in PaCO2. The endoscopic control performed after 60 days in 21 out of 50 patients revealed a subglottal stenosis in 1 patient, the presence of nonstenosing cicatricial granuloma in 2 patients, edema in 2 patients and dysepithelisation of the tracheal mucosa in a further 2 patients. The remaining 66% showed flattening of the mucosa and complete restitutium ad integrum. No usurpations and cicatricial tractions of the tube insertion site were observed. CONCLUSIONS: This prospective study of intraoperative ventilatory function and the final outcome of PDT according to Ciaglia confirms that this is a reliable technique for the ventilatory management of critical patients with a low percentage of long-term complications.