European Journal of Cardio-thoracic Surgery 29 (2006) 35—39

www.elsevier.com/locate/ejcts

Tracheal and cricotracheal resection for laryngotracheal stenosis:

experience in 54 consecutive cases
Juan Moya Amorós a,*, Ricard Ramos a, Rosa Villalonga b,
Ricard Morera a, Gerardo Ferrer a, Pablo Dı́az c
a
Department of Thoracic Surgery, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain
b
Department of Anaesthesiology and Reanimation, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain
c
Laser Unit, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain

Received 28 July 2005; received in revised form 12 October 2005; accepted 17 October 2005; Available online 6 December 2005

Abstract
Objective: Partial tracheal resection (Küster operation (KO)) and cricotracheal resection (Pearson operation (PO)) are currently the standard
operative techniques in the curative treatment of tracheal and cricotracheal stenosis, respectively. This study aims to analyze the outcomes of
tracheal and cricotracheal resection when a specific protocol is applied. Methods: Between 1990 and 2004 we treated 54 patients with
laryngotracheal stenosis. The mean age was 44.9 years with a sex ratio of 1:1. All patients were treated according to the random protocol
‘‘Lesions of the main airway (MA) protocol,’’ which considers the following stenosis variables: stage of development (S), caliber (C), and length
(L). We performed 38 Küster operations, 14 Pearson operations, and 2 combined Pearson—Küster—Rethi operations (ROs). Results: Overall
mortality of the series was 1.85%, with a specific morbidity of 27.7%. A total of 96.2% of patients were cured (85.6% of Pearson operation and 100%
of Küster operation). We performed 3.7% re-interventions (14.2% of Pearson operation and 0% of Küster operation), and the failure rate was 3.7%
(14.4% of Pearson operation and 0% of Küster operation). We had 27.5% who had postoperative complications (28.5% of Pearson operation and
26.3% of Küster operation). The most frequent complications were restenosis (14.2%), granulation tissue (13.1%), edema (10.5%), anastomotic
dehiscence (7.1%), and tracheoesophageal fistula (7.1%). In terms of the SCL variables, significant differences were only observed with respect to
morbidity between the S4 group and the other cases without tracheoesophageal fistula in the Küster operation group; we found no differences in
Pearson operation. Conclusions: Application of the Main Airway protocol allowed development of a strategy for the surgical treatment of main
airway stenosis. This, in turn, enabled a strict selection of cases and meticulous preoperative preparation that, coupled with a highly effective
surgical technique, led to excellent outcomes with minimal sequel. The presence of tracheoesophageal fistula could increase the complications.
# 2005 Published by Elsevier B.V.

Keywords: Laryngotracheal stenosis; Tracheal resection; Cricotracheal resection; Tracheoesophageal fistula

1. Introduction and cricotracheal resection through the Pearson operation

Within the field of main airway (MA) surgery, controversy
remains as to which technique should be used: conservative
treatments [1] (laser and endotracheal prosthesis) or full-
scale surgery. The usual pathologies requiring this type of
treatment are inflammatory stenosis of the trachea and/or
tracheoesophageal fistulas in critical patients on artificial
ventilation [2], and less frequently in the case of traumatic
lesions, tracheal and/or mediastinum tumors.
Currently, the standard techniques used in the curative
treatment of tracheal and cricotracheal stenosis are the
segmental resection and anastomoses of the trachea,
respectively, by means of the Küster operation (KO) [3]
* Corresponding author. Present address: C/Bruc 44-46, entl8-1a, 08950-
Esplugues, Barcelona, Spain. Tel.: +34 93260770; fax: +34 932607983.
E-mail address: jmoya@ub.edu (J.M. Amorós).
1010-7940/$ — see front matter # 2005 Published by Elsevier B.V.
doi:10.1016/j.ejcts.2005.10.023
(PO) [4]; the Rethi operation (RO) [5] is reserved for cases of
glottic and subglottic stenosis. Most of the research in this
area has taken the form of retrospective studies [6—13], thus
illustrating the difficulty of standard therapeutic indications.
The aim of the present study was to analyze the outcomes
of tracheal and cricotracheal resection when applying a
specific protocol.
2. Methods
The sample comprised 54 patients operated on consecu-
tively between January 1990 and October 2004. Paper
information about the technique, results, and complications
were given during the first consultation. This study is a review
of a prospectively gathered database. It was approved by our
institutional committee on human research, and all patients
provided written informed consent.
36 J.M. Amorós et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 35—39

Table 1 Table 2
Baseline pathology of patients with tracheal stenosis MA protocol: classification of the independent variables

Type of pathology No. Percent Stage of development Diameter of Length of ste-

stenosis (mm) nosis (mm)
Suicide attempt 1 1.85
Anorexia nervosa 1 1.85 S1 Chronic fibrosis C1 <7 L1 <20
Cerebral infarction 4 7.4 S2 Inflammation/granuloma C2 7—10 L2 20—40
Esophageal atresia 1 1.85 S3 Malacia C3 >10 L3 >40
Respiratory failure following surgery 9 16.66 S4 Tracheoesophageal fistula
Encephalitis 1 1.85
Cardiac insufficiency—acute 3 5.55 MA: main airway.
coronary syndrome
Respiratory insufficiency—chronic 1 1.85
obstructive pulmonary disease cricoid resection (PO), the anterior and lateral portions of
Malignant arterial hypertension 1 1.85
Neoplasia with tracheal invasion 7 12.96
the cartilage were removed, sparing the perichondrium and
Acute pancreatitis 1 1.85 mucosa; with the aim of sparing the caudal laryngeal nerves,
Politrauma 20 37 rongeur forceps were used until reaching the thyrocricoid
Burns 3 5.55 joint, described by Couraud et al. [8].
Tetanus 1 1.85
On one occasion, the tracheobronchial bifurcation was
Total 54 99.9 released to reduce the tension in the anastomosis line,
which was not necessary to carry out the Dedo [14]
maneuver. In seven cases of PO in which the suture was
The etiology of the benign stenosis (whether or not placed very close to the vocal chords, a Montgomery [15] T-
associated with a tracheoesophageal fistula) was prolonged tube was inserted for greater safety and remained in place
intubation or post-tracheostomy for cardiorespiratory for 18 months. The patients were extubated in the
resuscitation; no cases of idiopathic stenosis were operating room and were kept under observation for 48 h
observed. Table 1 shows the specific baseline pathology the intensive care unit.
of the patients. Systematic bronchoscopy was performed in
all cases; neck and chest computerized tomography (CT) 2.2. ‘‘Lesions of the main airway (MA)’’ protocol
and/or nuclear magnetic resonance (NMR) were carried out
in 49 patients (90.74%); and the flow/volume (F/V) curve In 1990 our hospital began to apply the ‘‘Diagnostic and
was applied in non-tracheostomy cases. Follow-up was Therapeutic MA protocol’’ (Tables 2 and 3). This protocol
completed in all patients from 2 month to 12 years, with a classified the inflamed laryngotracheal stenosis according to
median follow-up of 36 months; the evaluation included a topographic and lesional criteria, incorporating three
bronchoscopy, neck and chest CT scan, and F/V curve independent variables: stage of development (S), caliber (C)
monthly for 3 months. and length (L). This protocol was approved by the Institu-
tional Ethics Committee.
2.1. Surgical technique From the very beginning of applying MA protocol, all
patients admitted and diagnosed with main airway pathology
To perform tracheal or cricotracheal cuff resections, the in our department were evaluated using bronchoscopy, CT,
following procedures were carried out in all the cases: (a) and/or NMR. The results were classified according to Table 2
general anesthesia with orotracheal intubation using tubes of and the composition of three variables (S, C, and L) was used
caliber 5—6 (90.74% of cases), which were placed in a to determine the stage of lesion and treatment option, as
prestenotic position in nine cases (16.66%); in tracheosto- described in Table 3. Importantly, each case and the results of
mized patients, an intubation tube was left in the larynx; (b) diagnosing procedures were thoroughly evaluated by a
after the patient was placed in the position of hyperexten- multidisciplinary committee of surgeons, endoscopy specia-
sion, transversal cervicotomy was performed, with partial
sternotomy of the manubrium in two cases and associated
Table 3
with Grillo’s right thoracotomy in one case; and (c) dissection MA protocol: stage of lesion (SCL) and technical options
of the visceral compartment of the neck with transverse
section of the infrahyoid muscles, the anterior surface of the SCL stage First option Second option

trachea was exposed and circumferential dissection of the Chronic stage

trachea sparing the inferior laryngeal nerves, and circumfer- S1{C1—C2} {L1—L2} Laser (three sessions) Küster operation
S1 {C1—C2} L3 Laser + prosthesis —
ential tracheal and/or cricotracheal resection was per-
formed. Tracheal anastomosis or end-to-end tracheal tugging Subacute stage
was performed with sutures of 3-0 polyglactin (Vicryl1, S2 {C1—C2} {L1—L2} Laser (three sessions) Küster operation
S2 {C1—C2} L3 Laser + prosthesis —
Ethicon Inc.). In cases of tracheoesophageal fistula, an
esophagorrhaphy was performed with interrupted sutures of Malacia
S3 {C1—C2} {L1—L2} Küster operation Prosthesis
3-0 polyglactin and esophageal suture was buttressed with
S3 {C1—C2} L3 Prosthesis —
sternocleidomastoid muscular flap to isolate it from trachel
anastomosis. TEF Küster operation + myoplasty sternocleidomas-
toid muscle (SCMM)
During exeresis and anastomosis, the surgical field was
kept ventilated by means of a distal intubation tube. In the MA: main airway.
 J.M. Amorós et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 35—39 37

Table 4 Table 6
SCL Distribution of tracheal stenosis (n = 54) Outcome in Küster operation (n = 38)

Inflammatory Group Total

Parameter Group No. Without fistula With fistula
Stage of Development (S) S1 25 No. 24 14 38
S2 3
S3 5 Cured
S4 14 No. 24 14 38
Percent 100 100 100
Caliber (C) C1 36
C2 8 Minor procedures (No.) 5 5 10
C3 3

Length (L) L1 21
L2 26 3. Results
L3 0
The overall mortality of the series was 1.85%, with a
Neoplasic
specific morbidity of 27.7%. A total of 96.2% of patients were
Histology No. Localization CL state cured; the figures for re-intervention and minor procedures
Carcinoid 2 Thoracic trachea C1L1 were 3.7% and 24%, respectively, with a failure rate of 3.7%.
Insular cells-thyroid 1 Cervical trachea C2L2 Below, the results are analyzed according to the type of
Follicular cells-thyroid 1 Cervical trachea C2L2 intervention.
Glomangioma 1 Cervical trachea C2L2
Hemangioma 1 Thoracic trachea C2L1
Thyroid lymphoma 1 Cervical peritrachea C1L2
3.1. Küster operation

This operation was performed in 38 cases (17 stenosis, 14

lists, intensive care doctors and otorhinolaryngologists. The
committee discussed the cases and assigned a stage of injury
(SCL), and the best therapeutic option was chosen and
performed following Table 3. The distributions for the three
variables are listed in Table 4.
2.3. Tracheal (KO) and cricotracheal (PO) resection
We performed 38 tracheal resections (KO), 14 cricotra-
cheal resections (PO) and two PO + KO + RO (Table 5).
Inflammatory lesions were staged according to the SCL
variables, while neoplastic tumors were tabulated according
to the variables C and L (Table 4). Twenty-eight cases with
inflammatory stenosis receiving laser treatment were given a
maximum of three sessions over a period of 6 weeks, and, in
the event of failure, 3 months were allowed to elapse before
performing the surgery.
The mean age was 44.9 years (range, 18—79) with a sex
ratio of 1:1. The etiology of the stenosis was prolonged
intubation and/or tracheostomy in 47 cases, with a mean
intubation time of 9 days (range, 2—26); seven patients had
neoplastic stenosis with tracheal invasion. In 43 cases,
surgery was performed without applying a prosthesis; in
seven patients a Montgomery T-tube was inserted; and in four
cases an endotracheal prosthesis was fitted.
tracheoesophageal fistulas, and 7 neoplastic tumors). One
case (2.63%) died 5 days after surgery due to a post-traumatic
aneurysm of the internal carotid artery.
The specific morbidity was 26.3%: one case showed suture
dehiscence in the anterior face of the anastomosis (2.6%)
with subsequent formation of granulomas, requiring the
insertion of a Montgomery T-tube; four cases (10.5%)
presented with edema in the anastomosis, which was
resolved by endotracheal prosthesis; and five cases (13.1%)
presented granuloma tissue that was treated by laser. There
were no re-interventions.
In terms of the SCL variables, significant differences
were only observed with respect to morbidity between the
S4 group and the other cases without tracheoesophageal
fistula.
In the subgroup receiving radical treatment for tra-
cheoesophageal fistula (Table 5), the S4 variable presented
a specific morbidity of 50% compared with 25% for the
variables S1, S2, and S3. The S4 variable was also associated
with 28.5% granulomas, 14.2% vocal chord paralysis, and
7.1% tracheal restenosis. Five minor procedures were
carried out, with the evolution of one case remaining
pending.
The cure rate for this type of intervention was 100%, and
minor procedures were performed in 26.3% of cases but there
was no re-intervention (Table 6).

Table 5
Morbidity in Küster operation (n = 38)

No. Morbidity (No.) Dehiscence (No.) Edema (No.) Granuloma (No.) Vocal chord paralysis (No.) Stenosis (No.)

Group
Without fistula 24 6 (25%) 1 (4.1%) 4 (16.6%) 1 (4.1%) — —
With fistula 14 7 (50%) — — 4 (28.5%) 2 (14.2%) 1 (7.1%)

Total 38 13 1 4 5 2 1
Percent 100 34.2 2.6 10.5 13.1 5.2 2.6
38 J.M. Amorós et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 35—39

Table 7
Morbidity and outcome in Pearson operation and combined Küster and Pearson operations (n = 16)

Group Morbidity Dehiscence FTE Stenosis/granuloma Cured Re-interventions Minor procedures

(No.) (No.) (No.) (No.) (No.) (No.) (No.)

PO (n: 14) 4 28.5% 1 7.1% 1 7.1% 2/0 14.2% 12 (85,7%) 2 (14.2%) 2 (14.2%)
KO + PO + RO (n: 2) 1 (50%) 0 (0%) 0 (0%) 0/1 (50%) 2 (100%) 0 (0%) 1 (50%)
Total 5 1 1 3 14 2 3
Percent 31.25 7.1 7.1 18.7 87.5% 12.5 18.7

3.2. Pearson operation
This operation was performed in 14 cases, and no
mortality was recorded. The specific morbidity rate was
28.5%: two cases of restenosis (14.2%) in the same patient,
who also required a temporary Montgomery T-tube
(a complex case because of inhalation of inflammable
gases); one case of tracheoesophageal fistula (7.1%); and
one case of anastomotic dehiscence treated successfully
with surgical debridement and temporary Montgomery
T-tube.
Complications were not related to the SCL variables. The
cure rate for this subgroup was 85.7%, and the failure rate
was 14.2% (Table 7).
3.3. Combined Küster and Pearson operations
This procedure was carried out in two cases that showed a
good evolution in terms of clinical and endoscopic para-
meters. A Rethi laryngoplasty was also performed in both
cases: one case presented granulomas that were treated
by laser while the other showed a good evolution without
incident (Table 7).
4. Discussion
The present study concerns a group of patients who, after
application of the MA protocol, were assigned either to
surgery or conservative treatment, thus enabling selection of
surgical stages. In a previous report [1], we described the
benefits of conservative treatment with laser and/or
endotracheal prostheses.
When consulting surgical reports on this issue [6—13,16],
we noticed the lack of prospective protocols despite the
extensive experience of the authors in question. Mortality
was found to range from 0% to 24% (Table 8). For example, in
an extensive series [13] of 503 patients, the figure was 2.4%
with major complication rates of 13.9% (trachea—trachea
anastomosis, KO), 15.4% (trachea—cricoid anastomosis), and
12.9% (trachea—thyroid anastomosis, PO), respectively. For
the same series, the therapeutic failure rates were 2.2%,
6.0%, and 8.1% of the above-mentioned levels of anasto-
mosis, respectively.
In our series of 54 cases, mortality was 1.85% for both
tracheal (KO) and cricotracheal (PO) resection; although
overall specific morbidity was higher at 27.7% (26.3% for KO,
28.5% for PO, and 50% for KO + PO + RO), the rate of major
complications (dehiscence, restenosis, and tracheoesopha-
geal fistula) was only 9.2%. In terms of morbidity, a higher
rate was observed in the tracheoesophageal fistula (S4)
subgroup, while the C and L variables showed no differences.
Unlike previous reports [17], there was no need for re-
intervention, and neither was it necessary, as some authors
propose [18,19], to apply prophylactic mitomycin-C to avoid
restenosis.
In the extensive series reported by Grillo et al. [13],
outcomes were good in 84.9% of cases and satisfactory in
5.3%, with 3.6% having re-interventions, and 3.8% failures.
Mortality in this series was 2.6% in cases of stenosis without
tracheoesophageal fistula and 5% in those with such a fistula.
In our study of 54 patients with stenosis (both benign and
malignant), outcomes were good overall in 96.2%, with a
failure rate of 3.7% (0% in KO and 13.7% in PO). In terms of the
38 cases of tracheal resection (KO), 14 presented with a
fistula and the following results were found:
 In the tracheal resection (KO) without fistula group
(variables S1, S2, and S3), the specific morbidity was
25% (major complications 4.1%, minor complications
20.9%), and no mortality was recorded. The cure rate
for this group was 100%, and 25% required endoscopic and/
or prosthetic procedures.
 In cases of tracheal resection (KO) for tracheoesophageal
fistula (S4), the specific morbidity was 50.0% (major
complications 21.3%, minor complications 28.5%), and no
mortality was recorded. The cure rate for this group was
100% without re-intervention and 26.3% required endo-
scopic procedures.
We believe that the highly satisfactory nature of the
outcomes was due to protocol-based selection, which

Table 8
Comparative study of outcomes of tracheal resection

Author No. Mortality (%) Completely cured Major complications Re-interventions Failures

Grillo et al. [13] 543 2.4 94 13.9 3.6 3.8

?
Couraud et al. [8] 217 3.2 96 4.6 0.9
Rea et al. [16] 65 1.5 95.3 12.3 0 0
Canto et al. [6] 26 0 89 24 7.6 11.3
?
Tarazona [20] 162 6 90 12 2.4
Present authors 54 1.85 100 9.2 0 0
 J.M. Amorós et al. / European Journal of Cardio-thoracic Surgery 29 (2006) 35—39
enabled the specialists involved (intensive care staff,
surgeons, otorhinolaringologists, and endoscopy technicians)
to agree on the best approach and thus undoubtedly improve
the quality of life of these patients.
Application of the MA protocol in the surgical treatment of
tracheal and cricotracheal stenosis, with or without tra-
cheoesophageal fistulas, has enabled a more objective
selection of cases that may be cured at the first attempt.
The outcomes obtained were excellent or good in 96.2% of
cases, with an overall failure rate of 3.7% (0% in tracheal
resection and 13.7% in cricotracheal resection). These highly
satisfactory outcomes may be related to the protocol-based
selection of cases; surgery was reserved for potentially
curable states, and we chose the most suitable moment in the
evolution of the process and the optimum conditions for
favoring good scar-tissue formation.
Our prospective study demonstrated that evaluating and
cataloguing the SCL-independent variables enabled the
development of stage reference that subsequently was applied
to determine and perform the most appropriate intervention
for each specific case of laryngotracheal stenosis. Application
of the MA protocol has resulted in excellent outcomes of
surgical treatment, highlighting the benefit of standardization
of the protocol for daily use in the clinic.
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