بررسي علل عود تنگي بعد از رزكسيون آناستوموز در تنگي هاي بعد از لوله گذاري ناي

Evaluation of the Factors Responsible for the Recurrence of Post Intubation Tracheal Stenosis after Resection and Anastomosis

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺗﻌﺪﺍﺩﻱ ﺍﺯ ﺗﻨﮕﻲ ﻫﺎﻱ ﺑﻌﺪ ﺍﺯ ﻟﻮﻟﻪ ﮔﺬﺍﺭﻱ ﺩﺭ ﻧﺎﻱ ﺑﻪ ﺩﻧﺒﺎﻝ ﻋﻤﻞ ﺭﺯﻛﺴﻴﻮﻥ ـ ﺁﻧﺎﺳﺘﻮﻣﻮﺯ ﻋﻮﺩ ﻣﻲ ﻛﻨﻨﺪ. ﻋﻮﺍﻣﻞ ﻣﺘﻌﺪﺩﻱ ﺭﺍ ﺑﺎﻋﺚ ﺍﻳﻦ ﻋﻮﺩ ﻣﻲ ﺩﺍﻧﻨﺪ ﻭﻟﻲ ﻣﻄﺎﻟﻌﺎﺕ ﻛﺎﻓﻲ ﺩﺭ ﺍﻳﻦ ﺯﻣﻴﻨﻪ ﺍﺭﺍﺋﻪ ﻧﺸﺪﻩ ﺍﺳﺖ. ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺩﺭ ﮔﺮﻭﻫﻲ ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﻛﻪ ﺩﺭ ﻳﻚ ﻣﺮﻛﺰ ﻭ ﺑﺎ ﻳﻚ ﺭﻭﺵ ﻋﻤﻞ ﺷﺪﻩ ﺍﻧﺪ، ﻋﻠﻞ ﻋﻮﺩ ﺗﻨﮕﻲ ﺑﻌﺪ ﺍﺯ ﺭﺯﻛﺴﻴﻮﻥ ﺁﻧﺎﺳﺘﻮﻣﻮﺯ ﺗﺤﺖ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﻣﻲ ﮔﻴﺮﻧﺪ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺗﻤﺎﻡ ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﺩﺭ ﻣﺪﺕ 11 ﺳﺎﻝ ﺑﻪ ﻋﻠﺖ ﺗﻨﮕﻲ ﺑﻌﺪ ﺍﺯ ﻟﻮﻟﻪ ﮔﺬﺍﺭﻱ ﺗﺤﺖ ﻋﻤﻞ ﺭﺯﻛﺴﻴﻮﻥ ﺁﻧﺎﺳﺘﻮﻣﻮﺯ ﻧﺎﻱ ﻭ ﻳﺎ ﺳﺎﺏ ﮔﻠﻮﺕ ﻫﻤﺮﺍﻩ ﺑﺎ ﻧﺎﻱ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ، ﺑﻪ ﺩﻭ ﮔﺮﻭﻩ ﺗﻘﺴﻴﻢ ﺷﺪﻧﺪ : ﮔـﺮﻭﻩ ﻣـﻮﺭﺩ ﺁﻧﻬﺎﺋﻲ ﺑﻮﺩﻧﺪ ﻛﻪ ﺗﻨﮕﻲ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ ﻋﻮﺩ ﻛﺮﺩﻩ ﺑﻮﺩ ﻭ ﮔﺮﻭﻩ ﺷﺎﻫﺪ ﺁﻧﻬﺎﺋﻲ ﺑﻮﺩﻧﺪ ﻛﻪ ﺗﻨﮕﻲ ﻋﻮﺩ ﻧﻜﺮﺩﻩ ﺑﻮﺩ. ﺗﺸﺨﻴﺺ ﻋﻮﺩ ﺗﻨﮕﻲ ﺑﺮﺍﺳﺎﺱ ﻭﺟـﻮﺩ ﻋﻼﺋﻢ ﺑﺎﻟﻴﻨﻲ ﻭ ﺗﺄﻳﻴﺪ ﺑﺮﻭﻧﻜﻮﺳﻜﻮﭘﻲ ﺻﻮﺭﺕ ﻣﻲ ﮔﺮﻓﺖ. ﻋﻮﺍﻣﻞ ﻣﻘﺎﻳﺴﻪ ﺷﺪﻩ ﻋﺒﺎﺭﺕ ﺑﻮﺩﻧﺪ ﺍﺯ: ﺳﻦ، ﺟﻨﺲ، ﻃﻮﻝ ﺯﻣﺎﻥ ﺍﻧﺘﻮﺑﺎﺳﻴـﻮﻥ، ﻋﻠﺖ ﺍﻧﺘﻮﺑﺎﺳﻴﻮﻥ، ﻓﺎﺻﻠﺔ ﺯﻣﺎﻧﻲ ﺑﻴﻦ ﺍﻧﺘﻮﺑﺎﺳﻴﻮﻥ ﻭ ﻋﻤﻞ ﺟﺮﺍﺣﻲ، ﺍﻧﺠﺎﻡ ﺗﺮﺍﻛﺌﻮﺗﻮﻣﻲ ﻗﺒﻠﻲ، ﻣﺪﺍﺧﻼﺕ ﺩﺭﻣﺎﻧﻲ ﻗﺒﻠﻲ ﻧﻈﻴﺮ ﻟﻴـﺰﺭ، ﺩﺭﮔﻴﺮﻱ ﺳﺎﺏ ﮔﻠﻮﺕ، ﻃﻮﻝ ﺭﺯﻛﺴﻴﻮﻥ، ﻭﺟﻮﺩ ﺗﻨﺸﻦ ﺯﻳﺎﺩ ﺩﺭ ﻣﺤﻞ ﺁﻧﺎﺳﺘﻮﻣﻮﺯ ﻭ ﺍﻳﺠﺎﺩ ﻋﻔﻮﻧﺖ ﻣﻮﺿﻌﻲ ﺑﻌﺪ ﺍﺯ ﻋﻤﻞ. ﺭﻭﺵ ﻣﻄﺎﻟﻌﻪ، ﻣـﻮﺭﺩ ـ ﺷﺎﻫﺪﻱ ﺑﻮﺩﻩ ﻭ ﺗﺤﻠﻴﻞ ﻫﺎﻱ ﺁﻣﺎﺭﻱ ﺗﻮﺳﻂ ﺑﺮﻧﺎﻣﺔ SPSS 15 ﺍﻧﺠﺎﻡ ﺷﺪﻩ ﺍﺳﺖ. ﻳﺎﻓﺘﻪ ﻫﺎ: 494 ﺑﻴﻤـﺎﺭ ﺗﺤﺖ ﻋﻤﻞ ﺭﺯﻛﺴﻴﻮﻥ ـ ﺁﻧﺎﺳﺘﻮﻣﻮﺯ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ ﻛﻪ ﺷﺎﻣﻞ 365 ﺯﻥ ﻭ 129 ﻣـﺮﺩ ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ 25 ﺗﺎ 34 ﺳﺎﻝ ﻣﺤـﺪﻭﺩﻩ: 4 ﻣﺎﻩ ﺗﺎ 83 ﺳﺎﻝ( ﺑـﻮﺩﻧﺪ. 52 ﺑﻴﻤﺎﺭ )10/5 ﺩﭼﺎﺭ ﻋﻮﺩ ﺗﻨﮕﻲ ﺷﺪﻧﺪ. ﺍﺯ ﻣﻴﺎﻥ ﻋـﻮﺍﻣﻞ ﻓﻮﻕ ﻣﻄﺎﺑﻖ ﺁﺯﻣـﻮﻥ ﻛﺎﻱ ﺍﺳﻜﻮﺭ ﻭ ﺁﺯﻣﻮﻥ ﺗﻲ ﭼﻬﺎﺭ ﻋﺎﻣﻞ ﻃﻮﻝ ﺭﺯﮐﺴﻴﻮﻥ، ﻭﺟﻮﺩ ﺗﻨﺸﻦ، ﺑﺮﻭﺯ ﻋﻔﻮﻧﺖ ﻭ ﺩﺭﮔﻴﺮﯼ ﺳﺎﺏ ﮔﻠـﻮﺕ ﺑﺎ ﺍﺭﺯﺵ ﺁﻣﺎﺭﯼ ﻣﺜﺒﺖ 0/05

Introduction & Objective: A few number of post-intubation tracheal stenosis recur following resection and anastomosis. Several factors appear to be responsible for recurrence but there is insufficient data available in this regard. In this study we assessed the factors responsible for the recurrence of post-intubation tracheal stenosis after resection and anastomosis in a large group of patients who were operated in our center by one surgical team. Materials & Methods: All patients who underwent tracheal and/or subglottic resection and anastomosis due to post intubation tracheal stenosis, at our center during 1995-2006 were divided into two groups (case and control). The study group consisted of patients who had developed recurrence while the controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic confirmation. The following variables were compared in both groups: Age, sex, duration of intubation, the reason for intubation, period of time between intubation and surgical operation, history of previous tracheotomy, previous therapeutic interventions such as laser therapy, subglottic involvement, length of resection, presence of tension at the site of anastomosis and the development of surgical site infection. This was a case - control study and statistical analyses were performed using SPSS 15. Results: Four hundred ninety-four patients underwent resection and anastomosis (365 women and 129 men) with a mean age of 25-34 years (in the range of 4 months to 83 yrs.). Fifty-two patients (10.5%) developed recurrence. Length of resection (mean 42.8 mm in the case group versus 37.8 mm in the control group; P=0.012), the presence of tension at the site of anastomosis (32.7% versus 19.3%; P=0.03), the development of infection at the site of operation (18.2% versus 5%, P=0.006) and subglottic involvement (36.5% versus 19.2%, P=0.005) were higher in the case group and it seems that these factors are responsible for the recurrence. Conclusions: In this study, the factors responsible for increasing the recurrence rate of post- intubation tracheal stenoses were long lengths of resection, presence of too much tension at the site of anastomosis, wound infection and subglottic involvement. We believe that the surgeon can play an important role by decreasing tension, preventing infection, and preserving subglottic structures