Percutaneous dilational tracheostomy (PDT) is a technique that can place a tracheostomy tube safely without visually identifying the trachea. We evaluated its feasibility during head and neck cancer surgery.
PDT has many advantages, such as less bleeding, easier technique, and shorter procedural time.
Twelve patients who underwent PDT during head and neck cancer surgery from September 2016 to March 2018 were enrolled, and their medical records were reviewed retrospectively. Medical records of another 12 patients who underwent conventional tracheostomy during head and neck cancer surgery were analyzed. PDT was performed using a Ciaglia Percutaneous Tracheostomy Set. The tracheostomy point was determined by palpation without the guidance of bronchoscopy or ultrasonography. Blood loss, procedural time, communication between the cervical wound and tracheostomy wound, and complications were compared between the PDT group and the conventional group.
The PDT group had less blood loss, a shorter procedural time, and a lower incidence of communication between the cervical and tracheostomy wound. There was 1 case of conversion to conventional tracheostomy due to wrong tracheal penetration in the PDT group.
PDT is safe and effective as an adjunctive procedure during head and neck cancer surgery.
Tracheostomy is an essential procedure before major head and neck cancer surgery, to bypass the airway from the surgical field and secure an intact airway. Traditionally, surgical tracheostomy has been performed either under general anesthesia with endotracheal intubation or under local anesthesia in cases of difficult intubation due to a tumor mass. Currently, percutaneous dilational tracheostomy (PDT) is actively being performed in intensive care units.1 Compared with conventional surgical tracheostomy, PDT is technically simpler and less invasive, takes less time, has a lower operative bleeding rate, and is associated with fewer postoperative complications.2 It is indicated in patients who are under adequate oxygenation via endotracheal intubation. Therefore, patients with head and neck cancer who are undergoing major operations are the best candidates for PDT. In this study, we identify the safety and feasibility of PDT during head and neck cancer surgery.
Materials and Methods
The medical records of 12 patients who underwent PDT during head and neck cancer surgery from September 2016 to March 2018 were reviewed retrospectively (PDT group). PDT was selectively performed in patients who had no previous history of surgery or irradiation in the neck and who were not so obese that surface anatomic landmarks such as cricoid cartilage and the sternal notch could not be easily palpated. All PDT was performed under adequate oxygenation through orotracheal intubation.
PDT was performed as Ciaglia et al3 described in the first report on PDT. The preparation and patient positioning should be the same as in conventional surgical tracheostomy. Any adhesive securing the endotracheal tube to the patient should be removed, and the endotracheal tube should be withdrawn to a level just below the vocal cords. Care must be taken not to withdraw the tube above the vocal cords, because this would create the need for reintubation. PDT was performed using a Ciaglia Percutaneous Tracheostomy Set (Cook Critical Care, Bloomington, Indiana) (Fig. 1). After palpating the outline of the trachea, we marked the skin, centered between the cricoid cartilage and sternal notch. A 0.5-cm horizontal incision was made through the skin markings, and an 18-gauge syringe containing saline was inserted into the midline of the anterior tracheal wall. Once the wall was punctured, the syringe was regurgitated to identify air bubbles. Regurgitation of air bubbles indicated that the needle was well positioned within the trachea. The surgeon should use the nondominant hand to stabilize the trachea during this maneuver. Next, a Seldinger guidewire was inserted into the trachea. Then the tract was dilated with the short, firm tracheal dilator. A generously lubricated single gradual dilator was placed on the guidewire track after seating it on the guiding catheter and advanced into the trachea. The dilator was removed, leaving the guidewire in place. Then the tracheostomy tube was inserted into the trachea thorough the guidewire (Supplemental Video content). The tracheostomy tube should have a trocar with a small hole for the guidewire. If not, a loading dilator and the tracheostomy tube should be inserted into the trachea as a single unit. To secure a proper operation field, the flange of the tracheostomy tube should be removed and reloaded later, at the end of the surgery (Fig. 2).
For comparison, medical records of another 12 patients who underwent conventional surgical tracheostomy during head and neck cancer surgery were consecutively acquired and analyzed (ST group). Parameters of blood loss, procedural time, communication between the cervical wound and the tracheostomy wound, and complications were compared between the groups. The amount of blood loss in the PDT group was too minimal to calculate exactly, so the amount was divided into 2 categories: <1 mL and >1 mL.
Statistical analyses were performed using SPSS version 14.0 (SPSS Inc., Chicago, Illinois). The χ2 test and independent t test or Mann-Whitney U test were used. Continuous variables are expressed as the mean ± standard deviation, with statistical significance defined as P < 0.05. The institutional review board of our institution approved this study.
There were 11 male patients and 1 female patient in the PDT group, with a mean age of 66.3 ± 7.9 years, and 10 male and 2 female patients with a mean age of 68.14 ± 8.3 years in the ST group. The age and sex ratio did not differ between the 2 groups. The primary tumor site in the PDT group was the oral cavity (7 cases) and oropharynx (5 cases), and that in the ST group was the oral cavity (7 cases), oropharynx (4 cases), and hypopharynx (1 case). The time between tracheostomy and decannulation was 11.5 days in the PDT group and 13.1 days in the ST group, with no significant difference between the groups (Table 1).
The total blood loss was <1 mL in all patients in the PDT group and >1 mL in most ST patients (91.7%); the intergroup difference was statistically significant. The duration of the procedure was significantly shorter in the PDT group (5.8 versus 18.9 minutes, P = 0.04). No patients in the PDT group and 5 (41.7%) in the ST group exhibited wound communication. There was 1 patient with a complication in the PDT group who was converted to surgical tracheostomy after failure of PDT. There were 2 patients with minor stomal bleeding in the ST group. The duration of stomal closure after decannulation was 4.1 days in the PDT group and 5.8 days in the ST group, with no significant differences between the groups (Table 2).
In 1985, Ciaglia et al3 described an alternative method in which tracheostomy is performed percutaneously, using a Seldinger approach. Compared with conventional surgical tracheostomy, this percutaneous method has a number of potential advantages. PDT is relatively simple to learn and perform.4 As a consequence, even individuals who lack extensive training may quickly become adept at the procedure.5,6 In addition, PDT may be performed at the patient's bedside with a limited number of personnel,4 thus eliminating the potential risks associated with transporting a critically ill patient, as well as the inconvenience and expense of scheduling and using operating room facilities. Because of these and other advantages, PDT is gaining increasing popularity, and it is replacing surgical tracheostomy in intensive care unit patients.1
However, PDT is not possible in all cases; there are definite indications and contraindications. Patient selection criteria should include physiological and anatomic factors.7 Physiological stability and adequate oxygenation not requiring aggressive ventilator support must be ensured. PDT is generally indicated in patients whose airway is secured, that is, who are intubated. In addition, absence of coagulopathy must be ensured. In addition, this technique is contraindicated in pediatric patients. In head and neck cancer surgery, almost every patient undergoes intubation for general anesthesia before surgery except those who have large tumors that interrupt intubation. Every patient who is scheduled to undergo major surgery is checked for the absence of coagulopathy or is in a corrected state preoperatively. In addition, most patients with head and neck cancer are adults. Therefore, patients with head and neck cancer who are scheduled to undergo primary surgery are good candidates for PDT. However, there are several relative contraindications to PDT, such as obesity, short neck, enlarged thyroid isthmus or goiters, high-riding innominate artery, and previous tracheostomy. Therefore, careful patient selection is important.
In our study, the amount of bleeding was significantly less and the procedure time was shorter in the PDT group, consistent with previous studies.8–12 According to a meta-analysis that analyzed prospective trials comparing percutaneous and surgical tracheostomy, PDT was performed approximately 10 minutes more quickly than ST and was associated with less bleeding.2 Although the time and the amount of bleeding for the tracheostomy procedure seem to be quite minimal compared with the total operation time and bleeding, it may be beneficial for the patient to reduce the amount of bleeding and to shorten the operation time as much as possible.
No patients experienced communication between the tracheostomy wound and the neck wound in the PDT group, whereas 41.7% of patients in the ST group did. During PDT, dissection of the subplatysmal plane and surrounding tissue of the trachea, which is inevitable during surgical tracheostomy, is omitted. Therefore, the chances of wound communication can be minimized during PDT. If wound communication occurs, the possibility of wound contamination by sputum increases, and additional procedures are needed to close the communication at the end of surgery, which can result in prolongation of total operation time.
There were no cases of postoperative stomal bleeding in the PDT group, whereas 2 patients in the ST group experienced stomal bleeding. Following PDT, the stoma fits snugly around the tracheostomy tube, essentially plugging bleeding vessels. By contrast, following ST, the stoma fits loosely around the tracheostomy tube. One patient was converted to surgical tracheostomy after failure of PDT. This patient had a short, thick neck, which is a relative contraindication for PDT. Therefore, consideration of anatomic factors and careful patient selection are important.
The duration of stomal closure after decannulation was slightly shorter in the PDT group, but the difference between groups was not significant. Due to the absence of the subplatysmal dissection procedure, the stoma closure time is expected to be shorter in the PDT group. The lack of a statistically significant difference may be due to the small number of cases, the duration of tracheostomy, surgical techniques, or other factors. Further studies on a large number of cases may be able to identify the exact effects of PDT on stomal closure time.
The drawback of PDT during head and neck cancer surgery is the interference of the surgical field by the flange of the tracheostomy tube. This can be overcome by removing the flange after the tracheostomy (Fig. 2) and remounting it at the end of surgery. Several manufacturers make tracheostomy tubes with removable flanges. Another disadvantage is that there is a risk of extubation during withdrawal of the endotracheal tube before the procedure. This can be overcome with close communication and cooperation with an experienced anesthesiologist or by using flexible bronchoscopy during withdrawal. Another drawback is that it can be difficult to change the tracheostomy tube after surgery, because of the lack of dead space around the tube in PDT. For this reason, it is generally recommended to change the tube later in PDT than in ST, and this recommendation should be applied for patients with head and neck cancer who undergo PDT. At our institution, tubes are generally changed 2 to 3 days after surgery after ST, but 5 to 7 days after PDT.
This study has several limitations. First, the sample size was small because it was a preliminary study that was conducted to determine feasibility before starting a prospective study in order to assess the usefulness of PDT. Second, we analyzed the feasibility of PDT in patients with head and neck cancer, so there was limited patient selection and matching. Third, because it is a preliminary study to apply PDT to head and neck cancer surgery for the first time, it was conducted as a retrospective study. However, our results suggest that PDT is safe and efficacious during head and neck cancer surgery. Further studies on a large study population and prospective trials should be conducted to identify the feasibility of this technique more precisely.
PDT is safe and effective as an adjunctive procedure during head and neck cancer surgery. PDT has the advantages of less bleeding, shorter procedural time, and lower incidence of communication between the cervical wound and tracheostomy wound than conventional tracheostomy.
This work was supported by a National Research Foundation (NRF) of Korea grant funded by the Korean government (NRF-2020R1C1C1005965). No potential conflicts of interest relevant to this article were reported.