Discussion
Endoscopic dilation for primary management of pediatric laryngotracheal stenosis has become commonplace. Despite this, outcomes of this procedure have only been described in case series and meta-analyses [2–5]. The relative rarity of pediatric laryngotracheal stenosis suggests the need for large, multi-institutional data for purposes of patient selection and medical decision-making.
This study utilized the ACS-NSQIP-Pediatric database to highlight 30-day outcomes of endoscopic dilation and to compare these outcomes to those of open airway reconstruction procedures. The ACS-NSQIP database has been endorsed by multiple organizations, including the Center for Medicare and Medicaid Services, the Joint Commission, and the American Medical Association. It has been shown to have higher sensitivity and a lower false-positive rate when compared to administrative data, in part due to data collection from trained personnel [11]. Furthermore, ACS-NSQIP use has the additional benefit of reporting an unplanned admission—a feature unavailable in review of claims data [12].
With respect to adverse events, our study demonstrates that endoscopic dilation is associated with an equally high rate of unplanned readmission when compared to open reconstruction. The high prevalence of comorbid disease such as chronic lung disease (32% of endoscopic dilation and 43% of open reconstruction) can account for some of the morbidity associated with any airway procedures.
Despite high rates of unplanned readmission, patients undergoing endoscopic dilation were less likely to have reoperations within 30 days of initial surgery when compared to those undergoing open reconstruction. While differences in disease severity may be partially responsible for this difference in the reoperation rate, this finding is notable given the health care costs associated with multiple operations as well as safety concerns with multiple anesthetics in the very young [13,14].
The ACS-NSQIP platform does not distinguish unplanned from planned reoperations. In the setting of airway surgery, where multiple planned reoperations are commonplace, this metric is a suboptimal stand-alone indicator of adverse outcomes. Other markers available in the database—such as reintubations and performance of tracheostomy or open airway reconstruction within 30-days of surgery—are more indicative of surgical outcome in the setting of airway surgery. We found that both reintubations and salvage open reconstruction within 30-days were rare. It should be noted that the ACS-NSQIP data does not report any events occurring outside of the 30-day postoperative period, representing potential limitation of the use of this database. As was previously advocated by Roxbury and colleagues, procedure/subspecialty specific outcome data collection would also improve outcome analysis of airway and other otolaryngologic procedures [9]. In the setting of airway reconstruction, this would include data pertaining to Cotton-Meyer grading systems well as postoperative voice and swallow outcomes.
In addition to safety profile, endoscopic procedures were associated with shorter LOS when compared with open reconstruction, representing another potential source of cost savings with this less invasive method. This is especially significant given that open reconstruction patients spend much of their inpatient stay in an ICU setting. In patients who are candidates for endoscopic procedures, this lower-risk, lower-cost profile of endoscopic dilation has the opportunity to improve value in health care and may be the source of future improvement initiatives.
In addition to comparing overall outcomes between endoscopic and open management of laryngotracheal stenosis, our study aimed to identify factors that were associated with varied outcomes in patients undergoing primary endoscopic dilation. We found that children younger than 1 year of age were 5.8 times more likely to undergo an unplanned reoperation after an endoscopic dilation than children over 1 year. A similar finding was reported in open airway surgeries, with increased reoperation rates in children < 3 years old [9]. The justification of a dichotomization at 1 year was made as expert opinion recognizes that the infant airway is less forgiving to intervention given its small size. Young age was also a factor in prolonged LOS as was determined by linear regression. It is likely that this increased LOS may be in part due to associations of young age and the neonatal ICU population. One must balance the increased risk of surgery in the young with that of tracheostomy, which has a published complication rate of 18% to 50% and direct mortality rate of 1% to 2% in the pediatric population [15–18]. Understanding these relative risks may help guide the airway surgeon in preoperative counseling with families and medical decision-making.
As discussed above, the limitation of data to a 30-day period is a relative weakness of ACS-NSQIP database use for studies of airway reconstruction, as the ultimate outcome—a stable, decannulated airway—may occur outside of this time period. As many quality metrics utilize data from the 30-day postoperative period, knowledge of these outcomes remains valuable in surgical decision-making. Ultimately, collection of data in a large, long-term dataset would allow broader generalizations to be made about the differences between open and endoscopic procedures and would also give a more comprehensive picture of the outcomes of endoscopic dilation.
In conclusion, this study is the first to analyze 30-day postoperative outcomes in pediatric endoscopic airway dilations using data aggregated by ACS-NSQIP from institutions across the United States. This data indicates that endoscopic airway dilation is a relatively safe procedure, especially compared with open reconstruction; however, additional data on disease severity and other outcomes is necessary to draw final conclusions of superiority of technique. Future improvement initiatives could be aimed at the impact of this lower-risk, lower-cost procedure in the appropriately selected patient. Outcomes of endoscopic dilation are poorer in those less than 1 year of age, as they are associated with increased reoperation rates and increased length of stay compared to older children. One must balance these risks in the very young with the risks associated with tracheostomy and other alternative airway management modalities.
Note: This work was presented in a paper at the AAO-HNS 2017 meeting, Chicago, IL, 10 Sep 2017.
Corresponding author: Jennifer Lavin, MD, MS, 225 E Chicago Ave., Box 25, Chicago, IL 60611, JLavin@luriechildrens.org.
Financial disclosures: None.