190 / 412
difference in ISS between the 2 groups with the percuta-
neous group having a higher median score than the open
group (24 vs 26,
P
5
.007).
The overall complication rate was similar between the
OT and PT groups (
Table 2
). The incidence of tracheal ste-
nosis was also similar when comparing the open group with
the percutaneous group (1.9% vs 1.1%,
P
5
.509). The
open group had an incidence of major complications other
than tracheal stenosis of .8%. These complications involved
scar and excess granulation tissue requiring surgical scar
revision (
n
5
2). The percutaneous group had an incidence
of other major complications of 1.1% (
n
5
4). These
included tracheo-innominate artery fistula (
n
5
1), loss of
airway requiring conversion to open (
n
5
2), and bleeding
requiring conversion to open (
n
5
1). The patient with a
tracheo-innominate artery fistula hemorrhaged while on
the floor. The hemorrhage was occluded manually while
the patient was taken to the operating room for repair, but
the patient exsanguinated before repair could be accom-
plished. All conversions to an open procedure occurred dur-
ing the initial hospitalization.
Four of the 9 patients were immediately diagnosed with
tracheal stenosis after a failed decannulation attempt; how-
ever, the other 5 patients presented in a delayed fashion after
being decannulated. The delay ranged from 3 to 12 months,
with patients presenting with shortness of breath with
exertion (
n
5
4) and with trouble extubating after elective
laparoscopic cholecystectomy (
n
5
1). All of the 9 patients
underwent some form of treatment for their stenosis. Five
of these 9 patients underwent bronchoscopy with tracheal
balloon dilation, while 4 of the 9 patients underwent tracheal
resection. In our study, the risk of tracheal stenosis requiring
invasive intervention following tracheostomy was 1.5%.
There was a significant difference in patient disposition
between the 2 groups (
Table 2
). The open group was dis-
charged home more often and to a rehabilitation center
less often when compared with the percutaneous group
(
P
5
.007); however, mortality rate was higher in the
open group (15.5% vs 9.7%,
P
5
.030).
We also conducted analyses comparing those patients
with tracheal stenosis with those with no tracheal stenosis,
independent of which method of tracheostomy was per-
formed (
Table 3
). Patients who developed tracheal stenosis
were younger (29.8 vs 45.2 years of age,
P
5
.021), had a
longer ICU LOS (28.3 vs 18.9 days,
P
5
.036), and tended
to require mechanical ventilation for a longer interval (26.7
vs 16.1 days,
P
5
.055) compared with those who did not
develop tracheal stenosis. There were, however, no differ-
ences between the groups in regard to sex, ISS, GCS score,
mechanism of injury, interval between admission and
tracheostomy formation, hospital LOS, disposition, or
mortality.
Comments
While there is support in the literature of equivalent
early complication rates between open and percutaneous
techniques,
8,9
there is less evidence about their equivalency
with regard to late complications such as tracheal stenosis.
For this reason, there is still debate about which method
provides superior patient outcomes. The incidence of symp-
tomatic tracheal stenosis following OT or PT ranges in the
literature from 0% to 10%.
4–6
The true incidence of
tracheal stenosis is difficult to ascertain because it is often
subclinical in nature. In our study, tracheal stenosis was
identified based on clinical symptoms. Our study was
similar to these published results, demonstrating equivalent
symptomatic tracheal stenosis rates for OT and PT (1.9% vs
1.1%, respectively).
As stated earlier, several studies demonstrate complica-
tion rates that are equivalent for PT and OT. Our study
supports the literature in this regard with an overall
complication rate of 2.3% and 3.3%, respectively. The
types of complications encountered during tracheostomy
creation have been described in the literature and include
peristomal bleeding, peristomal infection, loss of airway
during procedure, surgical scar contracture, and tracheo-
innominate artery fistula.
2,10
The complications reported in
our study are in line with those previously described. Major
complications in our study were defined as need for surgi-
cal intervention or death. Both of the reoperations in the
Table 2
Comparison of complication, disposition, and death data for patients who received a tracheostomy through an open or
percutaneous procedure
Parameter
Open procedure
Percutaneous procedure
P
value
Number (%)
Number (%)
Complication
7 (2.6%)
8 (2.3%)
.773
Tracheal stenosis
5 (1.9%)
4 (1.1%)
.509
Other major complications
2 (.8%)
4 (1.1%)
.704
Disposition
.007
Home/home with home health care/jail/mental health facility
44 (16.6%)
35 (10.0%)
Rehabilitation center/select specialty hospital acute care/other
acute hospitals
165 (62.3%)
262 (75.1%)
Skilled nursing unit/nursing home
14 (5.3%)
14 (4.0%)
Hospice/death
42 (15.8%)
38 (10.9%)
Death
41 (15.5%)
34 (9.7%)
.030
The American Journal of Surgery, Vol 208, No 5, November 2014
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