The usefulness of laryngotracheal separation in the treatment of severe motor and intellectual disabilities

Abstract

Intractable aspiration is a life-threatening medical problem in patients with severe motor and intellectual disabilities (SMID). Laryngotracheal separation (LTS) is a surgical procedure for the treatment of intractable aspiration which separates the upper respiratory tract from the digestive tract. We performed LTS for 14 patients with SMID to prevent intractable aspiration, performing two types of operation. The standard diversion procedure connected the upper trachea to the esophagus. The modified diversion includes closure of the proximal trachea and a high tracheostomy, avoiding a tracheoesophageal anastomosis. LTS was performed on 14 patients. Operations performed before the LTS included tracheostomy in four patients, fundoplication in six and gastrostomy in two. A standard diversion was performed in 11 patients and a modified diversion in 3. There were no operative complications. Eleven patients were safely transferred to home-care after their LTS. Twelve patients are still alive and two died some months after operation. One patient died from their primary disease and the other died a tracheo-innominate artery fistula (TIAF). We recently experienced a patient who was at high risk of developing a TIAF. LTS is an effective operation, preventing intractable aspiration in patients with severe motor and intellectual disabilities. The results are similar for the standard or modified diversion procedure with the procedure chosen being related to the initial tracheostomy site. The most serious complication is a lethal TIAF.

Primary immunodeficiency associated with chromosomal aberration – an ESID survey

“…However, in these patients immunological work-up is often not performed because an immunodeficiency is not suspected. The infections are often ascribed to food and saliva aspiration [ 1 ], structural abnormalities of the upper respiratory tract, neuromuscular problems, malnutrition or institutionalization. Besides, other problems are often more prominent than the recurrent infections.…”

Immunodeficiency in a child with partial trisomy 6p

“…Recurrent respiratory infections are frequently seen in patients with mental retardation and they are a major cause of mortality in this patient group. The infections are often attributed to food and saliva aspiration (1). Moreover, in many patients, structural abnormalities of the palate, tongue or oesophagus, neuromuscular problems such as cerebral palsy, and factors like malnutrition or gastro‐oesophageal reflux lead to swallowing dysfunction and aspiration, with concomitant recurrent respiratory infections (2,3).…”

Tracheoinnominate artery fistula after laryngotracheal separation: prevention and management

“…In the bleeding group, 3 (1 male) children had major bleeding at mean age 10.3 (range, [4][5][6][7][8][9][10][11][12][13][14][15][16] years. This occurred at a mean time of 3.6 (range, 1-5) years after LTS.…”

“…The major risk factors contributing to the formation of the TIF are (1) a low tracheostomy, (2) overinflated cuffs, and (3) thoracic deformities such as scoliosis [15,16]. The last factor, scoliosis, is a characteristic finding in children with severe mental and physical disabilities, resulting in the trachea being shifted closer to the sternum, compressing the innominate artery [7]. Our experience suggested that there should be least 2 cm between the dorsal edge of sternum and the ventral edge of vertebrate to prevent TIF.…”