Respiratory Insufficiency with Tracheotomy_2
Short Summary

72-year-old female recovered from protracted bronchopneumonia and sepsis that demanded mechanical ventilation via oral intubation and tracheostomy. She developed post tracheotomy tracheal stenosis and failed 2 attempts of Montgomery T-tube insertion.


Patient's Questions
In consideration of the 2 failed attempts at Montgomery T-tube insertion, we ask:
1)    How is it possible to resolve the post-tracheotomy tracheal stenosis?

2) Can you indicate a center of excellence in Italy for Montgomery T-tube insertion or another effective surgical technique with the highest guarantee of success?

3) Prognosis?
Medical Background

72 years old, Female
Past Medical History:
Common childhood exanthems.
Arterial hypertension. Dysthymia.
Depressive syndrome for about 25 years.
Hypothyroidism for about 5 years.
Surgery for extrauterine pregnancy, gallstones and bilateral cataracts.
The patient was hospitalized on February 2008 in the Intensive Care Unit of the Santi Antonio e Biagio e Cesare Arrigo Hospital in Alessandria due to bronchopneumonia complicated by septic shock. The patient was then transferred on February 2008 to the department of Pulmonary Medicine of the same hospital with the complicated diagnosis of: acute respiratory insufficiency with recent results of right mediobasal bronchopneumonic foci with respiratory distress. Hypertensive hypertrophic heart disease. Renal insufficiency (Dialysis). Anemia. Drained left PNX. Tracheomalacia. Gastritis with petechial hemorrhage of the gastric fundus.
Over the course of hospital stay various medical procedures were performed, among which: transfusions; dialysis; pleural drainage. Tracheostomy tube replacement. Bronchial biopsy. Bronchoscopy. Esophagogastroduodenoscopy. 
When the patient's clinical conditions stabilized, she was transferred on May 2008 to the Rehabilitation unit of the Alexandria Hospital. Following the development of serious respiratory depression (post tracheotomy tracheal stenosis), the patient was again transferred to the department of Pulmonary Medicine on June 2008.
On June 2008, Montgomery T-tube insertion, which was placed with the help of endoscopic forceps. On June 2008, the Montgomery T-tube was found to be distally obstructed with dense mucous secretions. After repeated attempts to remove the obstruction, the stent was removed and a Bivona no. 7 tracheostomy tube was inserted. Another Montgomery T-tube with 15 mm proximal arm was inserted on July 2008, which was removed on July 2008 because it was obstructed by secretions with onset of acute dyspnea and cyanosis.
On July 2008, the patient was transferred to the ENT department. During her stay in that department, she developed pericarditis.
From August 2008 to October 2008, the patient was hospitalized in the rehabilitation unit of the Alexandria Hospital: at admittance fair general conditions, the patient was alert, oriented to place and time, cooperative, with tracheostomy tube in place. Hypertrophy and global hyposthenia of the 4 limbs from lack of use, primarily the lower limbs. Postural changes possible with assistance. During hospitalization, rehabilitation therapy was performed to improve muscle tone and trophism, postural changes and walking resistance.

Expert's Opinion

This is not an infrequent result of prolonged mechanical ventilation.
There are several operative ways to operate on the larynx and trachea.
In our experience, if the lesion does not involve the immediate sub-glottis area, than Crico-Tracheal Resection (CTR) would be preferable.
There're few centers in Europe who described their experience on this topic. In any case, there is a need for pre-op laryngo-tracheoscopy before making a decision. At times, direct laryngoscopy and tracheoscopy, performed under general anesthesia, may be needed for establishing the correct diagnosis prior to surgery. 
CTR is usually performed as a single stage procedure. The operative success rate = decanulation is pretty high (over 90%). Mean hospitaliztion stay is 7-10 days.