Stenosis at Stomal Site

Stomal stenosis may be minimized or avoided altogether by attention to details, performance, and management. First, the surgeon should make no larger an opening for the tracheostomy tube than is necessary. The tube should not be too large for the particular patient. Its curve should be appropriate. In order to minimize the size of the stoma and destruction of tracheal tissue, I prefer a simple linear vertical incision in the trachea (see Chapter 22, "Tracheostomy, Minitracheostomy, and Closure of Persistent Stoma"). The procedure is done in an operating room with aseptic technique. Bacteria are always present in the tracheal lumen and further colonization will occur after tube placement, despite exquisite postoperative care. Staphylococcus aureus and Pseudomonas aeruginosa are the most common. However, invasive sepsis may be limited by scrupulous postoperative care. The tracheostomy tube should be well seated and fastened securely to the patient's neck. Avoidance of leverage on the tracheostomy tube is most important. The weight of connecting tubing and adapters, transmitted through the tracheostomy tube against the tracheal wall, causes erosion of the stomal margin. Long-term exposure to ventilation and other factors such as diabetes and corticosteroids are additional likely agents. Lightweight swivel adapters attached to the tracheostomy tube move in multiple planes and are connected by light, flexible corrugated tubing to the ventilator. It has been hypothesized that accordion tubing helps to avoid transmission of the respirator's thrust to the stomal edges, and to the cuff itself, but conclusive experimental data is required. The ventilating connecting tubes are in turn suspended from supports. Clinical results support this protocol overall. Progressive careful attention to the points noted has eliminated stomal lesions at Massachusetts General Hospital.

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