Discussion
Cancer, bleeding, cartilage injury, Tracheal injuries
BLEEDING, COMPLICATIONS, CANCER
Tracheostomy was traditionally performed by surgeons in the operating room, but thanks to the development of percutaneous dilatational techniques nowadays is a routine procedure done by intensivists in most of the Intensive Care Units. PDT helps shorten overall time of tracheostomy procedures by decreasing the waiting time for operating room and general anesthesia (Although there are several studies, meta-analyses and excellent reviews which compare the different PDT techniques (According to our data, using a single tapered dilator significantly increases the risk of cartilage injury in cadavers compared to both standard and modified Griggs’ methods, in accordance with some previous experts’ observations (We have suggested a modification to the classical Griggs’ method in order to decrease the complications of PDT in our previous study (We suggest making a quite wide (50-mm) horizontal skin incision for the procedure. One might say that this increases the risk of major bleeding and makes the procedure longer but at the same time it provides enough space for secure pretracheal surgical blunt preparation until the tracheal wall can be visualized and palpated making critical intervention (i.e. tracheal puncture with partially lost airway) shorter and probably safer. Another important aspect is, that with good visibility bronchoscopy is nearly unnecessary, thus it is easier to avoid the significant rise of PaCOThe obvious limitation of our study is that PDTs were made in cadavers, which could influence cartilage flexibility, so cadaver’s tracheal cartilages could be more rigid than in case of living tissue. Performing PDT cartilage injury/fracture could be rare in living tissues but the correlation of the number of the cartilage injuries using different methods could be demonstrated on cadavers.Tracheal injuries were more common in our study (81/146 subjects, 55.48%) than what we would expect according to our clinical experience, although it was still less than mentioned in another PDT cadaver study (83%) (In conclusion, in cadavers we found that forceps dilatational methods are safer than Single dilator with respect to cartilage injury. Although we did not detect statistical significance, we still suggest the use of bidirectional dilatation with forceps, as cartilage injury and cannula malposition incidence was the lowest in the group where this modification was applied. Prospective study and long-term follow-up of patients undergoing PDTs would be necessary to further confirm its superiority over other methods.Authors are grateful to Professor András Matolcsy Gergely Rácz M.D. PhD, János Zalavári and all other contributing members of the 1st Department of Pathology and Experimental Cancer Research of Semmelweis University for supplying cadavers and providing special help during dissections. The critical reading of the manuscript by Professor László Tamás, Associate professor Balázs Hauser and Judit Laki management consultant (Semmelweis University) are acknowledged with many thanks.