gms | German Medical Science

Background: Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches to form a tracheostoma are the open surgical tracheotomy (ST) and the percutaneous dilatational tracheotomy (PDT). The aim of this systematic review and meta-analysis was to summarize and analyze existing evidence for peri- and postoperative complications.

Materials and methods: A systematic literature search was conducted in Central, MEDLINE, LILACS, and Embase to identify all randomized controlled trials comparing peri- and postoperative complications. The combined primary endpoint “potentially life-threatening events” was defined as any of the following: loss of airway, false route, tracheal/esophageal injury, major bleeding, pneumothorax/-mediastinum, subcutaneous emphysema, gastric aspiration or other potentially life-threatening events. Methodological quality was assessed according to the recommendations of the Cochrane Collaboration. Meta-analysis of extracted outcomes (potentially life-threatening events, mortality, stomal infection, stomal inflammation, duration of the procedure, late complications) was performed. Results are displayed as risk difference (RD) or mean difference (MD) with respective 95% confidence interval (95%-CI) and exact p-value.

Results: From 188 records 23 trials with overall 1549 patients were included. The primary endpoint potentially life-threatening events showed no difference between ST and PDT (RD 0.01; 95%-CI: -0.03 to 0.05; p=0.55). Loss of airway (RD 0.01; 95%-CI: -0.01 to 0.03; p=0.20), false route (RD 0.00; 95%-CI: -0.01 to 0.01; p=0.73), tracheal/esophageal injury (RD 0.00; 95%-CI: -0.01 to 0.01; p= 0.64), major bleeding (RD -0.00; 95%-CI: -0.02 to 0.02; p=0.95), pneumothorax/-mediastinum (RD 0.00; 95%-CI: -0.01 to 0.01; p=0.79), gastric aspiration (RD -0.00; 95%-CI: -0.02 to 0.01; p=0.93), mortality (RD -0.00; 95%-CI: -0.01 to 0.01; p=0.87) and late complications such as tracheal stenosis (RD -0.03; 95%-CI: -0.06 to 0.01; p=0.14), tracheomalacia (RD -0.00; 95%-CI: -0.03 to 0.03; p=0.87), and tracheocutaneous/-esophageal fistula (RD -0.00; 95%-CI: -0.03 to 0.02; p=0.74) showed no difference. However, stomal inflammation (RD -0.18; 95%-CI: -0.26 to -0.10; p<0.00001), stomal infection (RD -0.06; 95%-CI: -0.09 to -0.04; p<0.00001) and subcutaneous emphysema (RD -0.02; 95%-CI: -0.03 to -0.00; p=0.03) occurred more often with ST. The duration of the procedure was significantly longer for ST (MD -2.19 min; 95%-CI: -2.57 to -1.81; p<0.00001).

Conclusion: This systematic review is the most comprehensive study comparing the two strategies for tracheostomy. It reveals that the incidence of the clinically critical primary endpoint “potentially life-threatening events” was not different between ST and PDT.