What is The Maddern Procedure
(endoscopic tracheal reconstruction)?
This surgery is suitable for patients with an isolated subglottic stenosis in a mature, noninflammatory phase. Through an endoscopic approach (transoral – i.e., via the mouth), the stenosis is completely removed with the assistance of a soft-tissue shaver. The cricoid is then relined with either a buccal or skin graft, held in place for 2 weeks with a temporary silicone stent. This technique is minimally invasive, has the potential to preserve voice function completely, and may have a curative outcome.
How is The Maddern Technique different to a resection?
In a resection, the affected piece of trachea including the cartilage is removed via open surgery. With this reconstruction, the scarring is removed, and a skin graft placed temporarily into the trachea for 2 weeks to encourage healthy cells to re-grow in place of the diseased tissue.
This operation is endoscopic rather than via open surgery meaning the neck is not cut open. This has several benefits including a minimal risk to the vocal cords and the nerves that control them. Recovery is much faster as there is not a physical cut in the neck, nor a section removed.
Broadly what happens in the operation?
The scarred skin within your trachea is removed – just the skin, no cartilage. A piece of skin is grafted from your thigh, nose or cheek and wrapped around a plastic tube (stent) and inserted orally. This is then stitched in place with two small stitches at the base of the tube. All that is visible on the outside of your neck are the stitches. Depending on where the stenosis is, a temporary tracheostomy may be necessary too.
The stent is left in place for two weeks and then removed. One of the benefits for this method is that there is no scarring from the reconstruction, other than a small scar (about 1cm) from the tracheostomy if that was needed.
If I need a tracheostomy, how long is this for?
The tracheostomy is provided to allow you to breathe while your airway is swollen, and the stent is in. You will have this for around 5-7 days. If you do not bleed too much and your airway can cope well with a size 12+ open stent, then you are unlikely to have a tracheostomy.
When can I get up and walk around?
Usually the following morning after your operation you will at least be able to visit the bathroom (the bed pan is not a fun experience!), and you will feel more and more like exploring as the days pass. Once you are off the feeding tube and IV you will be able to make more extensive journeys to the coffee shop and even outside.
When can I eat and talk normally?
Once a speech and language therapist has visited you and ensured you can swallow properly you should be able to have the feeding tube removed. This depends on when they make it to see you - any time between 1-3 days.
How long am I in hospital?
You are likely to be in hospital for around one to two weeks. You may then be allowed home under strict instructions to remain healthy, nebulise lots and not overdo things, before returning for a day surgery to have the stent removed. Depending on your recovery you might be in hospital a little longer – up to two weeks in total (or until the stent is removed).
A month later you will need to return for another day surgery to laser ‘tidy up’ the new skin and so your doctor can check out how it is healing. You may need another final laser ‘tidy up’ a month later if only 50% is done the first time. Some patients will also need a third and final tidy up.
Will I be in pain?
The hospital is good at managing any pain you have with regular pain medicine (sometimes too regular!) and pain is minimal. Most of the discomfort will be from any stress you have, so ideally learn to recognize this, and use relaxation techniques to calm down.
How long until I feel better post op?
As soon as you are recovered from the general anaesthetic from having the stent removed you will be back to exercising and normal life. You should continue to nebulise daily to help with the healing process.
Some people may still have some difficulty with mucus – after the surgery you will need two ‘tidyups’- these are to ensure your airway is smoothed.
The graft site on your leg, nose or inner cheek will be the sorest point, so keep this covered and protected. It is important while in hospital to ensure the original dressing is left on and kept dry to aid the healing process. Tape a rectangle of plastic bag over the site when showering to protect it.
How long does it last?
The first patient to have this operation in 2012 is still breathing well with no restenosis.
Latest research suggests 80% of patients continue to breathe well with no restenosis for at least 5 years.