In Reference to Multi‐Institutional Endoscopic Resection and Reconstitution for Idiopathic Subglottic Stenosis

Dear Editor,

1.

We read with interest the multi‐institutional series by Lopez et al. on endoscopic resection and reconstruction for Idiopathic Subglottic Stenosis (iSGS) [1]. The authors are to be commended for assembling data across four academic centers. They demonstrate that ER as a primary definitive surgery can yield durable outcomes comparable to cricotracheal resection while avoiding the morbidity of open airway surgery. Their report of prolonged surgery‐free intervals and sustained peak expiratory flow rates suggests that minimally invasive approaches achieve long‐term airway stability.

The explicit separation of “primary” and “rescue” cohorts highlights how prior surgical history alters biology and prognosis. The small rescue cohort, although informative, is heterogeneous and confounded by prior open procedures, adjusted survival analyses or propensity weighting would strengthen conclusions.

The detailed operative descriptions including graft choice and stent sizing offer applicable insights. Moreover, the inclusion of patients seeking definitive surgery prior to pregnancy reflects a growing recognition of patient‐centered priorities in iSGS care.

Success was defined as absence of recurrence requiring intervention. However, the anchoring of surgery‐free interval to the second laser resurfacing may introduce lead‐time bias. We should standardize the index date at the initial ER excision to ensure comparability.

Reliance on peak expiratory flow rate, while practical, underutilizes available physiologic and patient‐reported measures. Voice outcomes, dyspnea indices, and secretion burden were not systematically captured, limiting the ability to fully assess functional benefit [2].

The complication reporting, though transparent, would benefit from uniform grading and timing. Only one event was classified by Clavien–Dindo, while others were described narratively. A standardized complication framework would allow benchmarking across institutions.

Similarly, details on perioperative pathways such as stent dwell‐time, graft selection criteria, and postoperative secretion management were limited. These variables likely influence outcomes and patient comfort [3, 4, 5].

Dense posterior scar consistently predicted recurrence, suggesting the need for a reproducible posterior involvement index to guide candidacy. The observation of recurrence in Fitzpatrick type I patients raises a provocative hypothesis about epithelial biology and melanin's role in scar remodeling. Finally, secretion burden remains a persistent patient complaint [6]. Quantifying this with a validated scale may transform anecdote into actionable endpoints.

Lopez et al. demonstrate ER as a durable, minimally invasive option for iSGS, especially in primary cases. Refining outcomes, expanding physiologic and patient‐reported measures, and probing biological predictors will standardize care and optimize technique.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.