Correspondence (letter to the editor): Negative Selection

The undoubtedly important review article described the ultimate complication of a common procedure in the intensive care unit, which is of relevance for different groups of medical professionals, with the particular focus on head and neck surgeons (1).

Even though Klemm and Nowak described similarly high death rates for percutaneous dilatational tracheotomy (PDT) and open surgical tracheotomy (OST), a negative selection should be assumed for the latter as it is particularly performed in patients with risk factors (e.g. coagulation disorders that cannot be corrected, severe obesity, unstable/stiffened cervical spine, struma/goiter, abnormal cervical vascular anatomy, impossibility of translaryngeal intubation, etc) in whom PDT is contraindicated (2).

For this reason, the presented morbidity/mortality rate is surprising, as a higher death rate might have been assumed for cases with an open approach (negative selection). Furthermore, differences in the technical undertaking of an OST exist. OST leaves an unsecured intubation canal and is different from OST where a circular mucocutaneous anastomosis with a stable intubation canal is performed (3).

OST is the standard technique performed by head and neck surgeons trained in otorhinolaryngology and reduces the risk of:

• Postoperative hemorrhage due to circular compression of the lateral soft tissues

• Recannulation problems because of a stable intubation canal

• Penetration of pathogens into the surrounding soft tissues.

In conclusion, as the authors pointed out, tracheotomy is certainly not a procedure which should be performed by unexperienced surgeons. The same applies to allegedly simpler operations, which should also always be carried out accordig to specialist standards (4).