Slide tracheoplasty for the management of complete tracheal rings

Background/purpose

Although rare, complete tracheal rings are the most common cause of congenital tracheal stenosis. The last 2 decades have seen an evolution in management, with increasing awareness of the potential advantages of slide tracheoplasty.

Methods

Between March 2001 and August 2002, 11 children had complete tracheal rings corrected by slide tracheoplasty. Ages ranged from newborn to 15 years, and weight ranged from 1.8 to 57 kg. Length of stenosis ranged from 3 rings to virtually the whole length of the trachea. The most narrow point in the airway varied from less than 1.9 mm to 4.8 mm. Eight children had other congenital anomalies, severe in one child. Most children underwent repair on cardiopulmonary bypass.

Results

Nine children are asymptomatic or minimally symptomatic, although 2 have endoscopic evidence of mild residual tracheal stenosis. One child, who had been unstable pre-operatively, died of multiple organ failure 7 weeks postoperatively. A second child required a tracheotomy for bronchomalacia at 6 months and died at 9 months with tracheotomy tube occlusion. Both children had adequate tracheal repairs. Complications have included lateral tracheal stenosis (the “Figure 8” trachea) and recurrent laryngeal nerve damage.

Conclusions

Our management of complete tracheal rings has evolved over the last decade, and slide tracheoplasty currently is our preferred surgical approach for tracheal stenosis regardless of the length of narrowing.     

Slide tracheoplasty for congenital tracheal stenosis

Background/purpose

The aim of this study was to add to the experience of slide tracheoplasty in infants with congenital tracheal stenosis (CTS), to review the recent literature on this subject, and to evaluate the diagnostic workup in infants with CTS.

Methods

A retrospective review of 3 infants with CTS treated with slide tracheoplasty was conducted at our institution. They all underwent bronchoscopy, tracheobronchography, and echocardiography. Therapy consisted of slide tracheoplasty and simultaneous correction of associated vascular malformations.

Results

A pulmonary artery sling was missed initially on esophagography in 2 patients. Stridor became worse in 2 patients after tracheobronchography. After surgical therapy, 2 patients survived and were discharged 12 days after surgery. Both are without symptoms at follow-up of 12 and 20 months. One patient had inoperable restenosis and died 27 days after the operation.

Conclusions

Esophagography is not a reliable tool to depict associated vascular anomalies for patients with CTS. According to the literature, computer tomography has become more reliable to depict the tracheobronchial tree and is useful to elucidate associated vascular anomalies as well. Compared with other surgical techniques for infants with CTS reported in the literature, slide tracheoplasty has fewer postoperative complications and comparable survival rates.     

Modified slide tracheoplasty for congenital tracheal stenosis

Slide tracheoplasty has become a standard procedure to treat long-segment congenital tracheal stenosis because it is a reasonable and simple technique. Slide tracheoplasty does not affect the carina during long-segment congenital tracheal stenosis management, and thus lesions of the carina, such as stenosis and tracheobronchomalacia can become important causes of extubation failure after surgery. In this manusript, we describe the effectiveness of our modified slide tracheoplasty, which includes reconstruction of the carina. We have performed this technique on three patients, all of whom were extubated without developing any respiratory symptoms.     

Surgical management of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is a rare but life-threatening disorder, particularly in neonates and infants. The stenotic lesions are commonly composed of complete rings of cartilage varying in length, location, and severity. A definitive diagnosis of CTS may be delayed because of the rarity of this disorder and thus its unfamiliarity among physicians, its variable onset time, its various clinical symptoms, and the diversity of associated clinical conditions due to the cardiovascular disorders that may accompany it. More than half of the patients who manifest clinical symptoms during early infancy show a long-segment stenosis. Long-segment CTS is problematic and challenging to manage. Over the last two decades several surgical techniques for long-segment CTS have been devised and developed, but no definitively advantageous surgical procedure has been established because of insufficient experience and the lack of large-scale studies. Although rib cartilage tracheoplasty and pericardial patch tracheoplasty have provided limited early to midterm success for infants with long-segment CTS, these procedures are associated with early and late complications, including granulation tissue formation, patch collapse, and restenosis necessitating reintervention. By contrast, slide tracheoplasty has given rise to better surgical outcomes. This procedure enables reconstruction of the stenotic trachea using native tracheal walls with preserved blood supply. The trachea is foreshortened by only one-half of the original stenosis, resulting in reduced tension on the anastomosis. Consequently, the technique has several advantages, including less formation of granulation tissue, satisfactory subsequent growth, and infrequent reoperation for restenosis. Slide tracheoplasty is currently recognized as the preferred technique for long-segment CTS. __________ This review was submitted at the invitation of the editorial committee.     

Management of congenital tracheal stenosis in infancy

Objective: Congenital tracheal stenosis (CTS) is a very infrequent malformation. Till recently, the outlook for these patients was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. We review the short- and long-term outcomes of a single institution experience in the management of children with CTS, comparing different treatment modalities. Methods: Between 1991 and 2004, 19 cases of CTS have been managed in our Unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy was performed for diagnostic purposes in all cases; other imaging techniques (computed tomography (CT), magnetic resonance imaging (MRI), bronchography, angiography, doppler-ultrasound) were performed on an individual basis. According to clinical and endoscopical features, patients were classified into three groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomical type, associated anomalies, treatment modality, complications, outcome and time of follow-up. Results: Ten boys and nine girls have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 4 months) and 84% of cases showed associated anomalies. Five patients presented mild or no symptoms and have been managed expectantly. The other 14 cases were operated on because of persistent or severe clinical symptoms. The following procedures were performed: slide tracheoplasty (n = 7), costal cartilage tracheoplasty (n = 5), tracheal resection and reconstruction (n = 3), endoscopical dilatation (n = 3), stent placement (n = 1), and laser resection (n = 1). Three patients required two or more procedures and surgical survival rate is 78%. Overall mortality in the series is 21% and all survivors (15 patients) are asymptomatic or show mild symptoms with respiratory infections only. Follow-up is complete, ranging from 8 months to 12.3 years (mean, 5 years). Conclusions: Bronchoscopy is our preferred diagnostic tool. Selection of the type of treatment depends on the patient's clinical status and the anatomical pattern of the stenosis. In symptomatic cases with short-segment stenosis (<30% of total tracheal length), we prefer tracheal resection with end-to-end anastomosis; for long-segment stenosis (>30%), slide tracheoplasty is our procedure of choice.     

Long segment congenital tracheal stenosis in twins successfully treated by slide tracheoplasty

Long segment congenital tracheal stenosis (LSCTS), associated with complete tracheal rings, is a rare condition, difficult to manage and historically associated with high mortality rate. We report two pairs of identical twins all affected by LSCTS successfully treated by sliding tracheoplasty. All had severe respiratory distress. Three infants had left pulmonary artery (LPA) sling and one intra-cardiac malformation. Slide tracheoplasty was done under cardiopulmonary bypass, and cardiovascular malformations were corrected at the same time. One child needed plication of paralyzed right hemi-diaphragm and another distal tracheal Palmaz stent insertion due severe tracheobronchomalacia. All children are doing well during 6 months follow-up. Slide tracheoplasty seems to produce the same good early results in twins as for singletons with LSCTS.     

The successful reconstruction of thoracic tracheal defects with free periosteal grafts

A defect was created in the thoracic trachea in nine piglets (10 kg) by excising a segment from the entire thoracic trachea proximal to the right upper lobe bronchus (3 to 3.5 cm in length) and 30% of the circumference in width (1 to 1.5 cm). The defect was repaired with a free tibial periosteal graft (FPG) and in four piglets an omental pedicle graft (OPG) was applied to the surface of the FPG. An internal tracheal splint was inserted for 12 to 16 days to support the repair and prevent air leak. The splints were removed bronchoscopically. None of the pigs developed signs of airway obstruction at any stage following the repair. Eight were killed 3 months postoperatively when four to six times their original weight. One pig died on the 18th postoperative day of unknown cause. The tracheas were removed, x-rayed, and examined grossly and histologically. The results demonstrated normal tracheal growth with absence of either stenosis, collapse, or granulation tissue. All grafts were viable, bone formation was present, and the lumenal surfaces were lined with columnar and respiratory epithelium. The OPG did not improve vascularization of the FPG. This model suggests that tracheal stenosis in children may be surgically corrected by simply incising the stenotic segment longitudinally and enlarging the tracheal diameter by inserting a FPG into the defect.     

Patterns of management of congenital tracheal stenosis

Background/purpose

Stenosing airway disease, including congenital and acquired lesions, is rare in the pediatric age group. Untill recently, the outlook for patients with congenital tracheal stenosis (CTS) was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. This report reviews the short and long-term outcomes of a single-institution experience in the management of CTS in children, comparing different treatment modalities.

Methods

From 1991 to 2002, 13 cases of CTS have been managed in the authors unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy established the diagnosis in all cases. According to clinical and endoscopical features, patients have been classified into 3 groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomic type, associated anomalies, treatment modality, complications, outcome, and time of follow-up.

Results

Seven girls and 6 boys have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 8 months), and 77% showed associated anomalies. Four patients presented mild or no symptoms and have been treated expectantly. The other 9 patients have been operated on because of persistent or severe symptomatology. The following procedures have been performed: costal cartilage tracheoplasty (n = 5), tracheal resection (n = 3), slide tracheoplasty (n = 2), endoscopical dilatation (n = 3), and laser resection (n = 1). Three patients required 2 or more procedures, and there were 3 early deaths, all after costal cartilage tracheoplasty. Overall mortality rate in the series is 23%. Follow-up is complete in all survivors (n = 10) ranging from 6 months to 10 years (mean, 4.7 years).

Conclusions

Selection of the type of treatment depends on the patient’s clinical status and the anatomic pattern of the stenosis. In symptomatic cases of short-segment stenoses the authors prefer tracheal resection with end-to-end anastomosis; for long-segment stenoses, slide tracheoplasty is the procedure of choice.     

Tracheoplasty for long segment congenital tracheal stenosis: analysis of 29 patients over two decades

Purpose: The authors determined the long-term outcome of patients who underwent surgical repair of long-segment congenital tracheal stenosis (LCTS) and compared the quality of cartilage graft and slide tracheoplasty techniques.Methods: Twenty-nine patients underwent surgical repair of LCTS at 29 days to 9 years of age. In 26 patients, more than 50% of the entire length of the trachea was involved. The early 12 patients (1981 through 1992) were treated with a costal cartilage graft for tracheal reconstruction. The remaining 17 patients (1997 through 2002) were treated with slide tracheoplasty. For both procedures, a median sternotomy was preferred because of convenience when using extracorporeal circulation and for simultaneous repair of associated cardiovascular anomalies.Results: Of the 12 patients who underwent a costal cartilage graft, 8 survived (66%). Six of these patients are free of disease, but 2 have persistent airway problems. Three patients died of residual stenosis and 1 of unrelated disease. Of the 17 patients who underwent slide tracheoplasty, 13 survived (76%), and 10 are free of disease. Three patients continue to require a stent because of tracheomalacia and granulation. Two patients died of cardiac failure, 1 of granulation, and 1 of aspiration pneumonia.Conclusions: The authors challenged LCTS with a unique surgical approach and succeeded in making an incurable disease curable. When the cartilage graft technique is compared with slide tracheoplasty, however, the latter is preferable because it preserves native tracheal tissue with less frequent complications.     

The surgical treatment of congenital tracheal stenosis —A report of two cases—

Two patients with congenital tracheal stenosis, one who had segmental type stenosis and the other who had extensive type stenosis, were surgically treated at our hospital. The patient with segmental tracheal stenosis was successfully treated by resection and anastomosis. Five years postoperatively, although she was asymptomatic, endoscopic examination revealed a circumferential stricture with an inner diameter of about 3 mm in the upper trachea. A second operation was thus performed to remove the stenotic trachea and her postoperative course was uneventful. The second patient was a male whose extensive tracheal stenosis was associated with vascular ring and tracheal bronchus. Division of the vascular ring was not effective and a tracheoplasty using costal cartilage was performed twice, also unsuccessfully. He is now managed with a tracheostomy, using a long endotracheal tube which was specially designed for him. A recent bronchoscopy revealed a flaccid distal trachea. In this report, we also discuss the technical problems associated with treating congenital tracheal stenosis.     

Prognostic factors in the surgical treatment of congenital tracheal stenosis : A multicenter analysis of the literature

Background

Congenital tracheal stenosis (CTS) often requires urgent surgical intervention. We evaluated prognostic factors to determine the risks of surgical interventions by conducting a retrospective review of recent case series.

Methods

Cases of CTS between 2002 and 2004 from our institution and recently published series that provided primary data on the demographics, complications, and outcomes of patients with CTS were analyzed. Univariate, model fit, and multivariate logistic regression analyses were performed using the SAS Statistical Program.

Results

There were 68 patients who were treated (cartilage patch tracheoplasty, n = 31; slide tracheoplasty, n = 37), with 19 deaths (overall mortality = 28%). A total of 10 patients who underwent cartilage patch tracheoplasty died (32% mortality), whereas only 9 patients died following slide tracheoplasty (24% mortality). A total of 8 of 11 patients who were repaired at the age of 1 month or younger died (73% mortality), whereas only 11 of 57 patients who were repaired at an age older than 1 month died (19% mortality) (P = .04). A total of 10 of 19 patients with CTS who had comorbid intracardiac anomalies died following CTS repair (53% mortality), whereas only 9 of 49 patients with CTS who did not have intracardiac anomalies died (18% mortality) (P = .02).

Conclusions

This is the first report on the prognostic factors determining surgical outcomes for CTS. The highest mortality rate was observed in CTS patients younger than 1 month and in those with intracardiac anomalies. Congenital tracheal stenosis repairs in these patient subgroups should be considered with caution.     

Epidural analgesia in the surgery of congenital tracheal stenosis: slide tracheoplasty on cardiopulmonary bypass

Epidural analgesia in children is highly effective and safe; however, it has not enjoyed great popularity in surgery that requires cardiopulmonary bypass. A major concern is the possibility of damage to blood vessels with the epidural needle or catheter and epidural hematoma formation. There seems to be a low incidence of epidural hematoma if certain guidelines are followed, so that in children, epidural analgesia can be used in selected patients, with safety, when surgical repair requires cardiopulmonary bypass. Epidural morphine has been used for clinical pain relief in pediatric cardiac surgery. Improved pulmonary function, suppressed hormonal and metabolic stress responses, easy early tracheal extubation, and good analgesia and sedation that allows neurological examination to alert any possibles hidden complications, are the advantages. A dedicated medical team is essential in the perioperative management to achieve maximum benefit for these patients.     

Tracheoplasty for congenital stenosis of the entire trachea

Congenital stenosis involving the entire length of the trachea has generally been regarded as a fatal disease. Tracheoplasty using costal cartilage grafts to enlarge the lumen was successfully employed in such a case, and the technique is described. A 12-mo-old female was referred with recurrent severe respiratory distress since birth. By tracheoscopy and bronchography, the entire trachea was seen to be stenotic. The left bronchus was of normal caliber by bronchogram and the left lung was over inflated, while the right lung was aplastic. Through a midsternal thoracotomy, the left bronchus was incised and cannulated for ventilation. Longitudinal incision of the entire length of the anterior wall of the trachea permitted the advance of a nasotracheal tube along the inner surface of the divided trachea to the carina. Two pieces of costal cartilage were used to fill the defect in the anterior wall of the trachea. The grafts were attached to the tracheal edges by interrupted 5-0 Dexon sutures. The endotracheal tube was successfully removed two months later. The subsequent course of the patient has been satisfactory.     

婴幼儿先天性心脏病伴气管狭窄的一期矫治

目的回顾总结一期纠治婴幼儿先天性心脏病（先心病）伴气管狭窄的体会。方法2001年8月至2005年11月，6例先心病伴气管狭窄的婴幼儿行一期手术矫治。手术年龄24d～3岁；体重4．2～10．0kg，平均（7．98±2．03）kg。其中法洛四联症3例，1例伴肺动脉闭锁；室间隔缺损2例，1例伴主动脉缩窄；肺动脉吊带1例。所有病儿均在低温体外循环下行先心病纠治术，同时处理气管狭窄。结果术后早期1例左、右支气管均匀性狭窄，不能脱离呼吸机死亡。1例肺动脉吊带者术后顺利出院，3个月后出现气管内肉芽增生，家属放弃治疗。余4例术后恢复良好，随访6个月至4年，临床上无气促表现。超声复查心功能良好，其中3例经CT复查，显示气管吻合口通畅，无明显狭窄。结论先心病伴先天性气管狭窄，以一期手术治疗为好，不但术中在体外循环下纠治气管狭窄较安全，而且同时纠治先心病有利于手术后病儿康复。     

Tracheal diaphragm: a very unusual form of congenital tracheal stenosis

A 3.2-kg newborn was intubated for neonatal respiratory distress owing to a congenital tracheal stenosis. The preoperative assessment showed a sphincter-like stenosis located 1 cm above the carina. The child was cured by resection-anastomosis through sternotomy under cardiopulmonary bypass. The pathological examination showed hypoplastic cartilage islets embedded in a fibroelastic conjunctive tissue. The posterior membranous region was preserved with the existence of smooth muscle cells. This curious malformation resembled a diaphragm at the junction between trachea and carina.     

Analysis of 40 patients who underwent tracheal resection due to benign complex tracheal stenosis

BackgroundBenign tracheal stenosis is a common complication in patients followed up in intensive care units. We aimed to analyze the etiology, diagnostic approaches, treatment methods for benign tracheal stenosis, and the predicting factors for complications after tracheal resection for benign stenosis.Material-methodForty patients who underwent tracheal resection reconstruction due to benign tracheal stenosis were analyzed retrospectively. Predictive factors for complications were determined by statistical analysis.ResultsThere were 23 patients (57.5%) in the intubation group, 11 patients (27.5%) in the tracheostomy group, and 6 patients (15%) in the subsequent tracheostomy group. Preoperatively, rigid dilatation was applied to all patients between 2 and 6 sessions (median = 3). Tracheal resections were performed in all patients after rigid dilatations. The mean of the resected segment lengths is 32.1 ± 8.8 mm. There was a statistically significant difference between preoperative bronchoscopic measurements, preoperative tomography measurements, and intraoperative measurements of the stenosis segment (?2 (2) = 71,500; p < 0.001). The patients' mean follow-up period was 27.4 ± 21.7 months (3–84). Mortality due to tracheal surgery and major anastomotic complications were not observed. The minor anastomotic complication rate was 12.5%, the non-anastomotic complication rate was 17.5%. The effect of resection length and surgical experience were found to be statistically significant risk factors for anastomotic complications.Conclusions: Rigid dilatation does not provide significant palliation in complex stenosis. Bronchoscopic measurements give closer results than CT measurements in the preoperative estimation of resection length. The risk of anastomotic complications increases when the length of the resection increases and when the surgical experience is less.     

Slide tracheoplasty in infant with congenital tracheal stenosis and tracheomalacia after esophageal atresia with tracheoesophageal fistula repair

Slide tracheoplasty can be applied successfully to all types of long segment congenital tracheal stenosis. In case of short segment tracheal stenosis, direct resection and anastomosis is often preferred. We report a case illustrating a new side benefit of the slide tracheoplasty in a patient presenting a relatively short hypoplastic tracheal segment coexisting with tracheomalacia after EA with TEF repair.     

Long-term outcomes of clinically significant vascular rings associated with congenital tracheal stenosis

Aim

Congenital tracheal stenosis (CTS) associated with vascular rings (VRs) is considered a secondary condition, but relative indications for selective VRs or combined VR and CTS repairs are unclear. Here, we report long-term outcomes after VR repair associated with tracheal narrowing (TN).

Method

Retrospective analysis of patients admitted to a single institution with VR from 1982 to 2004. Of 131 patients with VR (Cardiac Registry Database), 29 (19 males, 10 females; age range, 0 days-4 years) associated with symptomatic TN. Patients were followed until age 18 years.

Results

One hundred thirty-one patients with VR were categorized into 3 treatment groups. There were 102 patients with VR with no symptomatic TN treated by VR repair (4 deaths, 4% mortality). Of the 29 patients with VR + TN symptoms, 16 were treated by selective VR repair (mean age, 5.3 months; range, 17-288 days) with 3 deaths (19% mortality) and 13 underwent combined VR and CTS repairs (mean age, 11 months; range, 1 day-4 years) with 6 deaths (46% mortality), for an overall mortality of 31% (P < .01, χ² test). Of the 102 patients with VR, 17 had intracardiac anomalies with 3 deaths (18% mortality). In contrast, 7 of 29 patients with VR with TN and intracardiac anomalies died (57% mortality); 3 patients in combined cardiac and CTS repairs (2 deaths, 67% mortality) and 4 in selective VR repairs (2 deaths, 50% mortality).

Conclusions

Not all cases of TN associated with VR require combined repairs. The presence of TN and/or intracardiac anomalies in patients with VR, however, increases mortality risk to the repair of VR. Surgical decision requires individualized clinical pathway.     

先天性唇腭裂小儿并气道狭小的临床观察

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