Bronchial flap closure of the lower membranous trachea

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.     

Blunt tracheal transection and long tear in posterior membranous trachea

Blunt tracheobronchial injuries are rare, but can be life-threatening. A precise preoperative diagnosis and a well-recognised plan of surgical treatment, which may be unique for each patient, are needed to restore the continuity of tracheobronchial tree in a one-stage intervention. We encountered a patient with complete tracheal transection and 15 cm tear in the posterior membranous trachea and right bronchus, and whose tracheal injury was difficult to repair using direct intubation of distal airway by bronchoscopy. We achieved a good result of one-stage repair using a percutaneous cardiopulmonary support (PCPS).     

Case report: Endotracheal tube malposition in a patient with a tracheal bronchus

PURPOSE: A tracheal bronchus is a congenital abnormality of the tracheobronchial tree, in which a displaced or accessory bronchus arises from the trachea superior to its bifurcation. We report a patient with a tracheal bronchus that was found incidentally during surgery in the prone position, and the potential airway management problems which may have ensued. CLINICAL FEATURES: A 70-yr-old female underwent posterior spinal decompression and fusion in the prone position. Intraoperatively, end-tidal CO2 and airway pressure increased. Fibreoptic bronchoscopy revealed that the endotracheal tube (ETT) was kinked at the 16 cm mark, which was corrected by rotating the patient's head and ETT. When the bronchoscope was advanced beyond the tip of the ETT, a tracheal-bronchial tree trifurcation was identified. Endobronchial intubation was suspected. As the ETT was withdrawn, the endoluminal view remained unchanged. During bronchoscopy, the patient's trachea was nearly extubated in the prone position. Subsequent bronchoscopy of the major bronchial divisions showed that the trifurcation represented left main stem bronchus, bronchus intermedius and right upper lobe bronchus. Once the tracheal bronchus was recognized, the tip of the ETT was repositioned 3 cm above the tracheal trifurcation, and the rest of the case was uneventful. CONCLUSION: This case highlights the diagnostic challenge and airway management implications of one variant of a tracheal bronchus when airway problems are encountered intraoperatively. This knowledge should be applied in the differential diagnosis and management of intraoperative hypoxemia; and in the proper positioning of the ETT.     

Postoperative airway stenosis and stent therapy in carinal reconstruction for lung cancer.

A 48-year-old male had adenocarcinoma of the right upper lung lobe that invaded the lower trachea. The right upper lobe, the carina, and 5 rings of the lower trachea were resected. The carina was reconstructed using end-to-end anastomosis between the trachea and right intermediate bronchus, with the left main bronchus anastomosed to the side wall of the intermediate bronchus. Two months after surgery, the right intermediate bronchus developed bronchomalacia and the tracheal anastomosis granulatory stenosis. Bronchomalacia was treated with 2 expandable metallic stents, and granulatory stenosis with a Dumon stent. Although the silicone stent successfully dilated the granulatory stenosis, the metallic stents caused delayed glanulatory stenosis. We concluded that a metallic stent is not desirable for treating postreconstructive airway stenosis including bronchomalacia, whereas a Dumon stent may be effective.     

Postoperative airway stenosis and stent therapy in carinal reconstruction for lung cancer

A 48-year-old male had adenocarcinoma of the right upper lung lobe that invaded the lower trachea. The right upper lobe, the carina, and 5 rings of the lower trachea were resected. The carina was reconstructed using end-to-end anastomosis between the trachea and right intermediate bronchus, with the left main bronchus anastomosed to the side wall of the intermediate bronchus. Two months after surgery, the right intermediate bronchus developed bronchomalacia and the tracheal anastomosis granulatory stenosis. Bronchomalacia was treated with 2 expandable metallic stents, and granulatory stenosis with a Dumon stent. Although the silicone stent successfully dilated the granulatory stenosis, the metallic stents caused delayed glanulatory stenosis. We concluded that a metallic stent is not desirable for treating postreconstructive airway stenosis including bronchomalacia, whereas a Dumon stent may be effective.     

Tracheal bronchus: classification, endoscopic analysis, and airway management.

OBJECTIVE: Tracheal bronchus (bronchus suis) is an unusual congenital anomaly in which the right upper lobe has its origin in the trachea rather than distal to the carina. We sought to analyze the anatomy, presentation, and airway management principles of tracheal bronchi, and we present the first endoscopically documented tracheal diverticulum. STUDY DESIGN/METHODS: Retrospective case series. RESULTS: The tracheal bronchus is located at the junction of the mid and distal thirds of the right lateral trachea, is more common in males and children with other congenital anomalies, and may be associated with right main bronchus stenosis. Bronchoscopy provides a clear definitive view of the anomaly, which we found in 5 children during a 12-year period (0.5% of pediatric bronchoscopy procedures). We illustrate 3 types of tracheal bronchi: (1) vestigial tracheal diverticulum (newly described), (2) high apical lobe, and (3) fully developed supranumerary aerated tracheal bronchus. Endoscopic documentation of each type is presented. Children with tracheal bronchi may present with stridor, cough, and/or recurrent right-sided pneumonia and/or to have foreign body aspiration ruled out. Treatment is based on the severity of symptoms and ranges from observation to right upper lobectomy. CONCLUSIONS: Otolaryngologists should be aware of the tracheal bronchus, to include classification, endoscopic analysis, and airway management of this uncommon anomaly. Bronchoscopy with selected radiographic imaging allows the otolaryngologist to fully evaluate the child with a tracheal bronchus and to present timely therapeutic options.     

Successful weaning from mechanical ventilation in an infant with congenital tracheal stenosis and bronchial malacia using endobronchial stent, nasal CPAP and continuous sedation

A 1.9 kg male infant who showed respiratory distress at his birth, was diagnosed by bronchoscopy as having congenital segmental stenosis of trachea with complete ring. Tracheoplasty was performed and the infant was admitted to ICU. After admission to ICU, we suspected the residual tracheal stenosis and the left main bronchial malacia by bronchoscopy. Although we tried to wean him from mechanical ventilation, but failed and re-intubated him four times because of marked respiratory acidosis after extubation. Bronchoscopy was performed repeatedly, and the residual tracheal stenosis and the left main bronchial malacia were apparent. After patch tracheoplasty of the costal cartilage to the residual tracheal stenosis and implantation of angioplastic expandable metallic stent to the left main bronchus, he was successfully extubated under continuous sedation. In addition, nasal CPAP was effective to reduce retraction and wheezing after extubation. He was discharged from ICU on the 183rd ICU day.     

Surgical treatment of congenital distal tracheal stenosis involving the carina

Untreated congenital stenosis of the distal trachea frequently results in lethal airway obstruction. A 3-year-old boy with segmental stenosis of the distal trachea and a 2-year-old girl with segmental stenosis involving the carina and the right main bronchus were treated successfully with resection and reanastomosis. Operative techniques, anesthetic management, postoperative care, and tracheal growth after anastomosis are discussed.     

Successfully repaired traumatic tracheal disruption and cardiac rupture with cardiopulmonary support

A 19-year-old man suffering from dyspnea associated with tracheal and cardiac rupture from a traffic accident was found by bronchoscopy to have a 7.5 cm longitudinal tear in the membranous portion of the trachea. Right posterolateral thoracotomy was conducted and open ventilation through the left main bronchus initiated with standby cardiopulmonary bypass cannulation of the right femoral artery and vein. When oxygenation was poor, extracorporeal circulation was initiated through the cannulated artery and vein. Under the cardiopulmonary bypass, we safely repaired the tracheal laceration and cardiac rupture.     

Airway anomalies in patients with congenital diaphragmatic hernia

PURPOSE: Congenital diaphragmatic hernias (CDH) sometimes are associated with airway anomalies such as congenital stenosis, abnormal branching of the bronchi, and pulmonary hypoplasia. The incidence of these associated airway anomalies has not been reported previously. METHODS: Bronchoscopy was performed in all neonates with CDH from 1987 to 1999. In addition to anatomic anomalies, bronchial hypoplasia was defined as narrowing and shortening of the bronchi at bronchoscopy. RESULTS: Anatomic anomalies were identified in 7 of 39 patients with CDH: 1 had congenital tracheal stenosis with pulmonary artery sling, 1 had a defect of the right upper lobe bronchus, 2 had a tracheal bronchus, and 3 had a trifurcated trachea. Bronchial hypoplasia on the affected side was identified in 15 patients and was seen in all patients with anatomic anomalies of the tracheobronchial tree except the 2 with tracheal bronchus. After excluding 5 patients with severe associated anomalies, 6 of 14 patients with an abnormal tracheobronchial tree died, whereas 1 of 20 patients without airway abnormalities died. CONCLUSIONS: Anatomic anomalies of the tracheobronchial tree and bronchial hypoplasia on the affected side were identified in 17.9% and 38.4% of patients with CDH, respectively. CDH patients who exhibited these abnormalities showed a poor outcome.     

Stenting for postoperative airway stenosis due to traumatic tracheobronchial rupture

A 43-year-old man underwent repair for the broken trachea, left main bronchus and right main brouchus due to trauma. Twenty-seven months after the initial surgery, he developed dyspnea and required ventilatory support. Computed tomography showed severe stenosis of the left main bronchus, tracheomalasia and bronchomalasia of right main bronchus. A self-expandable metallic stent (SEMS) was placed in the bilateral main bronchus and T-tube in the trachea. SEMS developed granulatory and cicatricial stenosis of the airway, which caused severe dyspnea. Replacement of SEMS with Dumon stents was successfully done and dyspnea was disappeared. A silicon stent should be used for treating postreconstructive airway stenosis including tracheobronchomalasia.     

Surgical approaches to membranous tracheal wall lacerations

BACKGROUND: Smaller postintubation tracheal tears are often misdiagnosed and, when recognized, they are effectively managed in a conservative fashion. Large membranous lacerations, especially if associated with important manifestations, require immediate surgical repair. We report our experience over the past 7 years. METHODS: From 1993 to 1999, 11 patients with a postintubation posterior tracheal wall laceration were treated in our institution. One patient was male and 10 were female, with a mean age of 68 years. Ten patients underwent orotracheal intubation under general anesthesia for elective surgery, 4 of whom were treated with a double-lumen selective tube. One patient underwent emergency intubation because of anaphylactic shock. In 9 cases the tracheal tear was promptly repaired, by way of a thoracotomy in 4 and by way of a cervicotomy and longitudinal tracheotomy in 5. In 2 cases the tear was small and was consequently managed conservatively. RESULTS: All surgical procedures proved effective in repairing the laceration, and there was no mortality or morbidity in the perioperative period. Early and late endoscopic follow-up showed no signs of tracheobronchial stenosis. CONCLUSIONS: When repair of membranous tracheal laceration is required, the surgical approach should be through a thoracotomy if the tear involves the distal trachea, a main stem, or both, and through a cervicotomy when the laceration is located in the proximal two thirds of the trachea. Performing a longitudinal tracheotomy to reach and suture the posterior tracheal wall is a reliable, quick, and safe procedure, and it avoids lateral and posterior dissection of the trachea.     

Troubled endotracheal intubation: an adult case of anomalous tracheal bronchus]

We experienced troubled endotracheal intubation in an adult patient with asymptomatic tracheal bronchus. The breath sounds of the right upper lobe were found to be absent right after the placement of a tracheal tube. An anomalous tracheal bronchus (displaced right upper lobar bronchus originating about 1 cm above carina) was found by fiberoptic bronchoscopy. The length of trachea of the patient was about 6 cm shorter than that of the normal value of adult male, which significantly reduced the safe range of positioning a tracheal tube. In a patient with this anomaly, who is otherwise healthy, a placement of a tracheal tube may cause pulmonary complications. Thus, as a diminished breath sound is found to be located at the upper right lobe after endotracheal intubation, we have to think of tracheal bronchus as one of the possible causes.     

Carinal reconstruction with wide airway resection by a new technique

Carinal reconstruction with wide airway resection by a new technique was conducted in two cases. A 61-year man with tracheal stenosis by tracheal cancer, 6 tracheal rings, 2 left bronchial rings, total right main bronchus, for which carina was resected and reconstructed by a new technique and for a 69 year man with lung cancer in right upper lobe, for which right upper-middle bilobectomy, S6 segmental resection and circumferential pulmonary artery resection were performed. The tracea, left main bronchus, and right basal segment bronchus were anastomosed by new technique and the right main pulmonary artery and basal segment artery was anastomosed subsequent to chemotherapy. Both patients discharged within seventeen postoperative days in consideration of the absence of postoperative complication. Bronchoscopic findings after reconstruction indicated neither stenosis nor dehiscence at the site of anastomosis. The new reconstructive method of carina permits simple anastomosis, the possibility of carina reconstruction even in the case of wide airway resection and loss tension at the site of anastomosis.     

Partial sleeve right pneumonectomy with carinal flap closure

We describe a technique used in 2 patients for resection of carcinoid tumor arising from the right main bronchus and extending along the lateral wall of the lower trachea. A flap was mobilized from the non-involved membranous posterior wall of the right main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea. Both patients did well after surgery and were followed-up for 10 to 17 years with no evidence of recurrence.     

气管切除与人工气管重建手术25例麻醉方法分析

目的 分析讨论气管切除吻合或人工气管替代等手术的麻醉方式和结果.方法 对采用不同手术方式治疗的25例气管良、恶性疾病患者的麻醉和手术过程进行了回顾性分析.其中良性疾病患者10例,恶性疾病患者15例.全组患者气管管腔均有不同程度的狭窄,严重者伴有明显呼吸困难.气管病变长度2.0～7.5cm.气管切除最长者8 cm,行一期吻合者14例,行人工气管替代者7例.该组患者采用单纯全身麻醉气管插管者13例,同时行心肺转流者2例;经已有的气管切开行全身麻醉者8例,在局部麻醉下行气管切开后全身麻醉者2例;行高频喷射通气辅助者2例.气管切断后,均需经远端气管或对侧主支气管内插管维持麻醉和通气.结果 全组患者均顺利完成手术,无麻醉和手术死亡.2例患者于气管切开后向左主支气管插管困难,1例患者向左主支气管插管过深,仅余左下肺通气,造成血氧饱和度下降;1例患者术毕改换无气囊导管时造成吻合口裂开;均经处理后好转.结论 气管手术麻醉风险高,个性化、周密的麻醉和手术方案以及麻醉医师与手术医师的密切配合,是保证麻醉和手术安全的关键.     

Surgical treatment of adenoid cystic carcinoma of the left main bronchus and trachea by left pneumonectomy, resection of 7.5 cm of trachea, and direct reanastomosis of right lung.

A 23-year-old woman, who had suffered recurrent acute bronchitis, dyspnoea, and stridor, was found to have a tracheal stenosis and complete left main bronchus obstruction. Biopsy of the tumour showed an adenoid cystic carcinoma. After pneumonectomy the trachea was closed through tumour tissue. Two weeks later a right thoracotomy showed that a tumour had invaded the trachea from the carina up to 6 cm and the right stem bronchus for 1 cm. Under extracorporeal circulation 7.5 cm of the trachea and right bronchus were resected. A direct tracheal anastomosis was easy to perform. Spontaneous respiration with efficient coughing returned after five days. Unfortunately, one month later, high fever caused by a lung abscess developed, which provoked a massive haemoptysis with fatal outcome.     

Deviated trachea in hypoplasia and aplasia of the right lung: airway obstruction and its release by aortopexy

Three cases of male infants with hypoplasia and aplasia of the right lung and dextrocardia are reported. The infants developed increasing obstructive respiratory distress in the first 4 months of life. In all three cases, there was an opaque right hemithorax with overinflation of the left lung, a posterior deviation of the trachea with pulsatile stenosis, and a posteriorly located aortic arch. Hypoplasia (two cases) or aplasia (one case) of the right pulmonary artery and an absence or a remnant of the right main bronchus were also observed. Associated malformations were esophageal atresia with an abnormal high pouch of the proximal esophagus in case 1, and hypertelorismus syndrome in case 2. Because of severe respiratory distress in all three patients, an aortopexy was performed at the ages of 5 months (one infant) and 10 months (two infants). The obstructive respiratory signs disappeared postoperatively in the following weeks. It has been observed that tracheal stenosis in aplasia or hypoplasia of the right lung may be caused by the dislocated aortic arch. An aortopexy can release the airway compression in such cases. Because of associated malformations, a careful evaluation of the airway and vessels is recommended.     

Extratracheal biodegradable splint to treat life-threatening tracheomalacia

A 9-month-old girl presented with life-threatening acute respiratory failure 1 week after the surgical correction of a double aortic arch, which was due to a severe bulging of the pars membranacea into the lumen of the trachea that produced a complete obstruction of the lower trachea. Under cardiopulmonary bypass, a Y-shaped posterior biodegradable splint was placed behind the trachea and sutured to the posterior trachea, and a simultaneous right aortic arch aortopexy was performed. Thereafter, the child recovered normal respiratory function. Follow-up bronchoscopy showed a posterior dip at the splint level and an asymptomatic persistent posterior compression of the right main bronchus.