Novel use of neonatal cuffed tracheal tube to occlude tracheo-oesophageal fistula

The use of a cuffed tracheal tube is described to occlude the leak through a tracheo-oesophageal fistula (TOF) in a neonate and prevent gastric dilatation during positive-pressure lung ventilation.     

Surgical repair for tracheo-innominate artery fistula with a muscle flap

A 70-year-old woman was quickly diagnosed as having tracheo-innominate artery fistula by three-dimensional computed tomography. Immediate surgical exploration was performed to control the bleeding using a temporary shunt. After the damaged artery was excised, vascular reconstruction was performed to preserve the connection between the proximal and distal ends of the innominate artery with the interposition of a saphenous vein graft. A pedicled sternocleidomastoid muscle flap was successfully used for the tracheal reconstruction.     

Carinal resection and double-barrel reconstruction following oesophagectomy for oesophageal carcinoma with broncho-oesophageal fistula

A 54-year-old man presenting with dysphagia was diagnosed with locally advanced oesophageal carcinoma with a broncho-oesophageal fistula (c-T4bN2M0 stage IVa). Concurrent chemoradiotherapy (60 Gy) was planned; however, bleeding from the oesophageal lesions progressed during chemoradiotherapy (16 Gy). Oesophagectomy with carinal resection and double-barrelled reconstruction was performed. Despite the inevitable recurrent nerve palsy and a minor fistula at the tracheal anastomosis, he recovered with conservative treatment and was discharged 4 months after the salvage surgery. He is alive without recurrence 28 months after the surgery.     

The design of pediatric tracheal tubes

Differences in the anatomy and physiology of the young child necessitate specialist equipment and anesthetic equipment is constantly evolving. We will review the factors influencing the design of pediatric tubes and highlight those areas of special interest. There have been pleas for more standardization of tube markings, as this would help with positioning of tubes, especially in small babies, and there are recent advances in this area. Anesthetists need to be aware that there are important differences between tubes so that they take this into account when choosing an appropriate tube. In addition, developments in the design of cuffed tubes are increasingly being used both for routine care and specialist surgery.     

Use of a distal arteriovenous fistula in a complex vascular reconstruction after resection of an osteosarcoma in a high-risk child

Osteosarcoma is the most common osseous malignancy of childhood. Vascular reconstruction during resection is uncommon. However, when required, thrombosis is a major cause of failed limb salvage surgery. A 19-year-old patient required complex vascular reconstruction in conjunction with lower extremity osteosarcoma resection. Preoperatively, his case was complicated by an ipsilateral popliteal deep vein thrombosis presenting during neoadjuvant chemotherapy. At the time of resection, to increase vascular graft flow, a distal arteriovenous fistula was created between the posterior tibial artery and the greater saphenous vein. This case illustrates a patient with a complex extirpation procedure requiring concomitant vascular reconstruction. This technique should be considered when limb salvage with vascular resection is being attempted in a high-risk patient.     

Extracorporeal membrane oxygenation as a bridge to definitive tracheal reconstruction in neonates

Purpose

Infants born with severe tracheal anomalies may not survive beyond the first few hours of life without aggressive cardiopulmonary support and/or emergent airway surgery. The purpose of this study was to review our experience with critically ill neonates supported on extracorporeal membrane oxygenation (ECMO) before tracheal reconstruction.

Methods

A retrospective review of a single institution ECMO registry was conducted. Outcomes of neonates requiring tracheal repair were examined.

Results

Three children with tracheal anomalies (complete tracheal rings [n = 2]; bronchogenic cyst [n = 1]) underwent definitive airway reconstruction. All were placed on ECMO (venovenous [n = 2]; venoarterial [n = 1]) within 24 hours after birth. Tracheoplasties (tracheal resection with end-to-end anastomosis [n = 1]; slide tracheoplasty [n = 1]; carinal resection and reconstruction [n = 1]) were performed at 3.7 ± 2.2 days of life. There were no hemorrhagic or thrombotic complications for an ECMO time of 117.3 ± 60.1 hours. The postoperative durations until extubation and hospital discharge were 12.0 ± 3.2 and 34.3 ± 11.6 days, respectively. All children remain alive and well without cardiopulmonary and neurologic sequelae at a mean follow-up of 4.5 years.

Conclusions

Excellent clinical outcomes can be achieved in neonates born with severe tracheal anomalies using ECMO as a bridge to definitive tracheal reconstruction.     

New formulae for predicting tracheal tube length

Background : The aim of this study was to determine the accuracy of standard techniques for estimating oral and nasal tracheal tube length in children and to devise more accurate predictive formulae that can be used at the bedside. Methods : Data were collected from 255 children who required tracheal intubation whilst on the Pediatric Intensive Care Unit over a period of 1 year. Age, weight, the final length of the tracheal tube and the internal diameter were documented. Patients with a tracheostomy were excluded from the study. Results : Using linear regression the following formulae best predicted final tracheal tube length. For children over 1 year of age: For children below 1 year of age: Conclusions : Current Advanced Paediatric Life Support guidelines underestimate the appropriate tracheal tube lengths for orotracheal intubation in children over 1 year of age. Similarly, the novel weight‐based formulae for tracheal tube lengths in children below the age of 1 year proved more accurate than standard reference charts. We therefore recommend that these new formulae are prospectively evaluated.     

Influence of utility of fascia lata homograft on the palatal fistula in cleft palate repair

After palatoplasty operations, we are faced with a palatal fistula rate of 30% repair which is one of the most difficult tasks in Plastic Surgery. Placement of a biological material between the two anatomic layers of the palate was performed to reduce the rate of fistula formation. Commercially available fascia lata homograft was used in order to decrease the time of operation and avoid donor site morbidity. This method has reduced the rate of palatal fistulae to 8.3%.Presented at the 14th National Congress of Plastic Surgery, Ankara, Turkey, 1992     

Complete tracheal stenosis following percutaneous tracheostomy

Percutaneous tracheostomy is an effective method of airway management in the critically ill patient, avoiding an open exposure of the trachea. This method is time and cost-efficient and is used in many intensive care units. However, we would like to draw attention to one serious potential complication of this technique. This case report describes a case of complete tracheal stenosis above the level of tracheostoma as a direct result of the procedure. The aetiology of the stenosis as well as the surgical and postoperative managements is discussed.     

Arteriotracheal fistula as a fatal complication after tracheal resection and twice-a-day-irradiation for thyroid carcinoma

Background The arteriotracheal fistula is a severe, and mostly fatal complication in the treatment of patients with head and neck cancer. Methods We report a case of fatal haemorrhage from a fistula between the right brachiocephalic trunk and the trachea after radical thyroidectomy, resection of the frontal wall of the cervical trachea, and twice-a-day-irradiation. Results Compared to conventional irradiation therapy, twice-a-day-irradiation seems to be the major cause of this fatal complication. Conclusions Therefore we prefer conventional irradiation therapy to twice-a-day-irradiation in patients with R0 resection (curative tumor removal) and reconstructive surgery of the trachea and/or esophagus. In patients where R0 resection is impracticable, a reconstructive approach to the trachea or esophagus has to be avoided. In these cases, early postoperative twice-a-day-irradiation may prevent early tumor recurrence.      

Mammillary fistula revisited: Implications for immediate breast reconstruction

We present two patients with inverted nipples who underwent bilateral nipple‐sparing mastectomies (NSM) with immediate placement of tissue expanders with acellular dermal matrix (ADM). Both were complicated by postoperative infection and developed mammillary fistulae from the nipple into the breast capsule, and eroding through the ADM. For the first time, we report inverted nipples as a risk for the iatrogenic formation of mammillary fistulae and their infectious implications after NSM.     

Arteriovenous fistula reconstruction in patients with kidney allograft failure

Abstract: Background:  Kidney recipients with failing allograft function face the vascular access problem again before returning to hemodialysis. An autologous arteriovenous fistula (AVF), according to the recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, is the optimal vascular access and the use of prosthetic grafts and catheters should be limited. The objective of this study was to assess the feasibility of AVF reconstruction in patients reentering hemodialysis after kidney allograft failure.
Materials and methods:  Two hundred and forty-one transplant recipients reentered hemodialysis between 1990 and 2005. Before kidney transplantation, 221 patients had a functioning AVF on the forearm. Fistula reconstruction was attempted in 112 (51%) patients because of AVF thrombosis. Three strategies were applied according to forearm vein patency: a new radial-cephalic fistula, a radial-perforating vein fistula, or a radial-basilic forearm transposition was created.
Results:  Forearm AVFs were successfully reconstructed in 85 of the 112 patients (73%). The primary patency of the reconstructed AVFs was 57.6% and 44% at 12 and 24 months. Secondary patency was 64.9% and 54.9% at 12 and 24 months, respectively.
Conclusions:  The reconstruction of an old, thrombosed AVF is possible in kidney recipients returning to dialysis, even if the time from thrombosis to fistula repair is a few years.     

Percutaneous dilation tracheostomy in a patient with tracheal stent

We reported the case of a patient with obstruction of tracheal stent, deployed previously for anaplastic thyroid carcinoma. The extension of malignant stricture above and below the stent and close to the vocal folds made unfeasible the stent recanalization and/or its replacement with another longer. Thus, tracheostomy was the only option to assure ventilation. After partial air-way recanalization with rigid bronchoscope, tracheostomy cannula was inserted through the stenosis using percutaneous dilatation tracheostomy technique.     

Severe postintubation tracheobronchial rupture

Tracheal injury is a rare complication after pediatric intubation. The choice of treatment depends on the size of the lesion and on the underlying disease. We present a complex case of severe tracheal injury treated with success with tracheal stent positioning.     

Immediate reconstruction of the anal sphincter after fistulectomy in the management of complex anal fistulas

An analysis was made of the indications and outcome of immediate reconstruction of the anal sphincter after fistulectomy in the management of a selected group of patients who were at risk of post-operative incontinence. A total of 31 patients underwent surgery, with 25 high trans-sphincteric fistulas (80.6%), four low trans-sphincteric fistulas (12.9%), and two suprasphincteric fistulas (6.5%). The median post-operative stay was 7.0 days, with a median follow up of 24.0 months. We describe one case (3.2%) of post-operative infection and dehiscence of the muscle suture. The fistula recurred in three patients (9.7%). At the end of follow up of 25 patients with full preoperative continence, five patients (20.0%) presented with perianal soiling and one (4.0%) had incontinence to flatus. Sphincter reconstruction after fistulectomy constitutes a management option that should be considered in the treatment of certain fistulas. It allows both rapid recovery and the preservation of anal function.