Prosthetic reconstruction of the trachea

Tracheal reconstruction has been a difficult and challenging problem over the years, mainly because of graft infection and extrusion. A small segment of the trachea can be resected and primary anastomosis can be performed easily with satisfactory results. The problem is always complex when a substantial portion of the trachea must be resected. A variety of prosthetic materials have been used, both in experimental animals and human subjects, with limited short-term success. This study describes an experiment using polytetrafluoroethylene (PTFE) grafts in dogs. PTFE patch and interposition grafts were used for tracheal reconstruction with very satisfactory results. Inflammatory reaction near the grafts and nonincorporation of long graft segments continue to be problems, but despite this, prosthetic reconstruction of the trachea using PTFE provided very satisfactory results in our experimental study.     

Prosthetic reconstruction of the trachea in rabbit

BACKGROUND: Various tracheal reconstruction techniques have been developed for stenosis. Different types of grafts, flaps and synthetic materials have been used for reconstruction of the defect when primary anastomosis was unsuccessful or not indicated. The mentioned reconstruction methods have limited success. Polytetrafluoro-ethylene (PTFE) prosthesis is a microporous polymer and has been applied for implantation on a wide range. It is also appropriate for tracheal reconstruction. METHODS: In the present study, segmental defects were created in 12 New Zealand rabbits. The rabbits were divided into 2 subgroups; the first group was applied an end-to-end anastomosis whilst the second a PTFE prosthesis. After 2 months, these applications were compared clinically, endoscopically and histopathologically to each other. RESULTS: Necrosis and extrusion were not observed in the rabbits with PTFE applications. After 1 month, the tracheal stenosis was found on endoscopic examination in 5 animals in the first group and 2 animals in the second group. While in longer defects, end-to-end anastomosis causes tracheal tension, PTFE applications have been well tolerated. CONCLUSIONS: It is concluded that PTFE prosthesis is a suitable alternative method in reconstruction of circumferential tracheal defects.     

Reconstruction of the trachea, carina and bronchi

In the past 30 years to March 1985, at Keio University Hospital, 72 tracheal reconstructions, 7 carinal reconstructions, 5 sleeve pneumonectomies and 75 bronchial reconstructions were performed. One patient underwent right upper sleeve lobectomy and sleeve resection of the anterior basal segment of the left lower lobe, both for squamous cell carcinoma. Without these sophisticated procedures and if conventional operation had been performed, right pneumonectomy and left lower lobectomy would have been required in this patient. With the application of bronchoplastic operation this patient could maintain fair lung function for daily life. Although rate of postoperative complications in tracheobronchial reconstruction can not be negligible, appropriate adoption of this procedure with skillness will improve postoperative result.     

Extensive resection of the distal trachea and bilateral bronchi for the tumor arising from the carina: a successful reconstruction of the carina

This paper reports the case of an 8-year-old girl who successfully underwent tracheobronchial reconstruction for neoplastic obstruction at the carina. Reconstruction of the carina was performed using an end-to-end type anastomosis between the trachea and bronchi.     

Anatomy of the trachea, carina, and bronchi

This article summarizes the pertinent points of tracheal and bronchial anatomy, including the relationships to surrounding structures. Tracheal and bronchial anatomy is essential knowledge for the thoracic surgeon, and an understanding of the anatomic relationships surrounding the airway is crucial to the safe performance of many thoracic surgical procedures. In addition, the more precise delineation of tracheal anatomy has contributed largely to the advancement of airway surgery in recent years. This article serves as a foundation for learning or reviewing this important topic.     

Experience with primary neoplasms of the trachea and carina

From 1963 to 1983, 44 patients presented with a primary tracheal neoplasm that was amenable to surgical treatment. Forty-two of the 44 tumors were malignant. Thirty-three patients were managed by resection and primary anastomosis. The following resections were done: trachea only, 12; trachea plus carina, 13; trachea plus cricoid cartilage, four; and trachea plus larynx, four. There were two operative deaths in these 33 patients. Prosthetic reconstruction with heavy-duty Marlex mesh was done in six patients. Three of the six died of erosion of the innominate artery during the postoperative period. In three patients with nonresectable tumors, a silicone-coated Montgomery T-tube provided transient but worthwhile palliation. In two patients with nonobstructive adenoid cystic carcinoma involving the subglottis, irradiation was chosen as the initial treatment, since resection would necessitate laryngectomy. Resection, including laryngectomy, may be required in the future. The following points are emphasized: (1) A majority of operable neoplasms can be resected through a cervical collar incision and median sternotomy. Median sternotomy is the optimal operative exposure in most neoplasms necessitating resection of the carina. (2) Partial resection of the cricoid with sparing of the recurrent laryngeal nerves and larynx is possible in some patients with primary malignant tumors involving the proximal trachea and subglottic region. (3) In patients with adenoid cystic carcinoma, resection may afford excellent, long-term palliation even when the resection is incomplete. Pulmonary metastases are common in patients with adenoid cystic tumors. However, they usually progress slowly, may remain asymptomatic for many years, and are not necessarily a contraindication to resection of the primary tumor even when they are synchronous. Our experience suggests that adjunctive radiotherapy is beneficial in patients with adenoid cystic carcinoma.     

气管、隆突肿瘤外科治疗的技术探讨(附46例报告)

目的 总结气管、隆突肿瘤外科治疗经验,探讨其手术相关技术的合理应用.方法 回顾分析我科2001年2月至2008年10月手术治疗46例气管、隆突肿瘤的临床资料,其中恶性肿瘤29例,良性肿瘤17例;气管环形切除并对端吻合术33例,气管和隆突切除重建术12例,气管楔形切除1例,其中5例重度气管狭窄者在股动脉-股静脉部分体外循环辅助下完成麻醉和手术;43例采用多种带蒂的自体组织包埋气管吻合口.结果 气管切除长度2.0～6.5cm,平均3.2cm;无围手术期死亡,无气管吻合口瘘,临床治愈39例(84.8%);术后随访7个月～7年,死亡5例(10.9%),生存至今40例(87%),其中生存5年及以上者9例(20%).结论 外科手术是气管、隆突肿瘤的首选治疗方法 ;保障通气、合理术式和有效的吻合口包埋是手术成功和预防并发症的关键技术.     

Prosthetic reconstruction of the chest wall

Chest wall reconstructions can be complex and challenging procedures, especially when huge thoracic defects have been generated by radical excisions. Nonrigid reconstructions with meshes or patches have the goal of avoiding a lung hernia caused by the chest wall defect, or preventing the impaction of the scapula in case of posterior chest wall resections, especially when the resection is extended down to the 5th and 6th ribs. Large anterior and lateral resections result in thoracic instability and alteration of pulmonary physiology, and render intrathoracic structures vulnerable to external impact. They necessitate rigid reconstructions according to several techniques using alloplastic materials (eg, methyl methacrylate-based customized plates or neo-ribs, osteosynthesis systems, or dedicated prosthesis). Nowadays, the availability of these multiple, possibly combined, more adapted, and better tolerated materials have pushed past the limits of resection to those involving soft tissue coverage.     

Elective resection of tumours of the trachea and main carina after endoscopic laser therapy.

In our patients with tumour affecting the trachea or carina elective surgery was carried out after endoscopic laser treatment. Laser treatment was performed as an emergency procedure in three of the patients, who presented with impending asphyxia; the improvement provided time in which to assess the disease, withdraw corticosteroids, and treat infection. The fourth patient was treated with the laser for life threatening haemoptysis, but further bleeding made it necessary to tamponade the tumour with a cuffed endotracheal tube for 24 hours. Elective resections of the trachea (three cases) and carina (one case) were performed successfully four to eight weeks after laser treatment. Frozen sections of the resection margins were clear in all cases and paraffin sections subsequently confirmed the localised nature of the lesions. All patients are alive and well with no evidence of tumour recurrence after 18 months to 4 years. Laser therapy appears to be an ideal preoperative treatment for patients with impending asphyxia but it may be of limited value in controlling very brisk haemorrhage.