Evolution of left-sided thoracoscopic approach for long gap esophageal atresia repair

BackgroundLeft-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheobronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process.MethodsWe retrospectively reviewed patients who underwent Foker process for LGEA at two institutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed.Results71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2–8) operations and median 13.5 (IQR 11–21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5–31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0–13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement.ConclusionsFor multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch.Level of evidenceLevel IV Treatment Study.     

Longitudinal quantification of growth and changes in primary tracheobronchomalacia sites in children

RATIONALE: Longitudinal follow-up of children with tracheobronchomalacia is essential to improving our understanding of these disorders, yet currently, there is no such data. OBJECTIVES: To longitudinally define malacia sites and quantify the cross-sectional area (CSA) of the lumen using a bronchoscopic technique and to relate these measurements to illness profiles. METHODS: The validated color histogram mode technique was utilized to quantify primary malacia lesions and airway sites' CSA. Illness frequency, validated scales of illness and cough diary scores were prospectively used to assess clinical profiles. RESULTS: Thirty-five malacia sites were defined from the 2 studies of 21 children. CSA of 21 (60%) of the malacia lesions increased, 5 (14%) new lesions appeared, 5 (14%) decreased in size, 3 (8%) remained unchanged, and 1(3%) was indeterminate. Overall there was no statistically significant change in paired-data assessments of malacia sites' area while there was a significant increase in area of non-malacia sites. The median yearly growth rate for the malacia sites and non-malacia was 3.65 mm2/year sites and 5.38 mm2/year, respectively (P = 0.31). The type and severity of lesion was not associated with any difference in growth rates, illness frequency or clinical scores. CONCLUSIONS: Malacia lesions increase in size at the same rate as non-malacia sites. However malacia may worsen and new primary lesions may develop. Neither malacia type nor severity influences their growth pattern or illness profile.     

Improvement in postoperative lung function in patients with moderate to severe airway obstruction after robotic-assisted thoracoscopic tracheobronchoplasty

ObjectiveThe study objective was to examine pulmonary function and quality of life improvement after robotic-assisted thoracoscopic tracheobronchoplasty for patients with different degrees of obstructive airway disease.MethodsWe performed a retrospective review of a prospective database of patients who underwent robotic-assisted thoracoscopic tracheobronchoplasty between 2013 and 2020.ResultsA total of 118 patients underwent robotic-assisted thoracoscopic tracheobronchoplasty. Preoperative and postoperative pulmonary function tests were available for 108 patients. Postoperative pulmonary function tests at a median of 16 months demonstrated a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 76.76% predicted, postoperative: 83% predicted, P = .002). Preoperative and postoperative St George Respiratory Questionnaires were available for 64 patients with a significant decrease in postoperative score at a median of 7 months (preoperative median: 61, postoperative: 41.60, P < .001). When stratified by preoperative degree of obstruction, robotic-assisted thoracoscopic tracheobronchoplasty improved forced expiratory volume in 1 second in moderate to very severe obstruction with a statistically significant improvement in moderate (preoperative median: 63.91% predicted, postoperative median: 73% predicted, P = .001) and severe (preoperative median: 44% predicted, postoperative median: 57% predicted, P = .007) obstruction. St George Respiratory Questionnaire scores improved for all patients. Improvement for mild (preoperative median: 61.27, postoperative median: 36.71, P < .001) and moderate (preoperative median: 57.15, postoperative median: 47.52, P = .03) obstruction was statistically significant.ConclusionsRobotic-assisted thoracoscopic tracheobronchoplasty improves obstruction and symptoms. With limited follow-up, subgroup analysis showed forced expiratory volume in 1 second improved in severe preoperative obstruction and quality of life improved in moderate obstruction. Future follow-up is required to determine robotic-assisted thoracoscopic tracheobronchoplasty effects on the most severe group, but we cannot conclude that increased degree of preoperative obstruction precludes surgery.     

Tracheobronchomalacia and excessive dynamic airway collapse

Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.     

External stenting: A reliable technique to relieve airway obstruction in small children

Objective

Airway obstruction in children may be caused by conditions such as vascular compression and congenital tracheobronchomalacia. Obstructive pulmonary vascular disease may be a detrimental sequel for patients with congenital heart disease. We evaluate our own original external stenting technique as a treatment option for these patients.

Comparison of Dynamic Expiratory CT With Bronchoscopy for Diagnosing Airway Malacia: A Pilot Evaluation

OBJECTIVE: To assess the accuracy of dynamic expiratory CT for detecting airway malacia using bronchoscopy as the diagnostic "gold standard." MATERIALS AND METHODS: A computerized hospital information system was used to retrospectively identify all patients with bronchoscopically proven airway malacia referred for CT airway imaging at our institution during a 19-month period. CT was performed within 1 week of bronchoscopy. All patients were scanned with a standard protocol, including end-inspiratory and dynamic expiratory volumetric imaging, using an eight-detector multislice helical CT scanner. For both CT and bronchoscopy, malacia was defined as >/= 50% expiratory reduction of the airway lumen. CT and bronchoscopic findings were subsequently jointly reviewed by the radiologist and bronchoscopist for concordance. RESULTS: Twenty-nine patients (12 men and 17 women; mean age, 60 years; range, 36 to 79 years) comprised the study cohort. CT correctly diagnosed malacia in 28 of 29 patients (97%). The most common presenting symptoms were dyspnea in 20 patients (69%), severe or persistent cough in 16 patients (55%), and recurrent infection in 7 patients (24%). The estimated radiation dose (expressed as dose-length product) for the dual-phase study is 508 mGy-cm, which is comparable to a routine chest CT. CONCLUSION: Dynamic expiratory CT is a highly sensitive method for detecting airway malacia and has the potential to serve as an effective, noninvasive test for diagnosing this condition.