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Role of aortopexy in the treatment of aberrant innominate artery in children. Pediatr Surg Int 2022; 39:47. [PMID: 36502450 DOI: 10.1007/s00383-022-05280-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to assess the surgical and follow-up outcomes in children who operated for aberrant innominate artery. METHODS A total of 15 consecutive patients (12 males, 3 females; mean age 16.3 ± 19.0 months; range 3 months to 6 years) who underwent aortopexy between February 2018 and December 2021 were evaluated. Demographic data, preoperative and postoperative clinical status and postoperative outcomes were retrospectively analyzed. RESULTS The mean age at operation was 16.3 ± 19.0 months. The median weight was 8.3 kg (range, 7-14.5 kg).There was no complications at intraoperative period. The mean percent degree of tracheal stenosis was 0.68 ± 0.12. The median (range) MV duration, PICU stay, and ward stay of the patients were 2 h (0-3 h), 2.5 days (1-4 days), and 5 days (3-8 days), respectively. The mean patients' number of emergency service applications and hospitalization at the preoperative period was 6.2 ± 3.9/2.3 ± 1.6 and, at the postoperative period was 3.3 ± 2.2/0.9 ± 0.8. In comparison of the preoperative and postoperative service application number and hospitalization number, there was significant difference (p < 0.005 and 0.006, respectively). No reoperation was required. There was no mortality. CONCLUSION Aberrant innominate artery is rarely seen. These pathologies misdiagnosis with different reactive airways. Following the diagnosis, treatment can be achieved by surgery successfully.
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Boonjindasup W, Marchant JM, McElrea MS, Yerkovich ST, Thomas RJ, Masters IB, Chang AB. Pulmonary function of children with tracheomalacia and associated clinical factors. Pediatr Pulmonol 2022; 57:2437-2444. [PMID: 35785487 PMCID: PMC9796637 DOI: 10.1002/ppul.26054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/01/2022] [Accepted: 06/25/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Spirometry is easily accessible yet there is limited data in children with tracheomalacia. Availability of such data may inform clinical practice. We aimed to describe spirometry indices of children with tracheomalacia, including Empey index and flow-volume curve pattern, and determine whether these indices relate with bronchoscopic features. METHODS From the database of children with tracheomalacia diagnosed during 2016-2019, we reviewed their flexible bronchoscopy and spirometry data in a blinded manner. We specially evaluated several spirometry indices and tracheomalacia features (cross-sectional lumen reduction, malacic length, and presence of bronchomalacia) and determined their association using multivariable regression. RESULTS Of 53 children with tracheomalacia, the mean (SD) peak expiratory flow (PEF) was below the normal range [68.9 percent of predicted value (23.08)]. However, all other spirometry parameters were within normal range [Z-score forced expired volume in 1 s (FEV1 ) = -1.18 (1.39), forced vital capacity (FVC) = -0.61 (1.46), forced expiratory flow between 25% and 75% of vital capacity (FEF25%-75% ) = -1.43 (1.10), FEV1 /FVC = -1.04 (1.08)], Empey Index = 8.21 (1.59). The most common flow-volume curve pattern was the "knee" pattern (n = 39, 73.6%). Multivariable linear regression identified the presence of bronchomalacia was significantly associated with lower flows: FEV1 [coefficient (95% CI) -0.78 (-1.54, -0.02)], FEF25%-75% [-0.61 (-1.22, 0)], and PEF [-12.69 (-21.13, -4.25)], all p ≤ 0.05. Other bronchoscopic-defined tracheomalacia features examined (cross-sectional lumen reduction, malacic length) were not significantly associated with spirometry indices. CONCLUSION The "knee" pattern in spirometry flow-volume curve is common in children with tracheomalacia but other indices, including Empey index, cannot be used to characterize tracheomalacia. Spirometry indices were not significantly associated with bronchoscopic tracheomalacia features but children with tracheobronchomalacia have significantly lower flow than those with tracheomalacia alone.
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Affiliation(s)
- Wicharn Boonjindasup
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie M Marchant
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Margaret S McElrea
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Stephanie T Yerkovich
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rahul J Thomas
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ian B Masters
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Anne B Chang
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Al Shamrani A, AlShammari A, AlAlkami H, AlShanwani J, Alharbi AS. When is asthma not guilty? Int J Pediatr Adolesc Med 2021; 8:203-211. [PMID: 34401444 PMCID: PMC8356124 DOI: 10.1016/j.ijpam.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/12/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
Abstract
Asthma is a common childhood condition. Its prevalence in Saudi Arabia is high, increasing, and could exceed 20% at the current trajectory. Asthma is a syndrome with different clinical presentations and phenotypes. Many conditions are often misdiagnosed as asthma because they share the same symptoms, particularly coughing and shortness of breath; physical findings, such as wheezing; radiological findings, such as hyperinflation on chest X-ray; or even responses to asthma therapies, as in some patients with bronchiolitis. When treating the younger age group (>5 years old), there should be a high degree of suspicion of alternative causes when evaluating patients presenting with clinical features suggestive of asthma or patients who do not respond well to asthma therapies. This study will highlight common conditions that may mimic asthma and, as a result of incorrect treatment, unnecessarily expose patients to steroids and other therapies for extended periods. Furthermore, we seek to alert healthcare providers to common symptoms and signs that suggest a cause other than asthma and suggest when to refer the patient to subspecialists.
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Affiliation(s)
| | - Ayshah AlShammari
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Halima AlAlkami
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Jawaher AlShanwani
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
| | - Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military Medical City, Saudi Arabia
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Dolmaci OB, Fockens MM, Oomen MW, van Woensel JB, Hoekstra CEL, Koolbergen DR. A modified surgical technique for aortopexy in tracheobronchomalacia. Interact Cardiovasc Thorac Surg 2021; 33:462-468. [PMID: 33963391 DOI: 10.1093/icvts/ivab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/11/2021] [Accepted: 03/10/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Tracheobronchomalacia (TBM) is characterized by collapse of trachea, bronchi or both, leading to dyspnoea, expiratory stridor, coughing or recurrent airway infections. Surgical treatment with aortopexy is warranted for severe TBM. We describe a modified aortopexy technique with aortic wall strap sutures that evenly distributes the traction force over the full width of the aortic arch. The aim of this study was to determine the outcomes of this modified anterior aortopexy technique. METHODS Retrospective chart review of all patients undergoing aortopexy with aortic wall strap sutures for TBM between January 2010 and June 2020 in 2 tertiary hospitals in the Netherlands. RESULTS Twenty-four patients [median age 9 months (interquartile range 2-117 months); 71% male] underwent aortopexy with the modified technique for TBM (52%), tracheomalacia (40%) or bonchomalacia (8%). Aortopexy was successful in 91.7%, defined as relief or decrease of respiratory symptoms and no need for respiratory support. Complications occurred in 8.3% and mortality was 4%. CONCLUSIONS Aortopexy with non-absorbable strap sutures seems an effective and safe treatment for severe TBM. This study supports the hypothesis that strap sutures provide a solid and reliable traction force, but future comparative studies should confirm the benefit of strap sutures over conventional techniques.
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Affiliation(s)
- Onur B Dolmaci
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Marc Matthijs Fockens
- Department of Otorhinolaryngology, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands
| | - Matthijs W Oomen
- Department of Pediatric Surgery, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands
| | - Job B van Woensel
- Department of Pediatric Intensive Care, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands
| | - Carlijn E L Hoekstra
- Department of Otorhinolaryngology, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands
| | - David R Koolbergen
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center location AMC, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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5
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Choi KH, Kim H, Sung SC, Lee HD, Ko H, Byun JH. Effectiveness of posterior aortopexy for the left pulmonary vein obstruction between the left atrium and the descending aorta. J Card Surg 2021; 36:2644-2650. [PMID: 33938583 DOI: 10.1111/jocs.15596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Left pulmonary vein (PV) obstruction can occur due to compression between the left atrium (LA) and the descending aorta (DA). One of the effective solutions for this problem is posterior aortopexy. In this study, we have reported five cases of posterior aortopexy to relieve left PV obstruction between the LA and the DA. METHODS Since August 2012, five patients have undergone posterior aortopexy for compression of the left PV between the LA and the DA. The median age and weight of the patients at the time of operation were 5.5 months (range, 1-131 months) and 5.2 kg (range, 4.2-29.5 kg), respectively. The left PV obstruction was initially diagnosed on echocardiography in four patients and computed tomography angiography in one patient. The median peak pressure gradient across the obstructed left PV was 7.3 mmHg (range, 4-20 mmHg). Concomitant procedures were ventricular septal defect closure in one patient and patent ductus arteriosus ligation in one patient. RESULTS There was no PV obstruction on echocardiography in any of the patients after the operation except in the case of one patient who had diffuse pulmonary vein stenosis. The median follow-up duration was 34 months (range, 14-89 months), and during follow-up no incidence of the left PV obstruction was observed in any of the surviving patients. CONCLUSIONS The posterior aortopexy technique could be a good surgical option for the left PV obstruction caused by compression between the LA and the anteriorly positioned DA.
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Affiliation(s)
- Kwang Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Hyungtae Kim
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Hyoung Doo Lee
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Hoon Ko
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Joung-Hee Byun
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
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Kamran A, Friedman KG, Jennings RW, Baird CW. Aortic uncrossing and tracheobronchopexy corrects tracheal compression and tracheobronchomalacia associated with circumflex aortic arch. J Thorac Cardiovasc Surg 2020; 160:796-804. [DOI: 10.1016/j.jtcvs.2020.03.158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 02/26/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022]
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7
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Liu R, Rui L, Li S, Zhang B, Zhang H, Lin Y, Li H. Absorbable Microplate Externally Suspending Bronchomalacia in Congenital Heart Disease Infant. Pediatr Cardiol 2020; 41:1092-1098. [PMID: 32382764 DOI: 10.1007/s00246-020-02358-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Abstract
To evaluate the feasibility and efficacy of external suspension with absorbable poly-l-lactic acid material shaping microplates for infants with severe bronchomalacia and congenital heart disease. From November 2017 to January 2019, 11 continual patients with severe bronchomalacia and congenital heart disease underwent bronchial membrane external suspension together with cardiovascular surgery. An absorbable plate made with poly-l-lactic acid material was used as the shaping fixation material in all patients. Data included the details of the operation, and clinical results were collected. The mean age was 1.2 ± 1.0 years, and the mean weight was 7.7 ± 2.9 kg. The patients with cardiac malformations were operated on under low-temperature cardiopulmonary bypass (CPB) through median sternotomy. There were no in-hospital deaths. The CPB time, mechanical ventilation time, and length of intensive care unit stay were 123.9 ± 36.9 min, 20.7 ± 19.4 h, and 71.6 ± 54.9 h, respectively. Two patients underwent surgery through a left posterolateral incision without CPB. One was a double aortic arch repair, and the other was only bronchial membrane external suspension with prior IAA repair. No patients needed ECMO support. The mean follow-up time was 12.1 ± 5.6 months, and no patients were lost to follow-up. No cases of late death were noted, and no patients needed reoperation. According to the CT scans, no patients had bronchial restenosis. External bronchial membrane suspension with an absorbable poly-l-lactic acid material shaping plate, which had better histocompatibility, for infants with severe bronchomalacia and congenital heart disease was a safe and feasible procedure.
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Affiliation(s)
- Rui Liu
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Lu Rui
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Shoujun Li
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Benqing Zhang
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Heng Zhang
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Ye Lin
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Hanmei Li
- Division of Pediatric Cardiac Surgical Centre, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
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8
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Williams SP, Losty PD, Dhannapuneni R, Lotto A, Guerrero R, Donne AJ. Aortopexy for the management of paediatric tracheomalacia - the Alder Hey experience. J Laryngol Otol 2020; 134:1-4. [PMID: 31971119 DOI: 10.1017/s0022215120000031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Whilst aortopexy is an accepted and established procedure, there remains considerable heterogeneity within the literature, with inconsistencies in both the approach taken and the technique employed. Furthermore, limited data exist on both patient selection and long-term outcomes. This study aimed to report the experience of managing severe tracheomalacia by way of aortopexy in a large UK paediatric centre. METHOD A retrospective case note review was conducted. Mean follow up was five years. RESULTS Twenty-five patients underwent aortopexy for severe tracheomalacia caused by external vascular compression. Acute life-threatening events precipitated investigation in 72 per cent of cases. Twenty-one patients initially presented to ENT services for investigation, which comprised upper airway endoscopy and imaging with computed tomography angiography. Post-operatively, the majority of patients demonstrated complete resolution of symptoms and were discharged from all associated services. Only four patients required a tracheostomy. CONCLUSION Aortopexy offers an effective method of treating severe tracheomalacia due to vascular compression.
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Affiliation(s)
- S P Williams
- Department of Paediatric ENT, Alder Hey Children's Hospital, Liverpool, UK
| | - P D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - R Dhannapuneni
- Department of Paediatric Cardiothoracic Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - A Lotto
- Department of Paediatric Cardiothoracic Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - R Guerrero
- Department of Paediatric Cardiothoracic Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - A J Donne
- Department of Paediatric ENT, Alder Hey Children's Hospital, Liverpool, UK
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Serio P, Nenna R, Fainardi V, Grisotto L, Biggeri A, Leone R, Arcieri L, Di Maurizio M, Colosimo D, Baggi R, Murzi B, Mirabile L, Midulla F. Residual tracheobronchial malacia after surgery for vascular compression in children: treatment with stenting. Eur J Cardiothorac Surg 2019; 51:211-217. [PMID: 28186233 DOI: 10.1093/ejcts/ezw299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/25/2016] [Accepted: 08/02/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paola Serio
- Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Respiratory Endoscopy Unit, Florence, Italy
| | - Raffaella Nenna
- Department of Paediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | | | - Laura Grisotto
- Department of Statistics, Informatics and Applications 'G. Parenti' University of Florence, Florence, Italy
| | - Annibale Biggeri
- Department of Statistics, Informatics and Applications 'G. Parenti' University of Florence, Florence, Italy
| | - Roberto Leone
- Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Respiratory Endoscopy Unit, Florence, Italy
| | - Luigi Arcieri
- Pediatric Cardiac Surgery Unit, Heart Hospital, G. Monasterio Tuscany Foundation, Massa, Italy
| | | | - Denise Colosimo
- Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Respiratory Endoscopy Unit, Florence, Italy
| | - Roberto Baggi
- Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Respiratory Endoscopy Unit, Florence, Italy
| | - Bruno Murzi
- Pediatric Cardiac Surgery Unit, Heart Hospital, G. Monasterio Tuscany Foundation, Massa, Italy
| | - Lorenzo Mirabile
- Department of Paediatric Anesthesia and Intensive Care, Meyer Children Hospital, Respiratory Endoscopy Unit, Florence, Italy
| | - Fabio Midulla
- Department of Paediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
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10
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Rijnberg FM, Butler CR, Bieli C, Kumar S, Nouraei R, Asto J, McKavanagh E, de Coppi P, Muthialu N, Elliott MJ, Hewitt RJ. Aortopexy for the treatment of tracheobronchomalacia in 100 children: a 10-year single-centre experience. Eur J Cardiothorac Surg 2019. [PMID: 29514258 DOI: 10.1093/ejcts/ezy076] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children. METHODS Demographic data, characteristics and preoperative, operative and outcome details, including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016. RESULTS One hundred patients [median age 8.2 months, interquartile range (IQR) 3.3-26.0 months] underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012). CONCLUSIONS Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.
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Affiliation(s)
| | - Colin R Butler
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Otolaryngology, Great Ormond Street Hospital, London, UK.,Department of Academic Surgery, Institute of Child Health, UCL, London, UK
| | - Christian Bieli
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Respiratory Unit, University Children's Hospital, Zurich, Switzerland
| | - Sonia Kumar
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | - Reza Nouraei
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | - Joshua Asto
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | | | - Paolo de Coppi
- Stem Cells & Regenerative Medicine Section, DBC, University College London, UK.,Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Nagarajan Muthialu
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Martin J Elliott
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Richard J Hewitt
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Otolaryngology, Great Ormond Street Hospital, London, UK
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11
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Choi S, Lawlor C, Rahbar R, Jennings R. Diagnosis, Classification, and Management of Pediatric Tracheobronchomalacia. JAMA Otolaryngol Head Neck Surg 2019; 145:265-275. [DOI: 10.1001/jamaoto.2018.3276] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sukgi Choi
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Claire Lawlor
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Reza Rahbar
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Russell Jennings
- Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
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12
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Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Jennings RW, Baird CW. Descending Aortopexy and Posterior Tracheopexy for Severe Tracheomalacia and Left Mainstem Bronchomalacia. Semin Thorac Cardiovasc Surg 2019. [DOI: 10.1053/j.semtcvs.2018.02.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Wallis C, McLaren CA. Tracheobronchial stenting for airway malacia. Paediatr Respir Rev 2018; 27:48-59. [PMID: 29174374 DOI: 10.1016/j.prrv.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/28/2022]
Abstract
Tracheobronchomalacia is a rare but clinically troublesome condition in paediatrics. The softening of the major airways - which can include some or all of the tracheobronchial tree can lead to symptoms ranging from the minor (harsh barking cough, recurrent chest infections) to severe respiratory difficulties including prolonged ventilator support and 'near death attacks'. The causes are broadly divided into intrinsic softening of the airway wall which is considered a primary defect (e.g. syndromes; post tracheo-oesophageal fistula repair; extreme prematurity) or secondary malacia due to external compression from vascular structures or cardiac components. These secondary changes can persist even when the external compression is relieved, for example, following the repair of a pulmonary artery sling or double aortic arch. For children with severe clinical symptoms attributed to malacia, consideration is given to possible surgical remedies such as an aortopexy for short limited areas of malacia, or long term positive pressure support with CPAP either by non invasive or tracheostomy interface. More recently the role of stenting in children is receiving attention, especially with the development of newer techniques such as bioabsorbable stents which buy time for a natural history of improvement in the malacia to occur. This paper reviews the stents available and discusses the pros and cons of stenting in paediatric airway malacia.
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Affiliation(s)
- Colin Wallis
- Department of Respiratory Paediatrics, Great Ormond Street Hospital for Children, London, UK.
| | - Clare A McLaren
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
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Kotani Y, Sano T, Arai S, Kasahara S. Aortopexy for left pulmonary vein obstruction. J Thorac Cardiovasc Surg 2018; 155:e69-e70. [DOI: 10.1016/j.jtcvs.2017.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/18/2017] [Accepted: 09/02/2017] [Indexed: 10/18/2022]
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15
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Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Baird CW, Jennings RW. Posterior Tracheopexy for Severe Tracheomalacia Associated with Esophageal Atresia (EA): Primary Treatment at the Time of Initial EA Repair versus Secondary Treatment. Front Surg 2018; 4:80. [PMID: 29379786 PMCID: PMC5775263 DOI: 10.3389/fsurg.2017.00080] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/26/2017] [Indexed: 11/27/2022] Open
Abstract
Purpose We review outcomes of posterior tracheopexy for tracheomalacia in esophageal atresia (EA) patients, comparing primary treatment at the time of initial EA repair versus secondary treatment. Methods All EA patients who underwent posterior tracheopexy from October 2012 to September 2016 were retrospectively reviewed. Clinical symptoms, tracheomalacia scores, and persistent airway intrusion were collected. Indication for posterior tracheopexy was the presence of clinical symptoms, in combination with severe tracheomalacia as identified on bronchoscopic evaluation, typically defined as coaptation in one or more regions of the trachea. Secondary cases were usually those with chronic respiratory symptoms who underwent bronchoscopic evaluation, whereas primary cases were those found to have severe tracheomalacia on routine preoperative dynamic tracheobronchoscopy at the time of initial EA repair. Results A total of 118 patients underwent posterior tracheopexy: 18 (15%) primary versus 100 (85%) secondary cases. Median (interquartile range) age was 2 months (1–4 months) for primary (22% type C) and 18 months (8–40 months) for secondary (87% type C) cases (p < 0.001). There were statistically significant improvements in most clinical symptoms postoperatively for primary and secondary cases, with no significant differences in any postoperative symptoms between the two groups (p > 0.1). Total tracheomalacia scores improved significantly in primary (p = 0.013) and secondary (p < 0.001) cases. Multivariable Cox regression analysis indicated no differences in persistent airway intrusion requiring reoperation between primary and secondary tracheopexy adjusting for imbalances in age and EA type (p = 0.67). Conclusion Posterior tracheopexy is effective in treating severe tracheomalacia with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy. With no significant differences in outcomes between primary and secondary treatment, posterior tracheopexy should be selectively considered at the time of initial EA repair.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gary A Visner
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael A Manfredi
- Department of Gastroenterology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
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16
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Decompressing extrinsic pulmonary vein obstruction. J Thorac Cardiovasc Surg 2017; 155:e71-e72. [PMID: 29153435 DOI: 10.1016/j.jtcvs.2017.09.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 11/20/2022]
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17
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Hammond-Jack K, Ramakrishnan KV, Nath DS. Aortopexy for Life-Threatening Airway Obstruction Following Division of Double Aortic Arch. World J Pediatr Congenit Heart Surg 2017; 11:NP66-NP68. [PMID: 28933235 DOI: 10.1177/2150135117709023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Symptoms of airway compression secondary to double aortic arch are relieved by division of one of the two aortic arches. However, in some cases inherent tracheomalacia and other factors may result in persistence of symptoms. We report one such occurrence in our experience and describe the use of aortopexy as a curative procedure to tackle this problem.
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Affiliation(s)
| | | | - Dilip S Nath
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC, USACorresponding Author
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18
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Gruszka A, Sachweh JS, Schnoering H, Tenbrock K, Muehler EG, Laschat M, Vazquez-Jimenez JF. Aortopexy offers surgical options for a variety of pathological tracheal conditions in paediatric patients. Interact Cardiovasc Thorac Surg 2017; 25:589-594. [DOI: 10.1093/icvts/ivx163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/12/2017] [Indexed: 11/12/2022] Open
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Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Rhein LM, Manfredi MA, Baird CW, Jennings RW. Posterior tracheopexy for severe tracheomalacia. J Pediatr Surg 2017; 52:951-955. [PMID: 28385426 DOI: 10.1016/j.jpedsurg.2017.03.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In severe tracheomalacia, aortopexy addresses anterior vascular compression, but does not directly address posterior membranous tracheal intrusion. We review patient outcomes of posterior tracheopexy for tracheomalacia with posterior intrusion to determine if there were resolution of clinical symptoms and bronchoscopic evidence of improvement in airway collapse. METHODS All patients who underwent posterior tracheopexy from October 2012 to March 2016 were retrospectively reviewed. Clinical symptoms, tracheomalacia scores based on standardized dynamic airway evaluation by anatomical region, and persistent airway intrusion were collected. Data were analyzed by Wald and Wilcoxon signed-ranks tests. RESULTS 98 patients (51% male) underwent posterior tracheopexy at a median age of 15months (IQR 6-33months). Median follow-up was 5months (range 0.25-36months). There were statistically significant improvements in clinical symptoms postoperatively, including cough, noisy breathing, prolonged and recurrent respiratory infections, transient respiratory distress requiring positive pressure, oxygen dependence, blue spells, and apparent life-threatening events (p<0.001), as well as ventilator dependence (p=0.04). Tracheomalacia scores on bronchoscopy improved significantly in all regions of the trachea and bronchi (p<0.001). 9.2% had persistent airway intrusion requiring reoperation, usually with aortopexy. CONCLUSIONS Posterior tracheopexy is effective in treating severe tracheomalacia with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy. LEVEL OF EVIDENCE Level III, treatment study.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Lawrence M Rhein
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Michael A Manfredi
- Department of Gastroenterology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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20
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Abstract
Pediatric airway surgery is a challenging field in pediatric surgery. Laryngotracheal stenosis has a variety of congenital and acquired conditions that require precise assessment and tailored treatment for each individual patient. About 90% of acquired conditions are represented by subglottic stenosis (SGS) resulting as a complication of tracheal intubation. Congenital tracheal stenosis (CTS) is a rare and life-threatening malformation, usually associated with complete tracheal rings along a variable length of the trachea. Tracheomalacia (TM) is a process characterized by flaccidity of the supporting tracheal cartilage, widening of the posterior membranous wall, and reduced anterior-posterior airway caliber. The clinical presentation can vary from almost asymptomatic patients to near fatal airway obstruction. There is considerable variation in both the morphologic subtypes and the prognosis of pediatric airway. The patients are divided into three clinical groups (mild, moderate, and severe). A further division was proposed according to the presence or absence of associated anomalies. The definitive diagnosis of pediatric airway was made by means of rigid bronchoscope and computed tomography scan with three-dimensional reconstruction (3D-CT). Rigid bronchoscopy and 3D-CT confirmed the diagnosis in all the cases. Other associated anomalies include congenital heart disease, vascular anomalies, and BPFM (maldevelopment of aerodigestive tract). After definitive diagnosis of pediatric airway lesions, surgical intervention should be considered. Surgical strategy was presented on each lesion.
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Affiliation(s)
- Kosaku Maeda
- Department of Pediatric Surgery, Kobe Children's Hospital, 1-6-7, Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
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21
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Bergeron M, Cohen AP, Cotton RT. The Management of Cyanotic Spells in Children with Oesophageal Atresia. Front Pediatr 2017; 5:106. [PMID: 28555179 PMCID: PMC5430373 DOI: 10.3389/fped.2017.00106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/25/2017] [Indexed: 11/21/2022] Open
Abstract
Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation. Although this decrease may be transient and benign, it may also be indicative of a severe underlying problem that requires immediate intervention. Children with oesophageal atresia (OA) are at risk for a number of coexisting conditions that may trigger cyanotic spells. This current article will focus on the management of cyanotic spells both in children with innominate artery compression and those with tracheomalacia.
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Affiliation(s)
- Mathieu Bergeron
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aliza P Cohen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robin T Cotton
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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22
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Bairdain S, Zurakowski D, Baird CW, Jennings RW. Surgical Treatment of Tracheobronchomalacia: A novel approach. Paediatr Respir Rev 2016; 19:16-20. [PMID: 27237407 DOI: 10.1016/j.prrv.2016.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 04/13/2016] [Indexed: 11/19/2022]
Abstract
Tracheobronchomalacia, as a whole, is likely misdiagnosed and underestimated as a cause of respiratory compromise in pediatric patients. Currently, there is no standardized approach for the overall evaluation of pediatric tracheobronchomalacia (TBM) and the concept of excessive dynamic airway collapse (EDAC); no grading score for the evaluation of severity; nor a standardized means to successfully approach TBM and EDAC. This paper describes our experience standardizing the approach to these complex patients whose backgrounds include different disease etiologies, as well as a variety of comorbid conditions. Preoperative and postoperative evaluation of patients with severe TBM and EDAC, as well as concurrent development of a prospective grading scale, has allowed us to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments. Long-term, continued collection of patient characteristics, surgical technique, complications, and outcomes must be collected given the overall heterogeneity of this particular population.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115; Department of Anesthesia, Boston Children's Hospital, Boston MA 02115
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston MA 02115
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115.
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23
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Abstract
Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the tracheal cartilage and/or posterior membrane. Tracheomalacia has a wide range of etiologies but is most commonly present in children born with esophageal atresia and tracheal esophageal fistula. Clinical symptoms can range from minor expiratory stridor with typical barking cough to severe respiratory distress episodes to acute life-threatening events (ALTE). Although the majority of children have mild-to-moderate symptoms and will not need surgical intervention, some will need life-changing surgical treatment. This article examines the published pediatric literature on TM, discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.
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Affiliation(s)
- Jose Carlos Fraga
- Department of Surgery, Pediatric Surgeon at Hospitals de Clinicas, Moinhos de Vento and Materno-Infantil Presidente Vargas, Federal University of Rio Grande do Sul, Rua Ramiro Barcelos 2350, Sala 600-Porto Alegre, CEP90035-903, Porto Alegre, RS, Brazil.
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, USA, MA
| | - Peter C W Kim
- Department of General and Thoracic Surgery, Children's Medical Center, Washington University, Washington, DC
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24
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Ghezzi M, Silvestri M, Sacco O, Panigada S, Girosi D, Magnano GM, Rossi GA. Mild tracheal compression by aberrant innominate artery and chronic dry cough in children. Pediatr Pulmonol 2016; 51:286-94. [PMID: 26099051 DOI: 10.1002/ppul.23231] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 04/28/2015] [Accepted: 04/28/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND In children with aberrant innominate artery (AIA) one of the most prevalent respiratory symptom is dry cough. How frequently this mediastinal vessels anomaly, that can induce tracheal compression (TC) of different degree, may be detected in children with chronic dry cough is not known. METHODS In a 3-year retrospective study, the occurrence of mediastinal vessels abnormalities and the presence and degree of TC was evaluated in children with recurrent/chronic dry cough. RESULTS Vascular anomalies were detected in 68 out of the 209 children evaluated. A significant TC was detected in 54 children with AIA, in eight with right aortic arch, in four with double aortic arch but not in two with aberrant right subclavian artery. In AIA patients, TC evaluated on computed tomography scans, was mild in 47, moderate in six and severe in one. During bronchoscopy TC increased in expiration or during cough, but this finding was more pronounced in children with right aortic arch and double aortic arch in which a concomitant tracheomalacia was more evident. Comorbidities were detected in 21 AIA patients, including atopy, reversible bronchial obstruction and gastroesophageal reflux. Aortopexy was performed in eight AIA patients, while the remaining AIA patients were managed medically and showed progressive improvement with time. CONCLUSION Mild TC induced by AIA can be detected in a sizeable proportion of children with recurrent/chronic dry cough. The identification of this anomaly, that may at least partially explain the origin of their symptom, may avoid further unnecessary diagnostic examinations and ineffective chronic treatments.
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Affiliation(s)
- Michele Ghezzi
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
| | - Michela Silvestri
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
| | - Oliviero Sacco
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
| | - Serena Panigada
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
| | - Donata Girosi
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
| | | | - Giovanni A Rossi
- Pediatric Pulmonology and Allergy Unit and Cystic Fibrosis Center, Istituto Giannina Gaslini, Genoa, Italy
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25
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Oh J, Kim JW, Shin WJ, Gwak M, Park PH. Usefulness of intraoperative bronchoscopy during surgical repair of a congenital cardiac anomaly with possible airway obstruction: three cases report. Korean J Anesthesiol 2016; 69:71-5. [PMID: 26885306 PMCID: PMC4754271 DOI: 10.4097/kjae.2016.69.1.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 06/18/2015] [Accepted: 06/26/2015] [Indexed: 11/24/2022] Open
Abstract
Compression of the airway is relatively common in pediatric patients, although it is often an unrecognized complication of congenital cardiac and aortic arch anomalies. Aortopexy has been established as a surgical treatment for tracheobronchial obstruction associated with vascular anomaly, aortic arch anomaly, esophageal atresia, and tracheoesophageal fistula. The tissue-to-tissue arch repair technique could result in severe airway complication such as compression of the left main bronchus which was not a problem before the correction. We report three cases of corrective open heart surgery monitored by intraoperative bronchoscopy performed during prebypass, and performed immediately before weaning from bypass, to evaluate tracheobronchial obstruction caused by congenital, complex cardiac anomalies in the operating room.
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Affiliation(s)
- JongEun Oh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
| | - Jung-Won Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
| | - Mijeung Gwak
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
| | - Pyung Hwan Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
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26
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Ragalie WS, Mitchell ME. Advances in Surgical Treatment of Congenital Airway Disease. Semin Thorac Cardiovasc Surg 2016; 28:62-8. [DOI: 10.1053/j.semtcvs.2015.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 12/22/2022]
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27
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Bairdain S, Smithers CJ, Hamilton TE, Zurakowski D, Rhein L, Foker JE, Baird C, Jennings RW. Direct tracheobronchopexy to correct airway collapse due to severe tracheobronchomalacia: Short-term outcomes in a series of 20 patients. J Pediatr Surg 2015; 50:972-7. [PMID: 25824437 DOI: 10.1016/j.jpedsurg.2015.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Tracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea's anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM. METHODS The records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar's test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient. RESULTS Twenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5 months (range, 0.5-38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p=0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p=0.01), lower trachea (p<0.001), and right bronchus (p=0.04). CONCLUSION The use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Jason Smithers
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas E Hamilton
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lawrence Rhein
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Christopher Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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28
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Anatomical risk factors, surgical treatment, and clinical outcomes of left-sided pulmonary vein obstruction in single-ventricle patients. J Thorac Cardiovasc Surg 2015; 149:1332-8. [DOI: 10.1016/j.jtcvs.2014.11.089] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 10/25/2014] [Accepted: 11/29/2014] [Indexed: 11/24/2022]
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29
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Kay-Rivest E, Baird R, Laberge JM, Puligandla PS. Evaluation of aortopexy in the management of severe tracheomalacia after esophageal atresia repair. Dis Esophagus 2015; 28:234-9. [PMID: 24446971 DOI: 10.1111/dote.12179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Severe tracheomalacia (TM) is a difficult problem in esophageal atresia (EA) patients. We reviewed our experience with aortopexy and other interventions for severe TM in this population. With review ethics board approval, a retrospective review of TM in postoperative EA patients was conducted (1989-2010). Demographics, perinatal, and surgical information regarding EA repair was collected. TM infants were analyzed for symptomatology, clinical severity, investigations, interventions, and outcomes. Data are presented as proportions or median(range). One hundred and thirty-two EA patients were reviewed. Most had type C atresia (87.3%), and 18 patients (13.6%) died. Twenty-five patients (18.9%) had TM of whom five (20%) died. Median symptom onset was 18 days (0-729) after EA repair, with stridor (64%) or retractions/distress (44%) being most frequent. Four and two patients had airway obstruction or cardiorespiratory arrest, respectively. Median time from symptom onset to investigations was 11 days; these were most commonly rigid bronchoscopy (56%) and fluoroscopy (36%). Ten patients (40%) had severe TM on bronchoscopy. Six underwent aortopexy, one fundoplication, and three were treated medically. Length of hospital stay (LOS) post-aortopexy was 13 days (5-60), and ventilation time was 2 days (0-9). LOS was 60.5 (1-69) days postdiagnosis in non-aortopexy patients. Readmission rates for respiratory issues were significantly less in the aortopexy (median 0 vs. 5; P = 0.048) group over 2-year follow up after discharge. Complications of aortopexy included transfusion (1) and temporary diaphragmatic paresis (1), and one mortality secondary to severe congenital cardiac anomalies. Our experience suggests that aortopexy is safe and effective for the treatment of severe TM. It is associated with reduced LOS compared with other treatment strategies and few complications or long-term sequelae.
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Affiliation(s)
- E Kay-Rivest
- The Montreal Children's Hospital, Montreal, Quebec, Canada
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30
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Anterior Tracheal Suspension for Tracheobronchomalacia in Infants and Children. Ann Thorac Surg 2014; 98:1246-53. [DOI: 10.1016/j.athoracsur.2014.05.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/27/2014] [Accepted: 05/05/2014] [Indexed: 12/20/2022]
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Abstract
Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.
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Affiliation(s)
- Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Timothy D Kane
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; Surgical Residency Training Program, Division of Pediatric Surgery, Department of Surgery, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010-2970, USA.
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32
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Arnaud AP, Rex D, Elliott MJ, Curry J, Kiely E, Pierro A, Cross K, Coppi PD. Early Experience of Thoracoscopic Aortopexy for Severe Tracheomalacia in Infants After Esophageal Atresia and Tracheo-esophageal Fistula Repair. J Laparoendosc Adv Surg Tech A 2014; 24:508-12. [DOI: 10.1089/lap.2013.0376] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexis P. Arnaud
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Dean Rex
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Martin J. Elliott
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Joe Curry
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Edward Kiely
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Agostino Pierro
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Surgery Unit, UCL Institute of Child Health, London, United Kingdom
| | - Kate Cross
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Paolo De Coppi
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Surgery Unit, UCL Institute of Child Health, London, United Kingdom
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Mohammad Vahid Hosseini S, Zarenezhad M, Sabet B, Shoar MM, Kangari G. The Use of T-tube Cholangiocatheter Stents in the Treatment of Pediatric Tracheomalacia. J Surg Tech Case Rep 2014; 5:54-5. [PMID: 24470855 PMCID: PMC3889008 DOI: 10.4103/2006-8808.118632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Tracheomalacia is a common disorder in neonate and infants, which can lead to life-threatening airway occlusion, because of external pressure or intrinsic defect of tracheobroncial cartilage. Aortopexy and Stents are effective in relieving tracheomalacia in the latter patients. In this case we are to show how t-tube cholangiocatheter is effective and easy available in sever tracheomalacia neonates with intrinsic defect. It can be easily replaced and causes no infection, erosion, or sever complication in 9 months period.
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Affiliation(s)
| | - Mohammad Zarenezhad
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences and Member of Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Babak Sabet
- Department of Gastroenterohepatology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Malek Shoar
- Department of Anesthesialogy, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Gholamreza Kangari
- Department of Gastroenterohepatology Research Center, Shiraz University of Medical Sciences and Member of Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
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Jennings RW, Hamilton TE, Smithers CJ, Ngerncham M, Feins N, Foker JE. Surgical approaches to aortopexy for severe tracheomalacia. J Pediatr Surg 2014; 49:66-70; discussion 70-1. [PMID: 24439583 DOI: 10.1016/j.jpedsurg.2013.09.036] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to determine the outcomes among three different surgical approaches for performing an aortopexy to treat severe tracheomalacia (STM). METHODS A retrospective review was performed for all patients who underwent an aortopexy by pediatric surgeons at a single institution during 1997-2012. Data collected included details of the operative approaches and clinical results. The data were analyzed using Chi-square and Fisher exact test. RESULTS Forty-one patients underwent an aortopexy. The operation was chosen by the surgeon and not randomized. Exposure was by partial sternotomy (PS) (20), open thoracotomy (12), or thoracoscopic approach (7). Only the PS approach was done by a single team. All groups showed improvement in work of breathing, prevention of severe respiratory distress, and acute life threatening events. These effects were more dramatic for the PS group, especially regarding oxygen and/or ventilator dependence and the ability to undergo tracheostomy decannulation. Among the sixteen patients with failure-to-thrive before successful aortopexy by any technique, ten demonstrated significant improvement in their growth (p=0.025). The recurrence rate for the thoracoscopic approach was 38%, and there were no recurrences in the partial sternotomy and the thoracotomy groups, 38% vs 0% vs 0%, p=0.005. Simultaneous bronchoscopy was utilized more commonly in the PS group compared to the thoracotomy and thoracoscopic group, 95% vs 62% vs 38%. CONCLUSIONS In this series, the partial sternotomy technique had the most reliable resolution of symptoms and no recurrence requiring reoperation. The PS approach to STM has the technical advantages of an improved exposure with equal access to the vessels over the right and left mainstem bronchi, as well as the trachea and a more specific elevation of the arteries, including suspension of the pulmonary arteries and trachea itself when desirable. Simultaneous bronchoscopy during aortopexy and an experienced team also likely contribute to improved outcomes. The variations in populations, follow-up, and use of continuous intraoperative bronchoscopy, however, make firm conclusions difficult.
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Affiliation(s)
- Russell W Jennings
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA.
| | - Thomas E Hamilton
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - C Jason Smithers
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Neil Feins
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - John E Foker
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA; University of Minnesota Medical School, Minneapolis, MN, USA
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Outcomes of aortopexy for patients with congenital heart disease. Pediatr Cardiol 2013; 34:1469-75. [PMID: 23471485 DOI: 10.1007/s00246-013-0672-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 02/12/2013] [Indexed: 02/01/2023]
Abstract
Aortopexy is a surgical procedure in which the aortic arch is fixed at other structures, thus widening the interaortic space. This study aimed to evaluate the outcome of aortopexy by means of chest computed tomography for patients with congenital heart disease. The study retrospectively reviewed the medical records of 16 patients with congenital heart disease who had undergone aortopexy by compressed airway. The severity of compressed bronchus before aortopexy, immediately after aortopexy (≤ 1 month), and after the patient had grown up were compared. To estimate the efficacy of the aortopexy, the interaortic distance index was calculated. Of the 16 patients, aortopexy was performed at the ascending aorta in 7, at the descending aorta in 7, and at the transverse arch in 2. The diameter ratio between the narrowest bronchus and the trachea was improved after aortopexy, as was the diameter ratio before aortopexy versus immediately after aortopexy (n = 9; p = 0.018) and the diameter ratio before aortopexy versus after the patient had grown up (n = 11; p = 0.006). Also, the interaortic distance index was increased after aortopexy, as was the diameter before aortopexy versus immediately after aortopexy (n = 9; p = 0.039) and the diameter before aortopexy versus after the patient had grown up (n = 11; p = 0.014). The study had one case of mortality due to sepsis. As shown by the results, aortopexy in patients with a compressed airway between arches is a useful surgical option. Such a compressed airway between arches should be considered for patients with an unusual clinical course before and after open heart surgery.
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Luffy SA, Chou DT, Waterman J, Wearden PD, Kumta PN, Gilbert TW. Evaluation of magnesium-yttrium alloy as an extraluminal tracheal stent. J Biomed Mater Res A 2013; 102:611-20. [DOI: 10.1002/jbm.a.34731] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 01/28/2013] [Accepted: 03/04/2013] [Indexed: 01/21/2023]
Affiliation(s)
- Sarah A. Luffy
- Department of Surgery, McGowan Institute for Regenerative Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Bioengineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Da-Tren Chou
- Department of Surgery, McGowan Institute for Regenerative Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Bioengineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Jenora Waterman
- Department of Animal Sciences; North Carolina Agricultural and Technical State University; Greensboro North Carolina
| | - Peter D. Wearden
- Department of Surgery, McGowan Institute for Regenerative Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Bioengineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Cardiothoracic Surgery; Children's Hospital of Pittsburgh of UPMC; Pittsburgh Pennsylvania
| | - Prashant N. Kumta
- Department of Surgery, McGowan Institute for Regenerative Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Bioengineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Chemical and Petroleum Engineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Mechanical Engineering and Materials Science, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Oral Biology, School of Dental Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Thomas W. Gilbert
- Department of Surgery, McGowan Institute for Regenerative Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Bioengineering, Swanson School of Engineering; University of Pittsburgh; Pittsburgh Pennsylvania
- Department of Cardiothoracic Surgery; Children's Hospital of Pittsburgh of UPMC; Pittsburgh Pennsylvania
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Torre M, Carlucci M, Speggiorin S, Elliott MJ. Aortopexy for the treatment of tracheomalacia in children: review of the literature. Ital J Pediatr 2012; 38:62. [PMID: 23110796 PMCID: PMC3502176 DOI: 10.1186/1824-7288-38-62] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 10/04/2012] [Indexed: 11/10/2022] Open
Abstract
Abstract Severe tracheomalacia presents a significant challenge for Paediatricians, Intensivists, Respiratory Physicians, Otolaryngologists and Paediatric Surgeons. The treatment of tracheomacia remains controversial, but aortopexy is considered by most to be one of the best options. We conducted a review of the English literature relating to aortopexy. Among 125 papers, 40 have been included in this review. Among 758 patients (62% males) affected with tracheomalacia, 581 underwent aortopexy. Associated co-morbidities were reported in 659 patients. The most frequent association was with oesophageal atresia (44%), vascular ring or large vessel anomalies (18%) and innominate artery compression (16%); in 9% tracheomalacia was idiopathic. The symptoms reported were various, but the most important indication for aortopexy was an acute life-threatening event (ALTE), observed in 43% of patients. The main preoperative investigation was bronchoscopy. Surgical approach was through a left anterior thoracotomy in 72% of patients, while median approach was chosen in 14% and in 1.3% a thoracoscopic aortopexy was performed. At follow-up (median 47 months) more than 80% of the patients improved significantly, but 8% showed no improvement, 4% had a worsening of their symptoms and 6% died. Complications were observed in 15% of patients, in 1% a redo aortopexy was deemed necessary. In our review, we found a lack of general consensus about symptom description and evaluation, indications for surgery, though ALTE and bronchoscopy were considered by all an absolute indication to aortopexy and the gold standard for the diagnosis of tracheomalacia, respectively. Differences were reported also in surgical approaches and technical details, so that the same term “aortopexy” was used to describe different types of procedures. Whatever approach or technique was used, the efficacy of aortopexy was reported as high in the majority of cases (more than 80%). A subgroup of patients particularly delicate is represented by those with associated gastro-esophageal reflux, in whom a fundoplication should be performed. Other treatments of tracheomalacia, particularly tracheal stenting, were associated with a higher rate of failure, severe morbidity and mortality. Non english abstract La tracheomalacia severa rappresenta una sfida per Pediatri, Intensivisti, Pneumologi, Otorinolaringoiatri, Chirurghi Pediatri. Il trattamento della tracheomalacia è tuttora controverso. L’aortopessi è considerata da molti la migliore opzione terapeutica. Abbiamo condotto una revisione della letteratura di lingua inglese su tale argomento. Di 125 lavori, 40 sono stati inclusi nella revisione. Tra 758 pazienti (62% maschi) affetti da tracheomalacia, 581 sono stati sottoposti ad aortopessi tra il 1968 e il 2008. In 659 pazienti alcune comorbidità erano presenti. L’associazione più frequente era con l’atresia esofagea (44%), l’anello vascolare o un’anomalia dei grossi vasi (18%), la compressione da parte dell’arteria innominata (16%); nel 9% la tracheomalacia era idiopatica. I sintomi riportati sono stati variabili, ma l’indicazione più importante all’aortopessi sono stati eventi di ALTE, osservati nel 43% dei pazienti. Lo studio diagnostico preoperatorio principale è stato la broncoscopia. L’approccio chirurgico è avvenuto attraverso una toracotomia anteriore sinistra nel 72% dei pazienti, mentre un approccio mediano è stato scelto nel 14% e nell’1.3% dei casi è stato eseguito un approccio toracoscopico. Al follow-up (mediana di 47 mesi) la maggioranza dei pazienti sono migliorati significativamente, ma l’8% di essi non è migliorato, il 4% è peggiorato e il 6% è morto. Complicazioni sono state riportate nel 15% dei pazienti, nell’1% un nuovo intervento di aortopessi è stato necessario. In questa revisione abbiamo trovato che non c’è un consenso generale sulla valutazione e sulla descrizione dei sintomi, sulle indicazioni chirurgiche ed esami preoperatori, anche se le ALTE e la broncoscopia venivano considerate rispettivamente un’indicazione assoluta all’aortopessi e il “gold standard” diagnostico per la tracheomalacia. Venivano riportate differenze negli approcci chirurgici e nei dettagli tecnici, e lo stesso termine di aortopessi veniva usato per indicare diverse procedure chirurgiche. In ogni caso, indipendentemente dall’approccio o tecnica utilizzati, l’efficacia dell’aortopessi veniva riportata come elevata nella maggioranza dei casi (più dell’80%). Un sottogruppo di pazienti particolarmente delicato è rappresentato da quelli con reflusso gastroesofageo associato, nei quali sarebbe indicata una fundoplicatio. Altri trattamenti della tracheomalacia, quali stent tracheale, sembrano gravati da una maggiore percentuale di insuccessi, morbidità severa e mortalità.
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Affiliation(s)
- Michele Torre
- Paediatric Surgery, G, Gaslini Institute, Genova, Italy.
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Tracheobronchomalacia in children: review of diagnosis and definition. Pediatr Radiol 2012; 42:906-15; quiz 1027-8. [PMID: 22426568 DOI: 10.1007/s00247-012-2367-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/18/2012] [Accepted: 01/23/2012] [Indexed: 10/28/2022]
Abstract
Tracheobronchomalacia is characterised by excessive airway collapsibility due to weakness of airway walls and supporting cartilage. The standard definition requires reduction in cross-sectional area of at least 50% on expiration. However, there is a paucity of information regarding the normal range of central airway collapse among children of varying ages, ethnicities and genders, with and without coexisting pulmonary disease. Consequently, the threshold for pathological collapse is considered somewhat arbitrary. Available methods for assessing the airway dynamically--bronchoscopy, radiography, cine fluoroscopy, bronchography, CT and MR--have issues with reliability, the need for intubation, radiation dose and contrast administration. In addition, there are varying means of eliciting the diagnosis. Forced expiratory manoeuvres have been employed but can exaggerate normal physiological changes. Furthermore, radiographic evidence of tracheal compression does not necessarily translate into physiological or functional significance. Given that the criteria used to make the diagnosis of tracheobronchomalacia are poorly validated, further studies with larger patient samples are required to define the threshold for pathological airway collapse.
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Gangadharan SP. Tracheobronchomalacia in adults. Semin Thorac Cardiovasc Surg 2011; 22:165-73. [PMID: 21092895 DOI: 10.1053/j.semtcvs.2010.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2010] [Indexed: 11/11/2022]
Abstract
Severe, diffuse tracheobronchomalacia (TBM) is an underrecognized cause of dyspnea, recurrent respiratory infections, cough, secretion retention, and even respiratory insufficiency. Patients often have comorbidities, such as asthma or chronic obstructive pulmonary disease, and inappropriate treatment for these conditions may precede eventual recognition of TBM by months or years. Most of these patients have an acquired form of TBM in which the etiology in unknown. Diagnosis of TBM is made by airway computed tomography scan and flexible bronchoscopy with forced expiration. The prevailing definition of TBM as a 50% reduction in cross-sectional area is nonspecific, with a high proportion of healthy volunteers meeting this threshold. The clinically significant threshold is complete or near-complete collapse of the airway. Airway stenting may treat TBM, although complications resulting from indwelling prostheses often limit the durability of stents. Surgical stabilization of the airway by posterior splinting (tracheobronchoplasty) effectively and permanently corrects malacic airways. Proper surgical selection is facilitated by a short-term stent trial.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Gangadharan SP, Bakhos CT, Majid A, Kent MS, Michaud G, Ernst A, Ashiku SK, DeCamp MM. Technical aspects and outcomes of tracheobronchoplasty for severe tracheobronchomalacia. Ann Thorac Surg 2011; 91:1574-80; discussion 1580-1. [PMID: 21377650 DOI: 10.1016/j.athoracsur.2011.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 12/31/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tracheobronchomalacia is an underrecognized cause of dyspnea, recurrent respiratory infections, and cough. Surgical stabilization with posterior membranous tracheobronchoplasty has been shown to be effective in selected patients with severe disease. This study examines the technical details and complications of this operation. METHODS A prospectively maintained database of tracheobronchomalacia patients was queried retrospectively to review all consecutive tracheobronchoplasties performed from October 2002 to June 2009. Posterior splinting was performed with polypropylene mesh. Patient demographics, surgical outcomes, and operative data were reviewed. RESULTS Sixty-three patients underwent surgical correction of tracheal and bilateral bronchial malacia. Twenty-three patients had chronic obstructive pulmonary disease, 18 had asthma, 5 had Mounier-Kuhn syndrome, and 4 had interstitial lung disease. Seven patients had a previous tracheotomy. Operative time was 373 ± 93 minutes. Median length of stay was 8 days (range, 4 to 92 days), of which 3 days (range, 0 to 91 days) were in intensive care. Seventy-five percent of patients were discharged home (28% with visiting nurse follow-up), and 25% went to a rehabilitation facility. Two patients (3.2%) died postoperatively-1 of worsening usual interstitial pneumonia, and the other of massive pulmonary embolism. Complications included a new respiratory infection in 14 patients, pulmonary embolism in 2, and atrial fibrillation in 6. Six patients required reintubation, and 9 received a postoperative tracheotomy; 47 patients required postoperative aspiration bronchoscopy. CONCLUSIONS In experienced hands, tracheobronchoplasty can be performed with a very low mortality rate and an acceptable perioperative complications rate in patients with significant pulmonary comorbidity. Intervention for postoperative respiratory morbidity is often necessary.
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Affiliation(s)
- Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Hasegawa T, Zaima A, Hisamatsu C, Nishijima E, Okita Y. Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case. J Pediatr Surg 2010; 45:E1-4. [PMID: 20638508 DOI: 10.1016/j.jpedsurg.2010.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 04/04/2010] [Accepted: 04/05/2010] [Indexed: 10/19/2022]
Abstract
We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space.
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Affiliation(s)
- Tomomi Hasegawa
- Division of Cardiovascular and Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan.
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Lee EY, Tracy DA, Bastos MD, Casey AM, Zurakowski D, Boiselle PM. Expiratory Volumetric MDCT Evaluation of Air Trapping in Pediatric Patients With and Without Tracheomalacia. AJR Am J Roentgenol 2010; 194:1210-1215. [DOI: 10.2214/ajr.09.3259] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Edward Y. Lee
- Department of Radiology and Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115
| | - Donald A. Tracy
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Maria d'Almeida Bastos
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Alicia M. Casey
- Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - David Zurakowski
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Phillip M. Boiselle
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Gardella C, Girosi D, Rossi GA, Silvestri M, Tomà P, Bava G, Sacco O. Tracheal compression by aberrant innominate artery: clinical presentations in infants and children, indications for surgical correction by aortopexy, and short- and long-term outcome. J Pediatr Surg 2010; 45:564-73. [PMID: 20223321 DOI: 10.1016/j.jpedsurg.2009.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 04/24/2009] [Accepted: 04/25/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aberrant innominate artery (AIA) may cause various degrees of tracheal compression (TC). PURPOSE The aim of this study is to define the clinical manifestations of AIA-induced TC and outcome after aortopexy in infants and older children. METHODS Children with significant AIA-induced TC were evaluated, and information after surgery or conservative management was obtained by telephonic interview after 1 to 4 years since discharge. RESULTS Overall, 15 infants (mean age, 8 months; group A) and 13 older children (mean age, 56 months; group B) were evaluated. Although median age at onset of symptoms was comparable in the 2 groups, mean delay to diagnosis was higher in group B (P < .0001). Analysis of the most prevalent symptoms showed that reflex apneas were more frequent in group A (P = .02), whereas chronic "intractable" cough was more frequent in group B (P < .001). Because of the type and severity of symptoms and the degree of TC, 16 patients underwent aortopexy. Follow-up evaluation showed, in all but 1 patient, a significant improvement in symptoms and quality of life, measured by a modified Visick score. CONCLUSIONS Aberrant innominate artery-TC leads to a variety of respiratory disorders, with a difference in prevalence between infants and older children. When choice of treatment is based on clinical presentation and degree of TC, a good clinical outcome may be obtained also in children in whom aortopexy is indicated, that is, those presenting initially with more severe symptoms.
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Affiliation(s)
- Chiara Gardella
- Pulmonary Diseases Department, G. Gaslini Institute, Genoa, Italy
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Ley S, Loukanov T, Ley-Zaporozhan J, Springer W, Sebening C, Sommerburg O, Hagl S, Gorenflo M. Long-Term Outcome After External Tracheal Stabilization Due to Congenital Tracheal Instability. Ann Thorac Surg 2010; 89:918-25. [DOI: 10.1016/j.athoracsur.2009.11.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 11/21/2009] [Accepted: 11/23/2009] [Indexed: 10/19/2022]
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Fayon M, Donato L. Trachéobronchomalacie de l’enfant : de l’abstention à l’interventionnel. Arch Pediatr 2010; 17:97-104. [DOI: 10.1016/j.arcped.2009.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 09/01/2009] [Accepted: 09/22/2009] [Indexed: 11/30/2022]
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Lee EY, Boiselle PM. Tracheobronchomalacia in infants and children: multidetector CT evaluation. Radiology 2009; 252:7-22. [PMID: 19561247 DOI: 10.1148/radiol.2513081280] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tracheobronchomalacia (TBM) is the most common congenital central airway anomaly, but it frequently goes unrecognized or is misdiagnosed as other respiratory conditions such as asthma. Recent advances in multidetector computed tomography (CT) have enhanced the ability to noninvasively diagnose TBM with the potential to reduce the morbidity and mortality associated with this condition. Precise indications are evolving but may include symptomatic pediatric patients with known risk factors for TBM and patients with otherwise unexplained impaired exercise tolerance; recurrent lower airways infection; and therapy-resistant, irreversible, and/or atypical asthma. With multidetector CT, radiologists can now perform objective and quantitative assessment of TBM with accuracy similar to that of bronchoscopy, the reference standard for diagnosing this condition. Multidetector CT enables a comprehensive evaluation of pediatric patients suspected of having TBM by facilitating accurate diagnosis, determining the extent and degree of disease, identifying predisposing conditions, and providing objective pre- and postoperative assessments. In this article, the authors present a step-by-step primer of multidetector CT imaging for evaluating infants and children with suspected TBM, including clinical indications, patient preparation, multidetector CT techniques and protocols, two- and three-dimensional processing of multidetector CT data, and image interpretation. The major aim of this article is to facilitate the reader's ability to successfully employ multidetector CT imaging protocols for evaluation of TBM in infants and children in daily clinical practice.
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Affiliation(s)
- Edward Y Lee
- Department of Radiology and Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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