Patterns of management of congenital tracheal stenosis

Placement of Covered Retrievable Expandable Metallic Stents for Pediatric Tracheobronchial Obstruction

PURPOSE

To evaluate the safety and clinical effectiveness of placement of covered retrievable expandable metallic stents in seven children with tracheobronchial obstruction.

MATERIALS AND METHODS

Using bronchoscopic and fluoroscopic guidance, stent placement was performed in seven children (median age, 12 y; range, 2 mo-14 y). The stents were electively removed 6 months after placement or whenever there were symptom-producing complications. During the follow-up period, technical and clinical success, complications and related reinterventions, and long-term prognosis were retrospectively evaluated.

RESULTS

Stent placement was technically successful for a total of eight stents in all seven patients. Stent removal was also successful for six stents in five patients; two stents were removed electively 6 months after placement, and four stents were removed due to symptom-producing complications. Clinical success defined as ventilator weaning, extubation, or dyspnea improvement was achieved in all patients 1 week after stent placement. A possible infection source in one stent and abundant granulation tissue caused by three stents necessitated removal of four stents in three patients. During the mean follow-up period of 18.7 months (range, 1-31 mo) after stent placement, three patients died due to the progression of underlying cardiopulmonary disease or malignancy. There were no deaths directly related to stent placement or related complications.

CONCLUSION

Although the findings were based on a small series, placement of covered retrievable expandable metallic stents seems to be safe and effective for the treatment of pediatric tracheobronchial obstruction. Ventilator weaning, extubation, or dyspnea improvement was possible in all patients after stent placement.

Prognostic factors in the surgical treatment of congenital tracheal stenosis: a multicenter analysis of the literature

BACKGROUND

Congenital tracheal stenosis (CTS) often requires urgent surgical intervention. We evaluated prognostic factors to determine the risks of surgical interventions by conducting a retrospective review of recent case series.

METHODS

Cases of CTS between 2002 and 2004 from our institution and recently published series that provided primary data on the demographics, complications, and outcomes of patients with CTS were analyzed. Univariate, model fit, and multivariate logistic regression analyses were performed using the SAS Statistical Program.

RESULTS

There were 68 patients who were treated (cartilage patch tracheoplasty, n = 31; slide tracheoplasty, n = 37), with 19 deaths (overall mortality = 28%). A total of 10 patients who underwent cartilage patch tracheoplasty died (32% mortality), whereas only 9 patients died following slide tracheoplasty (24% mortality). A total of 8 of 11 patients who were repaired at the age of 1 month or younger died (73% mortality), whereas only 11 of 57 patients who were repaired at an age older than 1 month died (19% mortality) (P = .04). A total of 10 of 19 patients with CTS who had comorbid intracardiac anomalies died following CTS repair (53% mortality), whereas only 9 of 49 patients with CTS who did not have intracardiac anomalies died (18% mortality) (P = .02).

CONCLUSIONS

This is the first report on the prognostic factors determining surgical outcomes for CTS. The highest mortality rate was observed in CTS patients younger than 1 month and in those with intracardiac anomalies. Congenital tracheal stenosis repairs in these patient subgroups should be considered with caution.

Recent challenges in the management of congenital tracheal stenosis: an individualized approach

BACKGROUND

Congenital tracheal stenosis (CTS) may present as a life-threatening condition often requiring urgent surgical correction. We report our recent experience of 13 consecutive patients with CTS over the past 18 months.

METHOD

Retrospective analysis of all patients with CTS admitted to our institution from January 2003 to June 2004.

RESULTS

Five of 13 patients (6 boys and 7 girls) were premature at birth. Mean age at repair was 3.8 months (range, 7 days to 9 months). Ten presented with cardiac arrests or "near-death" spells, 4 with copresenting pulmonary infection. Nine patients were local and 4 were national. Surgical repairs included slide tracheoplasty (n = 5), cartilage patch tracheoplasty (n = 4), patch-and-slide tracheoplasty (n = 1), and balloon dilatation (n = 1). Preoperative computed tomographic imaging invariably underestimated the severity of pathology. Two patients with minimal symptoms were treated nonoperatively. Two patients required additional endobronchial stents for bronchomalacia. Cardiopulmonary bypass was used in 8 patients. There were 3 deaths, including 2 planned withdrawal of treatment. Two patients remained in hospital. The remaining patients were discharged from our hospital.

CONCLUSIONS

Presentation of CTS can be precipitated by respiratory infection. Preoperative imaging often underestimates the caliber and length of pathology. The treatment options for patients with CTS including observation should be individualized.