Innovative management of severe tracheobronchomalacia using anterior and posterior tracheobronchopexy

Primary Posterior Tracheopexy at Time of Esophageal Atresia Repair Significantly Reduces Respiratory Morbidity

PURPOSE

Esophageal atresia with tracheoesophageal fistula (EA/TEF) is often associated with tracheobronchomalacia (TBM), which contributes to respiratory morbidity. Posterior tracheopexy (PT) is an established technique to treat TBM that develops after EA/TEF repair. This study evaluates the impact of primary PT at the time of initial EA/TEF repair.

METHODS

Review of all newborn primary EA/TEF repairs (2016-2021) at two institutions. Long-gap EA and reoperative cases were excluded. Based on surgeon preference and preoperative bronchoscopy, neonates underwent primary PT (EA + PT Group) or not (EA Group). Perioperative, respiratory and nutritional outcomes within the first year of life were evaluated.

RESULTS

Among 63 neonates, 21 (33%) underwent PT during EA/TEF repair. Groups were similar in terms of demographics, approach, and complications. Neonates in the EA + PT Group were significantly less likely to have respiratory infections requiring hospitalization within the first year of life (0% vs 26%, p = 0.01) or blue spells (0% vs 19%, p = 0.04). Also, they demonstrated improved weight-for-age z scores at 12 months of age (0.24 vs -1.02, p < 0.001). Of the infants who did not undergo primary PT, 10 (24%) developed severe TBM symptoms and underwent tracheopexy during the first year of life, whereas no infant in the EA + PT Group needed additional airway surgery (p = 0.01).

CONCLUSION

Incorporation of posterior tracheopexy during newborn EA/TEF repair is associated with significantly reduced respiratory morbidity within the first year of life.

LEVEL OF EVIDENCE

Level III.

Effects of primary posterior tracheopexy in thoracoscopic repair of esophageal atresia

Background

This study aimed to evaluate the effectiveness of primary posterior tracheopexy (PPT) in reducing ventilator dependence after repair of esophageal atresia (EA), and the risk of respiratory tract infections (RTI) requiring readmissions within one year.

Methods

This retrospective cohort study recruited patients with EA admitted to our hospital between June 2020 and December 2021.

Results

In the PPT group (n = 17), the time to extubation after surgery was 86.7 h for 12 patients, with one patient (8.3%) requiring repeated postoperation intubation; six-in-sixteen patients (37.5%) experience at least one RTI requiring hospitalization in one year. In the non-PPT group (n = 17), the time to extubation was 127.0 h for 14 patients, with six-in-fourteen patients (42.9%) requiring repeated intubation; twelve-in-seventeen patients (70.6%) experienced at least one RTI requiring hospitalization in one year.

Conclusions

Although the differences did not reach statistical significance due to limited number of participants, patients underwent PPT during EA repair had lower chance of repeated intubation and decreased risk of RTI requiring admissions within one year.

Anterior and posterior tracheopexy for severe tracheomalacia

Objectives

Congenital tracheomalacia can be the cause of respiratory failure in young children. Although the indication for surgical treatment has already been discussed vigorously, no clear guidelines about the modality are available.

Methods

Through a sternotomy approach, a combination of posterior pexy and anterior tracheopexy using a tailored ringed polytetrafluoroethylene prosthesis is performed. Patient demographic characteristics, as well as operative details and postoperative outcomes, are included in the analysis.

Results

Between 2018 and 2022, 9 children underwent the operation under review. All patients showed severe clinical symptoms of tracheomalacia, which was confirmed on bronchoscopy. The median age was 9 months. There was no operative mortality. Eight patients could be weaned from the ventilator. One patient died because of interstitial lung disease with bronchomalacia and concomitant severe cardiac disease. The longest follow-up now is 4 years, and shows overall excellent clinical results, without any reintervention.

Conclusions

Surgical treatment of tracheomalacia through a combination of posterior and anterior pexy is feasible, with acceptable short- and midterm results.

Feeding and Growth Outcomes in Infants with Type C Esophageal Atresia Who Undergo Early Primary Repair

OBJECTIVES

To describe growth and feeding outcomes in patients with type C esophageal atresia who underwent early primary repair and to identify predictors for poor growth.

STUDY DESIGN

This single-center, retrospective, cohort study included all patients with type C esophageal atresia who underwent early primary repair from 2013 to 2019. Weight-for-age z score (WAZ) was calculated at birth, and every 6 months until 3 years postoperatively. Longitudinal median regression was used to evaluate WAZ over time. A multivariable logistic regression model explored predictors of growth outcomes.

RESULTS

Of 46 infants who met the inclusion criteria, 72% were term. The median age at repair was 1.5 days of life (IQR, 1-2 days of life) and the hospital length of stay was 20 days (IQR-14, 30 days). Two patients had esophageal leak (4.3%). The median WAZ at birth was below average (-0.72; IQR, -1.37 to -0.40), but improved to reach average by 3 years (-0.025; IQR, -0.85 to 0.97, P < .001). At discharge, 72% of patients were receiving full oral nutrition, which improved to 95% by 3 years. The only independent predictor of poor growth at 1 year (WAZ < -1 [33%]) was WAZ at discharge (P = .02).

CONCLUSIONS

Infants with esophageal atresia who undergo early primary repair are capable of achieving standard growth curves by 3 years of age. However, poor discharge WAZ score was predictive of poor WAZ score at 1 year. Efforts to identify at-risk patients and institute targeted inpatient and outpatient nutrition interventions are needed to improve their growth trajectory.

Surgical management of long-segment congenital tracheal stenosis with tracheobronchial malacia

OBJECTIVES

Slide tracheoplasty has become the mainstream treatment for long-segment congenital tracheal stenosis (LSCTS). However, technical improvements are still needed to improve the clinical outcomes of patients exhibiting LSCTS with tracheobronchial malacia.

METHODS

LSCTS patients who underwent tracheoplasty from January 2010 to December 2020 were reviewed. According to the time of surgical technique modifications for reconstructing a supportive carina, the patients were divided into 2 groups: group A (2010-2018) and group B (2019-2020). We identified a well-balanced cohort matched by propensity score to evaluate the differences in surgical outcomes between the 2 groups.

RESULTS

There were no significant differences between group A and group B in any of the 8 characteristics before and after propensity score matching. In the propensity score-matched cohort, the number of patients who accepted anterior carina tracheopexy (75/77 vs 4/77, P < 0.001) and in situ pericardium insertion (75/77 vs 14/77, P < 0.001) in group B was significantly greater than that in group A. The mechanical ventilation time [48.3 (interquartile range: 29.6, 116.3) h vs 73.3 (interquartile range: 47.9, 111.6) h, P = 0.009] and cumulative mortality (P = 0.023) were significantly lower in Group B than Group A.

CONCLUSIONS

Reconstructing a supportive, stable carina of the neotrachea and tracheobronchopexy are helpful to improve the outcomes of slide tracheoplasty.

Mid-term results of vascular ring surgery

BACKGROUND

Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery.

METHODS

Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time.

RESULTS

Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bronchodilator use,18.3% had at least one episode of pneumonia per year, 31% of children had dyspnoea or respiratory limitation, and 12.7% while doing physical activities. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up.

CONCLUSIONS

Surgical division of vascular rings results in significant clinical improvement within 1 year; nevertheless, some patients remain symptomatic to some degree. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Further evaluation is warranted to assess the nature of residual symptoms and explore whether anatomical causes can be identified leading to surgical modifications.

Surgical management strategy of slide tracheoplasty for infants with congenital tracheal stenosis

OBJECTIVE

The study objective was to evaluate the outcomes of slide tracheoplasty in infancy and identify predictors of adverse outcomes.

METHODS

We retrospectively reviewed the clinical data of infants aged less than 1 year with congenital tracheal stenosis who underwent slide tracheoplasty at a single center from April 2010 to September 2020.

RESULTS

Of 120 infants, 71.7% (86/120) had a pulmonary artery sling and 37.5% (45/120) had simultaneous intracardiac repairs. Additionally, 52.5% (63/120) of the patients had anomalous tracheobronchial arborization, and 17.5% (21/120) had diffuse tracheal stenosis. Six airway reoperations (5%) and 6 deaths (5%) occurred, and the mortality decreased annually. Multivariate analysis revealed that a low body weight, cardiovascular anomalies, and normal tracheobronchial arborization predicted a longer intubation duration. Univariate analysis revealed that a low body weight, preoperative invasive ventilation, a long cardiopulmonary bypass time, and granulation tissue were associated with death. After surgery, 26 patients had dysphagia, 24 of whom resumed oral feeding during follow-up. Ninety-two patients underwent chest computed tomography reexamination, and the trachea diameter had increased significantly from 2.32 ± 0.72 mm to 5.46 ± 1.24 mm. Nineteen and 29 patients underwent spirometry before and after surgery, respectively, and showed improvements in ventilation function, with the ratio of time to peak tidal expiratory flow to total expiratory time and ratio of volume to peak tidal expiratory flow to total expiratory volume values significantly improved from 19.80% (interquartile range, 16.90-23.80) and 23.10% (interquartile range, 21.10-25.90) to 26.80% (interquartile range, 21.20-34.40) and 30.20% (interquartile range, 25.00-34.50), respectively (P < .05).

CONCLUSIONS

A tailored individual management strategy of slide tracheoplasty in infancy facilitates favorable clinical outcomes. Close postoperative follow-up and long-term functional evaluations including clinical symptoms and pulmonary function are still needed.

Comparative Effectiveness of Recurrent Laryngeal Nerve Monitoring Techniques in Pediatric Surgery

OBJECTIVES/HYPOTHESIS

The recurrent laryngeal nerve (RLN) is at risk during pediatric cervical, thoracic, and cardiac surgery. We aim to determine the feasibility and effectiveness of RLN monitoring techniques in all pediatric patients.

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective review of patients/procedures with RLN(s) at risk and RLN monitoring at Boston Children's Hospital July 2019-October 2020. Primary outcomes: pre/postoperative vocal fold mobility by awake flexible fiberoptic laryngoscopy (FFL).

RESULTS

One hundred one patients (median [interquartile range, IQR] age 14.6 months [4.6-49.7 months], weight 10 kg [5.2-16.2 kg]) underwent 122 procedures with RLN(s) at risk. RLN monitoring attempted 111 cases, successful 96 (84%). Surgical indications: esophageal atresia/tracheoesophageal fistula, and tracheobronchomalacia. Sixty-two (56%) procedures in reoperative field. Median follow-up 112 days (IQR 41-230). Pre/postoperative FFL performed 84 procedures (69%), 19 new postoperative RLN injuries (16%), median age 12 months, reoperative fields 11 (18%). Prass probes: 34 cases (28 successful, 82%), 6 injuries (18%), age 12.2 (5.8-23.6) months. Dragonfly electrodes: 45 cases (37 successful, 82%), 8 injuries (18%), age 7.5 (3.8-19) months. Nerve integrity monitoring (NIM) integrated electrode endotracheal tube: 33 cases (33 successful, 100%), 5 injuries (15%), age 90 (58.8-136.7) months. Automatic periodic stimulation (APS): 16 cases, 13 successful (81%), four injuries (25%), age 7.2 (5.3-20.6) months. NIM RLN monitoring is significantly more successful than Prass, Dragonfly (95%CI -0.3 to 0.02, P = .02; and 95%CI 0.05-0.31, P = .008). Rates of injury are not different between types of RLN monitoring (P = .94), with APS use (P = .47), or with monitoring success (95%CI -0.36 to 0.09, P = .28).

CONCLUSIONS

RLN monitoring is feasible in pediatric patients of all ages. Although NIM type RLN monitoring success is superior, all forms offer similar rates of nerve protection.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Bronchomalacia in right aortic arch treated with descending aortic translocation and airway splint

Management of recurrent symptomatic tracheobronchomalacia and tracheobronchial compression after prior aortopexy and tracheobronchopexy is a surgical challenge. In patients with right aortic arch, the course of the aortic arch over the right mainstem bronchus can result in superior and posterior compression of the airway. We present two cases of recurrent bronchomalacia and bronchial compression treated with descending aortic translocation. The addition of bronchial splinting to aortic translocation effectively relieved airway symptoms.

Tracheal anomalies associated with Down syndrome: A systematic review

INTRODUCTION

Airway anomalies are accountable for a substantial part of morbidity and mortality in children with Down syndrome (DS). Although tracheal anomalies occur more often in DS children, a structured overview on the topic is lacking. We systematically reviewed the characteristics of tracheal anomalies in DS children.

METHODS

A MEDLINE and EMBASE search for DS and tracheal anomalies was performed. Tracheal anomalies included tracheal stenosis, complete tracheal ring deformity (CTRD), tracheal bronchus, tracheomalacia, tracheal web, tracheal agenesis or atresia, laryngotracheoesophageal cleft type 3 or 4, trachea sleeve, and absent tracheal rings.

RESULTS

Fifty-nine articles were included. The trachea of DS children is significantly smaller than non-DS children. Tracheomalacia and tracheal bronchus are seen significantly more often in DS children. Furthermore, tracheal stenosis, CTRD, and tracheal compression by vascular structures are seen regularly in children with DS. These findings are reflected by the significantly higher frequency of tracheostomy and tracheoplasty performed in DS children.

CONCLUSION

In children with DS, tracheal anomalies occur more frequently and tracheal surgery is performed more frequently than in non-DS children. When complaints indicative of tracheal airway obstruction like biphasic stridor, dyspnea, or wheezing are present in children with DS, diagnostic rigid laryngotracheobronchoscopy with special attention to the trachea is indicated. Furthermore, imaging studies (computed tomography, magnetic resonance imaging, and ultrasound) play an important role in the workup of DS children with airway symptoms. Management depends on the type, number, and extent of tracheal anomalies. Surgical treatment seems to be the mainstay in severe cases.

Experience with bioresorbable splints for treatment of airway collapse in a pediatric population

Objective

To report our experience with novel external tracheal and bronchial placed bioresorbable splints in children with severe symptomatic airway collapse.

Methods

Retrospective review of patients undergoing bioresorbable splint placement.

Results

Between July 2018 and February 2020, 14 patients received 16 external splints (trachea, n = 8; left bronchus, n = 7; and right bronchus, n = 1). Preoperatively, 7 patients had a tracheostomy; 6 of them were receiving mechanical ventilation with ventilator settings so high that they required an inpatient setting, often in an intensive care unit. Median age at implant was 14.5 months (range, 2 months-14 years). Splints were formed from moldable bioresorbable plates (RapidSorb; Synthes, Oberdorf, Switzerland) and were customized intraoperatively around a Hegar dilator. A series of Prolene sutures were placed through into the airway cartilage under simultaneous bronchoscopic and direct visualization and then tied securing the airway within the splint. Concomitant procedures were also performed in the region of the airway splints, consisting of airway reconstruction, cardiovascular procedures, and/or esophageal rotation (related to posterior tracheopexy). Median follow-up was 20 months (interquartile range, 12-21 months). Four patients required no further intervention. Although not necessarily in the splinted region, 7 patients required additional procedures, including posterior tracheobronchopexy (n = 2), temporary tracheal stent placement (n = 1), tracheal resection with end-to-end anastomosis (n = 1), closure tracheostomy (n = 1), and tracheostomy placement (n = 2). One patient required splint replacement and in 1 patient, the splint was removed later. All patients (except 2 deaths from unrelated causes) were discharged home. Three patients required mechanical ventilation at lower settings that allowed home ventilation (1 of those only at night), and 4 patients required tracheostomy collar. Indications for tracheostomy included subglottic stenosis, vocal cord paralysis, pulmonary insufficiency, small airway malacia, and laryngomalacia.

Conclusions

An external bioresorbable splint can provide temporary external support while allowing the age-proportional growth of the airway. We applied readily available bioresorbable plates that were custom-molded based on the location, shape, and length of the collapsing airway in selected patients presenting with severe tracheobronchomalacia from loss of structural support and/or cartilage deformation. Further study that includes long-term outcomes are necessary to define the best role for these external splints as part of comprehensive airway management.

Congenital Absence of Tracheal or Bronchial Rings

OBJECTIVE

Congenital airway stenosis secondary to absent tracheal or bronchial rings is a rare congenital anomaly that is difficult to manage both clinically and surgically. This typically manifests as severe segmental tracheomalacia, and only isolated cases with short-term follow-up have been previously described. We aim to describe a series of children with absent tracheal or bronchial rings who underwent surgical management and had long-term follow-up.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

METHODS

Patients with absent tracheal or bronchial rings from 2002 to 2016. Electronic and paper medical records were queried to obtain demographics, age at diagnosis and surgery, pre- and postoperative symptoms, location of absent rings, procedure performed, length of follow-up, and adjunctive procedures performed.

RESULTS

Nine subjects were identified who underwent slide tracheoplasty for correction of congenital absent tracheal or bronchial rings. Age at diagnosis ranged from 10 days to 5 years of age (median, 4 weeks). Age at surgery ranged from 3 weeks to 5 years of age (median, 5 weeks). Six out of 9 subjects were extubated on postoperative day 1. Only 1 subject required additional intervention, which included balloon dilation, tracheobronchial stenting, and aortopexy to alleviate the obstruction. Mean follow-up time was 5.89 years.

CONCLUSIONS

This is the largest series of children with absent tracheal rings who underwent slide tracheoplasty with long-term follow-up presented to date. Slide tracheoplasty is an effective surgical intervention for the treatment of absent tracheal or bronchial rings in infants and young children.

Early Infant Symptomatic Patients With Tetralogy of Fallot With Absent Pulmonary Valve: Pulmonary Artery Management and Airway Stabilization

BACKGROUND

Tracheobronchomalacia and airway obstruction from severely dilated pulmonary arteries in tetralogy of Fallot with absent pulmonary valve (TOF-APV) has been associated with high rates of respiratory failure and mortality (15% to 25%). It is not known whether aggressive pulmonary artery (PA) or direct airway intervention during early definitive cardiac repair improves outcomes.

METHODS

A retrospective observational study was made of all patients undergoing surgical repair for TOF-APV at our center between 2006 and 2018.

RESULTS

Twenty patients underwent repair at a median age of 51 days and PA Z-scores of 8.1. Twelve patients had a valve implanted, 6 of whom required reoperation for valve replacement at a median of 9 months (range, 3 to 28) compared with 8 who had initial transannular patch, and only 1 patient required subsequent valve replacement (P < .05). Seven patients had central PAs replaced with thin-walled Gore-Tex (WL Gore, Flagstaff, AZ) grafts; none of these required PA reoperation during a median follow-up of 26.5 months, whereas 3 of 13 patients who did not have PA replacement with Gore-Tex required subsequent PA reoperation (P < .05). Concomitant airway interventions (eg, tracheobronchopexy/plasty) were performed in 4 patients and none required subsequent airway interventions, whereas 2 patients not having initial airway intervention required subsequent tracheopexy (P < .05). Three patients in the cohort eventually required tracheostomy (15%), and 2 patients died (10%; on postoperative days 30 and 326); none had received initial airway intervention.

CONCLUSIONS

Pulmonary artery replacement and aggressive direct airway management at initial definitive repair of cardiac TOF-APV can be performed safely with acceptable survival outcomes and low rates of airway and PA reintervention.

Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review

Objective: Review techniques for intraoperative recurrent laryngeal nerve (RLN) monitoring during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Summary Background Data: Literature was reviewed for reports of intraoperative recurrent laryngeal nerve monitoring in cervical, thoracic, and cardiac surgical procedures which place the RLNs at risk for injury. Methods: Review paper. Results: The RLN is at risk during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Intraoperative nerve monitoring has decreased rates of RLN injury in thyroid surgery. Intraoperative RLN monitoring techniques appropriate for pediatric surgery are discussed, including endotracheal tubes with integrated surface electrodes, adhesive surface electrodes for smaller endotracheal tubes, endolaryngeal electrodes, and automatic periodic continuous intra-operative stimulation. Conclusions: Multiple techniques exist to monitor the RLN in children undergoing cervical, cardiac, and thoracic surgery. Monitoring the RLN during procedures that place the RLNs at risk may help decrease the rate of RLN injury.

Criticality in tailoring the treatment for tracheoesophageal fistulas in children

OBJECTIVE

Tracheo-oesophageal fistula (TOF) is a rare pathology. It can be congenital and concurrent with other congenital anomalies such as oesophageal atresia, laryngeal and tracheal agenesis, or it can be acquired. The purpose of this study was to analyse various management strategies and their outcomes in infants and children with TOF and identify potential areas for standardisation of the fistula repair procedures.

METHODS

At a single institution, a retrospective analysis of infants and children with congenital or acquired TOF between 2013 and 2019 was performed. Thirteen patients were identified. Data collection included: patient demography, associated congenital anomalies, details of fistula at the time of endoscopy, surgical approach and intra-operative findings, need for additional intervention(s), and outcomes.

RESULTS

Thirteen patients underwent endoscopic or open surgeries for correction of TOF. The TOF was congenital in ten patients and acquired in three patients. Eight patients had associated aero-digestive comorbidities, and six patients had systemic comorbidities. Three patients underwent endoscopic procedures and nine patients underwent an open TOF repair. One patient had tracheal agenesis and was not offered any treatment. Two patients required multiple endoscopic interventions for recurrent TOFs. Among four patients with prior tracheostomy, three were decannulated and one awaits decannulation. Conclusıon Appropriate case selection and surgical ergonomics are essential for patients with TOF to avoid recurrences. Preoperative endoscopy to obtain precise details regarding associated laryngotracheal lesions and demographics of the fistula is crucial.