Intermediate-Term Outcomes of Slide Tracheoplasty in Pediatric Patients With Ring-Sling Complex

Tracheoplasty should be proactively considered in the surgical strategy for treating the ring-sling complex

OBJECTIVE

To examine the safety and effectiveness of proactive tracheoplasty for pediatric ring-sling complex.

METHODS

We retrospectively collected data from 304 children who were diagnosed with a ring-sling complex and underwent surgery at 3 cardiac centers in China between January 2010 and June 2023. The children were categorized into 3 surgical groups: concurrent sling and tracheal surgery (group A; n = 258), staged sling and tracheal surgery (group B; n = 25), and sling-only surgery (group C; n = 21). We compared perioperative clinical characteristics, tracheal morphology changes, and outcomes across the 3 groups.

RESULTS

The median age of the children was 1.2 years (interquartile range, [IQR], 0.7-1.9 years). The anomalous tracheobronchial arborization rates were higher in group A (52.5%) and group B (60.0%) compared to group C (15.0%). The preoperative narrow-wide ratio (NWR) was lower in groups A and B than in group C, with values of 0.44 (IQR, 0.35-0.52), 0.44 (IQR, 0.33-0.59), and 0.68 (IQR, 0.54-0.72), respectively (P < .001). Preoperative subcarina angles were similar among the groups (P = .54). After specific surgeries, the NWR and subcarina angle were improved significantly in groups A and B but not in group C. There were 7 in-hospital deaths and 2 postdischarge deaths. Respiratory symptoms improved in groups A and B, but 7 children in group C remained in respiratory dysfunction. Six children presented with residual stenosis of the left pulmonary artery.

CONCLUSIONS

Concurrent sling and tracheal surgeries for children with the ring-sling complex are safe and effective and are especially preferable for those with NWR ≤0.6, long-segment or diffuse tracheal stenosis, anomalous tracheobronchial arborization, and pronounced respiratory symptoms.

Slide tracheoplasty for congenital tracheal stenosis: A systematic review

INTRODUCTION

Slide tracheoplasty has become the gold standard surgery for congenital tracheal stenosis (CTS). This condition is rare and the surgery can be challenging and is performed by experienced surgeons in tertiary centers. A few reports involving relatively small cohorts have been published. The aim of this review is to evaluate the post-operative mortality and morbidity of pediatric slide tracheoplasty for CTS.

METHODS

A systematic literature review was performed according to PRISMA guidelines. The Medline and EMBASE databases were screened using a search strategy defined in collaboration with a librarian. We included articles reporting the post-operative mortality rate of slide tracheoplasties for treatment of CTS in children, when at least 10 patients were included.

RESULTS

A total of 932 articles were reviewed, and 15 studies were eligible with a total of 845 patients. The overall post-operative mortality rate was 9.3 %, and most deaths were airway related. The open revision surgery rate after surgery was 2.8 % and the endoscopic revision rate was 27.6 %.

DISCUSSION

This study highlights key factors to consider before the surgery and helps anticipate post-operative follow-up considerations for children with CTS. Several factors were identified as predictors of mortality including young age, weight at the time of surgery and association with lung hypoplasia or aplasia.

CONCLUSION

Although slide tracheoplasty has gained popularity in recent years due to better outcomes, it remains a major surgery with mortality risk and the need for multidisciplinary management.

Morphologic classification of tracheobronchial arborization in children with congenital tracheobronchial stenosis and the associated cardiovascular defects

Background

We sought to classify patients with congenital tracheal stenosis (CTS) according to tracheobronchial morphology and determine anatomic features associated with tracheobronchial anomalies (TBAs) and concurrent cardiovascular defects (CVDs).

Methods

We enrolled 254 patients who underwent tracheoplasty between November 1, 2009 and December 30, 2018. The anatomic features of the tracheobronchial tree and cardiovascular system were abstracted from bronchoscopy, echocardiography, computerized tomography, and operative reports.

Results

Four types of tracheobronchial morphology were identified: Type-1, which included normal tracheobronchial arborization (Type-1A, n = 29) and tracheal bronchus (Type-1B, n = 22); Type-2 (tracheal trifurcation; n = 49), and Type-3 (typical bridging bronchus; n = 47). Type-4 (bronchus with an untypical bridging pattern) was divided into Type-4A (involving bronchial diverticulum; n = 52) and Type-4B (absent bronchus; n = 55). Carinal compression and tracheomalacia were significantly more frequent in Type-4 patients than in the other patients (P < 0.01). CVDs were common in patients with CTS, especially in patients with Type-3 and Type-4 (P < 0.01). Persistent left superior vena cava was most common among patients with Type-3 (P < 0.01), and pulmonary artery sling was most frequent among those with Type-4 (P < 0.01). Outflow tract defects were most likely to occur in Type-1B. Early mortality was detected in 12.2% of all patients, and young age (P = 0.02), operation in the early era (P < 0.01), and bronchial stenosis (P = 0.03) were proven to be risk factors.

Conclusions

We demonstrated a useful morphological classification for CTS. Bridging bronchus was most closely linked with vascular anomalies, while tracheal bronchus was frequently associated with outflow tract defects. These results may provide a clue to CTS pathogenesis.

Pulmonary artery sling: An overview

Pulmonary artery sling is a rare childhood vascular tracheobronchial compression syndrome that is frequently associated with tracheal stenosis. Consequently, neonates or infants may present with critical airway obstruction if there is long segment airway narrowing and complete rings. Rapid diagnosis of this cardiac vascular malformation and evaluation of the extent and severity of airway involvement is essential to plan surgery, typically a slide tracheoplasty to relieve critical airway obstruction. Long term outcome can be excellent following surgical repair of the stenosed airway and reimplantation of the left pulmonary artery. In this review we focus on the embryology, diagnostic workup, airway investigations and management for this rare but challenging congenital condition.

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.

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.

Slide Tracheoplasty for Congenital Tracheal Stenosis Repair: A Systematic Review and Meta-Analysis

OBJECTIVES

Congenital tracheal stenosis (CTS) is a rare but life-threatening condition in children. At present, slide tracheoplasty has been advocated as the preferred technique for most cases of CTS. However, the morbidity and mortality subsequent to slide tracheoplasty need further elaboration. Therefore, a meta-analysis was performed on the outcomes of slide tracheoplasty in children with CTS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Electronic databases, including PubMed, Embase, and Cochrane Library CENTRAL, were systematically searched for the period from January 1990 to March 2021 for literature that reported clinical outcomes of slide tracheoplasty for children with CTS. Meta-regression and subgroup analyses were performed to determine the risk factors for in-hospital mortality and airway reinterventions.

RESULTS

A total of 25 studies involving 577 patients were included. For children with CTS, in-hospital and overall mortality after slide tracheoplasty was 6.1% (95% CI = 4.2%-8.0%) and 9.7% (95% CI = 7.3%-12.1%), respectively. The incidence of airway reinterventions was 23.0% (95% CI = 15.6%-30.5%). The length of postoperative ventilation and hospital stay was 6.8 days (95% CI = 5.1-8.4 days) and 19.2 days (95% CI = 15.8-22.7 days), respectively. Postoperative complications occurred in 46.6% (95% CI = 35.8%-57.4%) of all patients. Meta-regression analysis showed that a higher proportion of the recently published studies reported significantly better in-hospital survival (coefficient -0.011, P = .021).

CONCLUSIONS

In conclusion, in-hospital mortality after slide tracheoplasty is 6.1%, and the incidence of airway reinterventions is 23.0%. In-hospital mortality after slide tracheoplasty has decreased chronologically.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Congenital tracheal stenosis & associated cardiac anomalies: operative management & techniques

Congenital tracheal stenosis can lead to symptomatic airway obstruction in children and often mandates surgical correction. Over the past half-century, numerous tracheal reconstruction techniques have been developed, including tracheal resection with end-to-end anastomosis (for short-segment complete tracheal stenosis), patch tracheoplasty, slide tracheoplasty, and homograft and autograft augmentation repairs. However, operative management of congenital tracheal stenosis is often complicated by the presence of congenital heart disease, the most common of which is pulmonary artery sling. When present concomitantly, combined repair of both defects is feasible and is currently the preferred approach. Questions have been raised about the optimal timing and sequence of surgery, and some have advocated staged repair for patients with complex associated cardiac lesions. However, evidence from the past two decades suggests that concomitant repair can be performed with excellent results. The current standard of care involves the use of cardiopulmonary bypass to simultaneously repair the tracheal defect using slide tracheoplasty and all associated cardiac anomalies. Advances in operative techniques and extracorporeal circulation, progressive understanding of the pathological basis of combined congenital tracheal and cardiac disease, and a multidisciplinary approach to patient care have all contributed to the successful outcomes seen in the modern era. This article describes the combined surgical correction of tracheal stenosis and double-outlet right ventricle-tetralogy of Fallot type in an infant, provides a detailed step-by-step description for performing a slide tracheoplasty along with various other less favored tracheoplasty techniques, and reviews the current literature discussing such combined repairs.