Risk Stratification of Slide Tracheoplasty for Pediatric Airway Stenosis

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.

Composite Biosynthetic Graft for Repair of Long-Segment Tracheal Stenosis: A Pilot In Vivo and In Vitro Feasibility Study

Pediatric patients who undergo surgery for long-segment congenital tracheal stenosis (LSCTS) have suboptimal outcomes and postsurgical complications. To address this, we propose a biosynthetic graft comprising (1) a porcine small intestinal submucosa extracellular matrix (SIS-ECM) patch for tracheal repair, and (2) a resorbable polymeric exostent for biomechanical support. The SIS-ECM patch was evaluated in vivo in an ovine trachea model over an 8 month period. Concurrently, the biosynthetic graft was evaluated in a benchtop lamb trachea model for biomechanical stability. In vivo results show that SIS-ECM performs better than bovine pericardium (control) by preventing granulation tissue/restenosis, restoring tracheal architecture, blood vessels, matrix components, pseudostratified columnar and stratified epithelium, ciliary structures, mucin production, and goblet cells. In vitro tests show that the biosynthetic graft can provide the desired axial and flexural stability, and biomechanical function approaching that of native trachea. These results encourage future studies to evaluate safety and efficacy, including biomechanics and collapse risk, biodegradation, and in vivo response enabling a stable long-term tracheal repair option for pediatric patients with LSCTS and other tracheal defects.

Characteristics and Outcomes of Surgical Treatment for Bronchial Anomalies

OBJECTIVES

Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty.

METHODS

This is a single-institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes.

RESULTS

There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow-up time was 13 months (with a range of 0.5-213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%).

CONCLUSION

This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3334-3340, 2023.

[Paediatric Airway Surgery - Indications and Techniques]

Even in specialised centres, surgical procedures on the airway are only rarely performed in paediatric patients. Moreover, knowledge of various specific anatomical characteristics, diseases and surgical techniques is a prerequisite to treat these patients. Most commonly, sequelae of long-term intubation or tracheostomy in multimorbid patients necessitate surgical repair. Moreover, congenital malformations of the airways might require surgical interventions. However, these are commonly associated with other organ malformations, which adds further complexity to the treatment concept. Thus, cooperation within an interdisciplinary team is absolutely necessary to treat these patients. However, good postoperative outcomes after paediatric airway surgery can be achieved in experienced centres with an appropriate infrastructure. Specifically, this means long-term tracheostomy-free survival with preserved laryngeal functions in most of the patients. This review provides a summary of common indications and surgical techniques in paediatric airway surgery.

Systematic Review of Slide Tracheoplasty Outcomes

OBJECTIVE

To identify factors predicting success in slide tracheoplasty surgery at a regional children's hospital and compare with available published literature.

MEASURES

Retrospective chart review comparing demographics (age, weight) and clinical (operative and hospital course, need for additional airway intervention) factors experienced with slide tracheoplasty. Findings were compared with a systematic review of published literature.

RESULTS

Of the 16 tracheal stenosis patients in our cohort, 13 (81.3%) presented with an additional congenital or cardiovascular anomaly. When adjusted for cardiovascular anomalies, congenital tracheal stenosis patients had a mean age of 5.2 months (range 6 days-17 months), mean weight of 5.04 kg, and average ICU and hospital length of stay of 31.5 and 36.0 days, respectively. Tracheostomy was required for 4 patients and no early deaths were recorded. Of the 391 children in the grouped cohort, mean age and weight was older at 7.67 months and larger at 5.70 kg. Length of stay in both ICU and overall hospital course was 31.6 and 43.5 days, respectively. Mortality etiology for 44 patients was reported: 17 (38.6%) cardiac-related and 28 (63.6%) late mortalities. Our overall calculated mortality risk of 1.26 (P < .05) was lower than reported ratios of 2.0+.

CONCLUSION

Despite the numerous institutional studies involving tracheal stenosis, mortality and surgical challenges remain high. Future studies with the inclusion of specific perioperative data can prove to further evaluate correlations between presentation characteristics and mortality.

Pädiatrische Atemwegschirurgie: Indikationen und Techniken

In der pädiatrischen Atemwegschirurgie sind zahlreiche anatomische Besonderheiten, spezifische Krankheitsbilder sowie spezielle Operationstechniken zu beachten. Auch an spezialisierten Zentren sind diese Eingriffe bei pädiatrischen Patienten eher selten. Ätiologisch handelt es sich meist um erworbene Stenosen als Folge von Frühgeburtlichkeit, Langzeitintubation oder -tracheotomie, welche typischerweise in Kindern mit zahlreichen Komorbiditäten auftreten. Kongenitale Fehlbildungen der Atemwege gehen häufig mit weiteren Malformationen einher, welche die erfolgreiche Behandlung zusätzlich erschweren. Voraussetzung zur Behandlung dieser Kinder sollte daher ein multidisziplinäres Team sein. An erfahrenen Zentren mit entsprechender Infrastruktur kann die chirurgische Behandlung dieser Kinder mit sehr guten Ergebnissen durchgeführt werden. So wird bei den meisten Patienten nach chirurgischer Behandlung eine sehr gute Lebensqualität ohne Notwendigkeit einer Langzeittracheostomie erreicht. Diese Übersichtsarbeit fasst die wichtigsten Indikationen, sowie die häufigsten Operationstechniken in der pädiatrischen Atemwegschirurgie zusammen.