Long-segment tracheal stenosis: Slide tracheoplasty and a multidisciplinary approach improve outcomes and reduce costs

Impact of preoperative respiratory distress on outcomes of slide tracheoplasty

OBJECTIVES

Children with congenital tracheal stenosis born in the developing world face a high risk of mortality due to limited access to proper treatment. Patients who required preoperative respiratory support were suspected to have poor survival after slide tracheoplasty; however, this was not clearly demonstrated in the previous studies. This study aims to investigate the impact of preoperative respiratory conditions on outcomes of slide tracheoplasty.

METHODS

From 2016 to 2022, children who underwent slide tracheoplasty were retrospectively reviewed. Patients with respiratory distress requiring emergency operations (group A) were compared with patients in stable condition who were scheduled for surgery (group B).

RESULTS

Perioperative results revealed that group A (n = 43) had a longer bypass time (P < 0.001), operation time (P = 0.01), postoperative ventilation time (P < 0.001) and length of intensive care unit stay (P = 0.00125) than group B (n = 60). The early mortality rate was 7.8%, and the actuarial 5-year survival rate was 85.3%. The cumulative incidence test revealed that group A was highly significant for overall mortality [sudistribution (SHR) 4.5; 95% confidence interval (CI) 1.23-16.4; P = 0.023]. Risk factors for overall mortality were prolonged postoperative ventilation time (hazard ratio 3.86; 95% CI 1.20-12.48; P = 0.024), bronchial stenosis (hazard ratio 5.77; 95% CI 1.72-19.31; P = 0.004), and preoperative tracheal mucositis (hazard ratio 5.67; 95% CI 1.51-21.31; P = 0.01). Four patients needed reintervention during a follow-up of 28.4 months (interquartile range 15.3-47.3).

CONCLUSIONS

Preoperative respiratory distress negatively affected the outcomes of patients who required slide tracheoplasty. Therefore, early detection of congenital tracheal stenosis and aggressive slide tracheoplasty are crucial and obligatory to enhance long-term survival in this lethal congenital airway disease.

A multicenter study analyzing the impact of pre-existing comorbidities on laryngotracheal reconstruction (LTR) outcomes

INTRODUCTION

Comorbidities such as chronic lung disease and gastroesophageal reflux (GERD), prematurity, and numerous other conditions may impact the success of LTR. Single-center studies are limited in terms of patient numbers and may be underpowered.

OBJECTIVES

To analyze the impact of specific comorbidities on the operation-specific and overall surgical success of LTR in a large multicenter cohort and validate a predictive model for surgical success.

METHODS

A large retrospective multicenter 10-year review was undertaken to validate the data of a previous single-center study (Wertz et al. Laryngoscope 2020) which identified specific predictive comorbidities which impacted LTR outcomes. A Monte Carlo simulation based on the previous data set suggested that 300-400 cases would be needed to optimize the statistical power of a Bayesian model developed from the single-center data to predict surgical success. An IRB-approved data-sharing agreement was executed for 4 large U.S.

CENTERS

A virtual REDCap® data entry form inquired about patient characteristics that best predicted surgical success in the single-center model. These included demographics, surgical approaches, cardiac, airway, genetic, endocrine, musculoskeletal, gastrointestinal, and pulmonary comorbidities; details of the surgical procedures, and results of esophagogastroduodenoscopy (EGD), esophageal pH/impedance and flexible bronchoscopy with bronchioalveolar lavage (BAL) were included. Surgical success defined as successful decannulation or resolution of airway symptoms was recorded as single surgery success and overall success following open surgical revision surgery. Multivariate Bayesian analysis, logistical regression, and Kaplan-Meier analysis were performed.

RESULTS

542 patients were identified, including 165 from the single-center study and an additional 377 patients from the multicenter group. The median age was 36 months at the time of the most recent surgery. 70.9% of the LTRs were double-staged procedures. The overall success rate was 86.4% and operation-specific success rate was 69.2%. The specific comorbidities and aerodigestive test results that impacted success based on univariate analysis included staging, bronchiectasis, pulmonary hypertension, GERD, ASD, PDA, grade of stenosis, advanced levels of stenosis, Trisomy 21, MRSA, prior open surgery at another hospital, and gross appearance on EGD. Bayesian model averaging with backward selection was used to validate and refine a predictive model for surgical success with favorable receiver operating curve characteristics - AUC values of 0.827 for single surgery success and 0.797 for overall success.

DISCUSSION

With over 500 patients reviewed, this was the largest multicenter study of LTR to date, which elucidated the impact of comorbidities on success with LTR and was able to improve upon the predictive modeling based on single-center data. Patient factors are most critical in the outcome of LTR. Stage and levels of stenosis, as well as pulmonary and GI conditions most strongly impact the likelihood of success. Future prospective case-control studies will be performed to further optimize the current model for outcome prediction and patient management.

Developing Virtual Reality Head Mounted Display (HMD) Set-Up for Thoracoscopic Surgery of Complex Congenital Lung MalFormations in Children

Video assisted thoracoscopic surgery (VATS) has been adopted in pediatric age for the treatment of congenital lung malformations (CLM). The success of VATS in pediatrics largely depends on the surgeon's skill ability to understand the airways, vascular system and lung parenchyma anatomy in CLM. In the last years, virtual reality (VR) and 3-dimensional (3D) printing of organ models and VR head mounted display (HMD) technologies have been introduced for completion of preoperative planning in adult patients. To date no reports about the use of VR HMD technologies in a pediatric setting are available. The aim of this report is to introduce a VR HMD model in VATS procedure to improve the quality of care in children with CLM. VR HMD set-up for planning thoracoscopic surgery was performed in a series of pediatric patients with diagnosis of CLM. The preoperative VR HMD evaluation allowed a navigation into the malformation with the aim to explore, interact, and make the surgeon more confident and skilled to answer to the traps. A development of surgical simulations models and teaching program dedicated to education and training in pediatric VATS is suitable among the pediatric surgery community. Further studies should demonstrate all the benefits of such technology in pediatric patients submitted to VATS procedure.

Closed-PICU perioperative management of congenital tracheal stenosis

BACKGROUND

Perioperative management of congenital tracheal stenosis (CTS) is challenging. In the present study, compared the effect of closed-pediatric intensive care unit (PICU) perioperative management by pediatric intensivists and open-PICU management by surgeons. Outcomes in terms of ventilator-free days (VFD) and length of postoperative PICU stay in children with CTS were evaluated.

METHODS

This retrospective cohort study was conducted in a PICU in Japan. Children with CTS who underwent slide tracheoplasty were grouped according to whether they were perioperatively managed in an open (January 2015 to April 2016) or a closed (May 2016 to August 2019) PICU. Data were extracted from patients' medical records.

RESULTS

In total, 13 and 38 patients were included in the open- and closed-PICU groups, respectively. Compared to the open-PICU group, the closed-PICU group had shorter duration of muscle relaxant administration (median 4 vs 5 days; P < 0.001), earlier enteral nutrition (34/38 [90%] vs 1/13 [8%]; P < 0.001), more 28-day VFD (median 21 vs 20 days; P = 0.04), and shorter duration of postoperative PICU stay (median 16 vs 36 days; P = 0.002), but mortality did not differ significantly between the two groups (0/38 [0%] vs 1/13 [8%]; P = 0.25).

CONCLUSIONS

Closed-PICU perioperative management with pediatric intensivists' participation significantly increased 28-day VFD and reduced the length of postoperative PICU stay in patients with congenital tracheal stenosis.

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.

Fetal Lung Tissue Engineering

Lung transplantation may be considered as a final treatment option for diseases such as chronic lung disease, pulmonary hypertension, bronchopulmonary dysplasia, pulmonary fibrosis, and end-stage lung disease. The five-year survival rate of lung transplants is nearly 50%. Unfortunately, many patients will die before a suitable lung donor can be found. Importantly, the shortage of donor organs has been a significant problem in lung transplantation. The tissue engineering approach uses de- and recellularization of lung tissue to create functional lung substitutes to overcome donor lung limitations. Decellularization is hope for generating an intact ECM in the development of the engineered lung. The goal of decellularization is to prepare a suitable scaffold of lung tissue that contains an appropriate framework for the functionality of regenerated lung tissue. In this chapter, we aim to describe the decellularization protocols for lung tissue regenerative purposes.

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.

Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study

Background

Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs).

Methods

This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days.

Results

Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million).

Conclusion

If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.

Working as a team in airway surgery: History, present and perspectives

Teamwork is one of the most important trend in modern medicine. Airway team were created in many places to respond in a multidisciplinary and coordinated way to challenging clinical problems which were beyond the possibility of an individual management. In this chapter, we illustrate the historical steps leading to the development of an airway team in a pediatric referral hospital, describe the present teamwork activity defining the key points for the creation of a team and discussing different organization models; finally we delineate possible future directions for the airway teams in the globalized world.

Pediatric interventional radiology - does it add value?

Although attempts have been made to show that pediatric interventional radiology adds value in children's hospitals, none has been particularly persuasive. An analysis of individual procedures would seem to be the most scientific approach, but there are numerous problems, including the effects that different health care systems have on clinical practice and the difficulty of generalizing the results of a single-center study to other hospitals, even within the same type of health care system. It is unsurprising that there are no published randomized controlled trials comparing both the costs and outcomes of specific pediatric interventional radiology procedures with surgical alternatives, and in fact these may not be feasible. There is only anecdotal evidence of the value of pediatric interventional radiology in multidisciplinary teams in children's hospitals. Currently, the best justification may be the counterfactual: demonstrating what can go wrong if pediatric interventional radiology expertise is not available.

Multidisciplinary care in surgery: Are team-based interventions cost-effective?

BACKGROUND

Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields.

METHODS

A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described.

RESULTS

A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved.

CONCLUSION

Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.

Impact of Pre-operative Multidisciplinary Evaluation on Laryngotracheal Reconstruction Outcomes

OBJECTIVE/HYPOTHESIS

Determine if diagnostic findings from pre-operative multidisciplinary evaluations are associated with single surgery or overall success rates in pediatric laryngotracheal reconstruction (LTR).

STUDY DESIGN

Retrospective cohort.

METHODS

Retrospective cohort study of patients undergoing LTR at a tertiary care children's hospital between January 01, 2008 and December 31, 2017. Success is defined as decannulation rate if tracheostomy present, and resolution of symptoms if tracheostomy not present. Cohorts compared were those who did and did not receive pulmonary and gastrointestinal preoperative testing. Multivariate, logistic regression, and Kaplan Meier analyses performed.

RESULTS

About 165 children were included in the study. Median age was 3 years at the time of surgery; 73% of LTRs were double-stage procedures. Single surgery and overall success rates were 75% and 87%, respectively. After adjusting for severity of stenosis and surgical approach, performing esophagogastroduodenoscopy (EGD) and normal gross appearance on EGD were associated with increased single surgery (P = .01, .005) and overall success (P = .005, .0003). Performing pH probe and normal EGD biopsy results was associated with increased overall success (P = .03, .007). Asthma and musculoskeletal comorbidities, postoperative complications, and need for postoperative balloon dilation were associated with decreased success. No other comorbidities evaluated impacted success.

CONCLUSIONS

Aerodigestive comorbidities are common in children undergoing LTR, and preoperative multidisciplinary workup often results in changes in management. After adjusting for grade and level of stenosis and staged approach, performing EGD and pH/impedance probe as well as normal gross and microscopic EGD findings was independently associated with increased LTR surgical success.

LEVEL OF EVIDENCE

4 (retrospective cohort study) Laryngoscope, 131:E2356-E2362, 2021.

Lethal severe congenital tracheal stenosis with tracheal ring complicating respiratory distress syndrome in an extremely premature infant: first reported case in Qatar with a literature review

In the context of prematurity, lethal congenital airways malforamtion can be masked by the symptoms of respiratory distress syndrome. A high index of suspicion is required. We present the case of a 28-week preterm infant, with atypical protracted respiratory insufficiency despite the escalation of mechanical ventilation. The possibility of airway obstruction was considered in view of severe chest retraction while on the mechanical ventilator. It was also difficult to pass suction catheters beyond a certain depth in the trachea; however, intubation of the upper trachea was accomplished twice without difficulty. Flexible bronchoscopy revealed complete tracheal ring with severe tracheal stenosis; there was no evidence of tracheo-oesophageal fistula. Due to advanced multi-organ dysfunction at diagnosis, a decision was made with the family to re-orientate from intensive care to compassionate care. Ethical considerations in similar cases should incorporate the improved outcomes of prematurity and recent advances in tracheal reconstruction.

Surgical repair for post-tuberculosis tracheobronchial stenosis

AIM

Post-tuberculosis tracheobronchial stenosis is rare but one of the most dangerous complications of tracheobronchial tuberculosis. Balloon dilatation, stent insertion, laser photoresection, argon plasma coagulation, and cryotherapy are some of the initial treatments recommended for mild to moderate cases. Here, we report a case series of patients who underwent segmental resection and end-to-end anastomosis for bronchial stenosis and a sliding technique for severe and long-segment tracheal stenosis.

METHODS

We retrospectively reviewed the medical records of patients with post-tuberculosis tracheobronchial stenosis operated on in our thoracic surgery department. Of the 7 cases that were treated, two had severe tracheal stenosis stretching over 50% of the tracheal length, one was operated on using resection and end-to-end anastomosis, and the other had sliding tracheoplasty. The other 5 cases of bronchial stem stenosis were treated with segmental resection and end-to-end anastomosis.

RESULTS

All five patients with bronchial stenosis had a good outcome; the ipsilateral lung was well ventilated and respiratory function was good. One patient with tracheal stenosis, treated with segmental resection and end-to-end anastomosis, died after the surgery, and the other patient, treated with slide tracheoplasty, had a good recovery.

CONCLUSION

The treatment plan for patients with post-tuberculosis tracheobronchial stenosis should be on a patient-by-patient basis. Sliding tracheoplasty can be a treatment option in patients with long-segment tracheal stenosis.

Bridging bronchus (pseudocarina) and left pulmonary artery sling: A case report and literature review

Congenital airway malformations can present with respiratory distress, cyanosis, and difficulty feeding in the neonate or infant. Clinical presentation may vary from asymptomatic to fatal airway obstruction. They may exist in isolation or in association with vascular rings and slings, bronchopulmonary malformations, and/or syndromes. We present an unusual case of bridging bronchus, complete bronchial rings, and left pulmonary artery sling presenting with recurrent croup, highlighting the importance of bronchoscopy and CT imaging to achieve an accurate diagnosis in patients with recurrent croup and/or respiratory failure not responding to usual treatment measures and a multidisciplinary treatment approach.

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.

Interventional radiology in the airway in children

Interventional procedures in the airway can be performed in interventional radiology suites or the operating room, by radiologists or other specialists. The most common therapeutic interventions carried out by radiologists are balloon dilatation, stenting, and the treatment of certain airway fistulas. These operations can be very challenging for anesthetists in terms of planning, airway management, the identification and treatment of procedural complications and postoperative care. In particular, a multidisciplinary approach to decision-making and planning is important to obtain the best results.

Management of Tracheal Diseases in Children

Tracheal pathology in children are primarily congenital. They can be considered primary or de novo, when this is seen as an inherent defect within the cartilages of the tracheal segment. While segmental cartilage defects are very rare, there are often occasions when one or more cartilages can be considered missing from the length of trachea, contributing to airway abnormality. Secondary tracheal pathologies can often be seen in relation to disorders affecting nearby vascular elements or thoracic cage in general. In general, the pathological entity of tracheal disorders can be classified into either tracheomalacia or tracheal stenosis.

A combination of tracheoplasty and tracheal stenting is an acceptable method of treating severe congenital tracheobronchial stenosis under extracorporeal membrane oxygenation

BACKGROUND

Congenital tracheobronchial stenosis (CTBS) is a rare congenital condition characterized by complete cartilage rings covering varying lengths of the major airway. In this study, we reviewed the outcomes of patients with CTBS receiving surgical tracheoplasty in our institute.

METHODS

We retrospectively analyzed the outcomes of consecutive patients with CTBS operated between 2006 and 2017 when extracorporeal membrane oxygenation (ECMO) was used perioperatively.

RESULTS

In total, 11 patients (median follow-up period, 4.2 years; interquartile range, 1.6-5.4) were included. Seven were symptomatic in the neonatal period, 10 had cardiorespiratory anomalies, 7 required preoperative bronchoscopic balloon dilatation, and 1 required preoperative stent placement. Slide tracheoplasty (STP) was performed in 9 patients, and 2 underwent pericardial patch tracheoplasty. Seven patients required postoperative balloon dilatation, and 6 required postoperative stent placement. Early stenting provided immediate ventilatory improvement in all patients and facilitated successful extubation in a median of 4 days after stenting in 80% of the patients.

CONCLUSIONS

Under ECMO, severe CTBS could be successfully treated through a combination of tracheoplasty and bronchoscopic management. STP provided excellent results for solitary trachea stenosis with a minimum diameter of ≥3 mm. In selected patients, postoperative tracheobronchial stent placement was crucial in minimizing the ECMO duration and facilitating extubation.

LEVEL OF EVIDENCE

IV.

Swallowing outcomes in children after slide tracheoplasty

INTRODUCTION

Slide tracheoplasty is now considered gold standard treatment for long segment congenital tracheal stenosis. Outcomes are typically focused upon airway patency. Dysphagia is often reported in children undergoing cardiothoracic surgery, but not specifically after slide tracheoplasty. This study was carried out to describe the nature and prevalence of dysphagia following slide tracheoplasty for long segment congenital tracheal stenosis.

METHODS

Retrospective case note review was conducted on a series of patients who underwent swallow evaluation following slide tracheoplasty between 2006 and 2014. A clinical swallow assessment was carried out by a Speech and Language Therapist with videofluoroscopic evaluation of swallowing where indicated. Logistic regression assessed the impact of gender, feeding history, weight, tracheal diameter, stenting and co-morbidities on the likelihood of having post-operative dysphagia.

RESULTS

43 out of 83 slide tracheoplasty patients underwent swallow evaluation. Dysphagia was identified in 30 (70%) of 43 patients. Videofluoroscopy was undertaken in 22 of these patients. All patients who had a videofluoroscopy presented with altered swallow physiology. Aspiration risk was confirmed in 15 patients with frank aspiration seen in 9. Pre-operative history of dysphagia was present in 9 patients. There were two cases of vocal fold palsy. The presence of a stent was the strongest predictor of post-operative dysphagia with an odds ratio of 10.6 (95% CI 1.2-92.8).

CONCLUSIONS

This study documents a high prevalence of post-operative dysphagia in a pediatric population following slide tracheoplasty. In most cases there was no history suggestive of dysphagia pre-operatively. Swallowing needs to be assessed after slide tracheoplasty and longitudinal studies are required.

The Multidisciplinary Approach to Pediatric Aerodigestive Disorders

Multidisciplinary programs for the care of children with upper and lower respiratory and gastrointestinal tract disorders have emerged across the United States and become known as aerodigestive centers. This model is designed to improve clinical outcomes and healthcare value through a coordinated approach by a team that appreciates the inter-relatedness of these disorders. The primary elements include: (1) Interdisciplinary medical and surgical team, (2) Care coordination, (3) Team meeting, and (4) Combined endoscopic procedures. This article will describe the origin and current trends in the multidisciplinary approach to pediatric aerodigestive disorders.

Impact of 3D printing on the surgical management of tracheal stenosis associated to pulmonary sling: a case report

Congenital tracheal stenosis (CTS) is rare lesions frequently associated with pulmonary sling (PS). Despite the recent improvement in the results by the introduction of slide tracheoplasty (ST) and multidisciplinary approach, surgical management remains difficult and several authors, for this reason, debate for a conservative approach in these cases. Preoperative planning, require hence the use of the most innovative technology to gain the best possible result. This report describes a complicated, unsuccessful surgically treated case of CTS associated to PS. Based on this result and in order to improve the outcomes, we have built a 3D model of patient's trachea simulating preoperative surgical planning. We have hypnotized that having the model preoperatively the choice of surgical technique would have been different. Since that case, 3D models are introduced in our practice and built before tracheal or cardiac cases considered to have complex anatomy. Future investigations are required but at the moment this experience confirms the utility of 3D model in the evaluation of children considered for tracheal surgery.

Temporary tracheal stenting using endovascular prosthesis in the management of severe refractory stenosis following slide tracheoplasty

OBJECTIVES

To evaluate the role of endovascular stents in temporary tracheal stenting and endoscopic treatment strategy for patients with severe refractory tracheal stenosis following slide tracheoplasty.

METHODS

Two patients had severe tracheal stenosis after slide tracheoplasty for long segment congenital tracheal stenosis. Both these patients were managed endoscopically and an endovascular prosthesis was used to temporarily stent the trachea. Short and long term results were evaluated clinically and with repeated endoscopies.

RESULTS

The 2 patients had an excellent recovery immediately after the stent placement and continue to have an optimal, age-appropriate stable tracheal diameter after stent removal.

CONCLUSION

Endovascular stents can be temporarily used to stent the trachea in the endoscopic treatment strategy to correct refractory severe tracheal stenosis following slide tracheoplasty.

Slide tracheoplasty in 81 children: Improved outcomes with modified surgical technique and optimal surgical age

The aim of this study was to evaluate the surgical outcome of slide tracheoplasty.Eighty-one patients who underwent slide tracheoplasty were retrospectively reviewed. Before and after operation, all patients were examined by computed tomography (CT) and bronchoscopy regularly.There were 8 deaths and the mortality was 9.9%. They all died of respiratory failure associated with the formation of granulation tissue in the airway postoperatively. The mortality was 15.8% from 2009 to 2012 and decreased to 8.1% from 2013 to 2016. The mortality of patients aged 10 to 24 months was 5.7%, which was significantly lower than those younger than 10 months and those older than 24 months. After surgery, 11 patients had granulation tissue growing at anastomosis edges and 8 of them died eventually. Twenty patients had mucosa varus at the site of anastomosis which mainly happened in the early time. Between different time periods and different age groups, there was significant difference in the incidence of granulation tissue and mucosa varus (P < .01). Clinical symptoms of tracheal stenosis disappeared and the results of CT were satisfactory after operation.Slide tracheoplasty is an effective surgical method for congenital tracheal stenosis associated with congenital heart disease. With the continuous improvement of surgical technique, the mortality has been reduced and the incidence of granulation tissue and mucosa varus also has been reduced. The period of 10 to 24 months of age is the optimal cure time.

Airway Problems in Neonates-A Review of the Current Investigation and Management Strategies

Airway problems in the neonatal population are often life threatening and raise challenging issues in diagnosis and management. The airway problems can result from congenital or acquired lesions and can be broadly classified into those causing obstruction or those due to an abnormal "communication" in the airway. Many different investigations are now available to identify the diagnosis and quantify the severity of the problem, and these tests can be simple or invasive. Bronchography and bronchoscopy are essential to determine the extent and severity of the airway problem and to plan treatment strategy. Further imaging techniques help to delineate other commonly associated abnormalities. Echocardiography is also important to confirm any associated cardiac abnormality. In this review, the merits and disadvantages of the various investigations now available to the clinician will be discussed. The current therapeutic strategies are discussed, and the review will focus on the most challenging conditions that cause the biggest management conundrums, specifically laryngotracheal cleft, congenital tracheal stenosis, and tracheobronchomalacia. Management of acquired stenosis secondary to airway injury from endotracheal intubation will also be discussed as this is a common problem. Slide tracheoplasty is the preferred surgical option for long-segment tracheal stenosis, and results have improved significantly. Stents are occasionally required for residual or recurrent stenosis following surgical repair. There is sufficient evidence that a multidisciplinary team approach for managing complex airway issues provides the best results for the patient. There is ongoing progress in the field with newer diagnostic tools as well as development of innovative management techniques, such as biodegradable stents and stem cell-based tracheal transplants, leading to a much better prognosis for these children in the future.

Tracheal and bronchial stenoses and other obstructive conditions

Although tracheal stenosis and bronchial stenosis are relatively rare in the pediatric population, they are both associated with significant morbidity and mortality. While most cases of congenital tracheal stenosis in children present as complete tracheal rings (CTRs), other congenital tracheal obstructions are also encountered in clinical practice. In addition, acquired obstructive tracheal conditions stemming from endotracheal trauma or previous surgical interventions may occur. Many affected children also have associated cardiovascular malformations, further complicating their management. Optimal management of children with tracheal or bronchial stenoses requires comprehensive diagnostic evaluation and optimization prior to surgery. Slide tracheoplasty has been the operative intervention of choice in the treatment of the majority of these children.

Virtual 3D Modeling of Airways in Congenital Heart Defects

The involvement of the airway is not uncommon in the presence of complex cardiovascular malformations. In these cases, a careful inspection of the relationship between the airway and the vasculature is paramount to plan the surgical procedure. Three-dimensional printing enhanced the visualization of the cardiovascular structure. Unfortunately, IT does not allow to remove selected anatomy to improve the visualization of the surrounding ones. Computerized modeling has the potential to fill this gap by allowing a dynamic handling of different anatomies, increasing the exposure of vessels or bronchi to show their relationship. We started to use this technique to plan the surgical repair in these complex cases where the airway is affected. This technique is routinely used in our Institution as an additional tool in the presurgical assessment. We report four cases in which the airways were compressed by vascular structures - ascending aorta in one, left pulmonary artery sling in one, patent ductus arteriosus in one, and major aorto-pulmonary collateral artery in one. We believe this technique can enhance the understanding of the causes of airway involvement and facilitate the creation of an appropriate surgical plan.

Evolution of Surgical Approaches in the Management of Congenital Tracheal Stenosis

Background:

Congenital tracheal stenosis (CTS) is a serious and rare condition that often presents a complex surgical challenge. We reviewed the evolution of surgical approaches to the management of CTS at a single institution.

Methods:

We conducted a retrospective clinical review of all patients who underwent surgical repair of CTS at our institution. From January 1992 to January 2014, a total of 30 patients (median age 92 days; range 3 days-1.7 years) underwent surgery for CTS at our institution. Techniques included slide tracheoplasty (n = 16), tracheal resection (n = 10), pericardial patch tracheoplasty (n = 3), and costal cartilage tracheoplasty (n = 1). Twenty-two (73%) patients had associated intracardiac or great vessel anomalies, including 18 (60%) with left pulmonary artery sling. Five (17%) patients had associated single lung malformation. All procedures were performed via a median sternotomy with cardiopulmonary bypass.

Results:

Median postoperative length of stay was 25 days (range, 5-431 days). Late airway reintervention was required in seven (26%), including two (15%) infants after slide tracheoplasty, two (22%) posttracheal resection, and two (100%) post pericardial patch tracheoplasty. The one patient who underwent costal cartilage tracheoplasty required multiple reinterventions. Overall mortality was 13% (n = 4), two deaths occurred post slide tracheoplasty, one death occurred after tracheal resection, and one after pericardial patch tracheoplasty, respectively.

Conclusion:

Slide tracheoplasty is the procedure of choice for repair of CTS, while tracheal resection is a viable option for patients with discreet, short-segment stenosis.

Cost of Stem Cell-Based Tissue-Engineered Airway Transplants in the United Kingdom: Case Series

Stem cell-based tissue-engineered tracheas are at an early stage in their product development cycle. Tens of patients have been treated worldwide in predominantly compassionate use settings, demonstrating significant promise. This potentially life-saving treatment is complex, and the cost and its implications for such treatments are yet to be fully understood. The costs are compounded by varying strategies for graft preparation and transplant, resulting in differing clinical and laboratory costs from different research groups. In this study, we present a detailed breakdown of the clinical and manufacturing costs for three of the United Kingdom (UK) patients treated with such transplants. All three patients were treated under Compassionate Use legislation, within the UK National Health Service (NHS) hospital setting. The total costs for the three UK patients treated ranged from $174,420 to $740,500. All three patients were in a state of poor health at time of treatment and had a number of complexities in addition to the restricted airway. This is the first time a cost analysis has been made for a tissue-engineered organ and provides a benchmark for future studies, as well as comparative data for use in reimbursement considerations.

Summarized institutional experience of paediatric airway surgery†

OBJECTIVES

The management of paediatric airway stenosis is complex, and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopaedics, paediatricians and anaesthetists. The majority of paediatric laryngotracheal stenosis is a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical correction is often difficult due to a frequent combination of glottic and subglottic defects.

METHODS

In 2012, the Laryngotracheal Program Vienna was launched. Since then, 18 paediatric patients were surgically treated for (laryngo-)tracheal problems.

RESULTS

The median age of our patients was 26 months (range 2-180 months). Laryngotracheal stenosis extending up to the level of the vocal cords was evident in 9 patients. Three children were diagnosed with an isolated subglottic, and four with a short-segment tracheal stenosis or malacia. Two patients had a long-segment congenital malformation together with vascular ring anomalies. Five children were pretreated by rigid endoscopy before surgical correction, 12 of our 18 patients had a tracheostomy, 3 children were intubated at the time of operation. Different techniques of corrections were applied: laryngotracheal reconstruction (n = 4), extended partial cricotracheal resection (n = 4), cricotracheal resection with or without anterior split or dorsal mucosal flap (n = 4), slide tracheoplasty (n = 2), tracheal resection (n = 4). In 8 patients, a rib cartilage interposition was necessary in order to obtain a sufficient lumen enlargement and in 7 of these patients, an LT-Mold was placed to stabilize the reconstruction. We lost 2 patients, who were referred to our institution after failure of multiple preceding interventions, 2 and 3 months after the operation. Twelve patients are currently in an excellent condition, one is in an acceptable condition without a need for an intervention. Two patients required an endoscopic reintervention 18 and 33 months after the operation, 1 child is currently still cannulated.

CONCLUSIONS

Paediatric airway surgery is complex, and requires a dedicated interdisciplinary team. An armamentarium of different resection and reconstruction techniques is necessary in order to achieve good long-term results.

Tracheobronchial issues in congenital heart disease

In children with congenital heart disease, tracheobronchial compromise is uncommon but potentially life-threatening. Airway lesions in these patients may be congenital or acquired, and may be stenotic, compressive, or malacic in nature. We present an overview of the etiologies of tracheobronchial lesions typically seen in children with congenital heart disease and review management options for these lesions.

Decellularized tracheal extracellular matrix supports epithelial migration, differentiation, and function

Tracheal loss is a source of significant morbidity for affected patients with no acceptable solution. Interest in engineering tracheal transplants has created a demand for small animal models of orthotopic tracheal transplantation. Here, we examine the use of a decellularized graft in a murine model of tracheal replacement. Fresh or decellularized tracheas harvested from age-matched female donor C57BL/6 mice were transplanted into syngeneic recipients. Tracheas were decellularized using repeated washes of water, 3% Triton X-100, and 3 M NaCl under cyclic pressure changes, followed by disinfection with 0.1% peracetic acid/4% ethanol, and terminal sterilization by gamma irradiation. Tracheas were explanted for immunolabeling at 1, 4, and 8 weeks following surgery. Video microscopy and computed tomography were performed to assess function and structure. Decellularized grafts supported complete reepithelialization by 8 weeks and motile cilia were observed. Cartilaginous portions of the trachea were maintained in mice receiving fresh transplants, but repopulation of the cartilage was not seen in mice receiving decellularized transplants. We observed superior postsurgical survival, weight gain, and ciliary function in mice receiving fresh transplants compared with those receiving decellularized transplants. The murine orthotopic tracheal transplant provides an appropriate model to assess the repopulation and functional regeneration of decellularized tracheal grafts.

Pediatric cardiothoracic surgery in patients with unilateral pulmonary agenesis or aplasia

BACKGROUND

Unilateral pulmonary agenesis or aplasia (UPA), a rare developmental defect of the lung, is sometimes associated with congenital heart and tracheal diseases. The purpose of this study was to assess our experience of pediatric cardiothoracic surgery in UPA patients.

METHODS

Cardiothoracic surgery for congenital heart defect or tracheal stenosis performed between 1981 and 2010 in 8 UPA patients (agenesis in 5 and aplasia in 3) was reviewed retrospectively. Associated cardiac anomalies included ventricular septal defect, double outlet right ventricle with pulmonary atresia, total anomalous pulmonary venous connection, and interrupted aortic arch complex.

RESULTS

For 7 patients with right UPA and 1 patient with left UPA, 12 cardiothoracic operations were performed, including 8 cardiac procedures in 4 patients and 4 tracheal procedures in 4 patients. Cardiac palliative repairs included Blalock-Park anastomosis, systemic-to-pulmonary artery shunt, and pulmonary artery banding. Cardiac definitive repairs included ventricular septal defect closure, subaortic membrane resection, modified Konno procedure, total anomalous pulmonary venous connection repair, and Rastelli-type operation. Tracheal repairs were costal cartilage tracheoplasty and slide tracheoplasty. The median age at surgery was 8 months and median body weight was 6.2 kg; the median operative time was 6.5 hours. There were 3 hospital deaths and 1 late death, with the 1-year mortality rate of 25%. Cardiopulmonary bypass-induced acute lung injury has occurred in 3 cases, 2 of which required extracorporeal membrane oxygenation support. Younger age of less than 1 month and prolonged cardiopulmonary bypass time of more than 200 minutes were related to operative risk factors for hospital mortality and morbidity.

CONCLUSIONS

Most of the pediatric cardiothoracic operations in UPA patients were successfully performed through an optimal surgical approach and procedure, but they still presented surgical risks of high mortality and morbidity. Perioperative management of UPA patients should be provided with a precise understanding of anatomic configuration and a careful consideration of underlying risk factors.

Stem-cell-based, tissue engineered tracheal replacement in a child: a 2-year follow-up study

BACKGROUND

Stem-cell-based, tissue engineered transplants might offer new therapeutic options for patients, including children, with failing organs. The reported replacement of an adult airway using stem cells on a biological scaffold with good results at 6 months supports this view. We describe the case of a child who received a stem-cell-based tracheal replacement and report findings after 2 years of follow-up.

METHODS

A 12-year-old boy was born with long-segment congenital tracheal stenosis and pulmonary sling. His airway had been maintained by metal stents, but, after failure, a cadaveric donor tracheal scaffold was decellularised. After a short course of granulocyte colony stimulating factor, bone marrow mesenchymal stem cells were retrieved preoperatively and seeded onto the scaffold, with patches of autologous epithelium. Topical human recombinant erythropoietin was applied to encourage angiogenesis, and transforming growth factor β to support chondrogenesis. Intravenous human recombinant erythropoietin was continued postoperatively. Outcomes were survival, morbidity, endoscopic appearance, cytology and proteomics of brushings, and peripheral blood counts.

FINDINGS

The graft revascularised within 1 week after surgery. A strong neutrophil response was noted locally for the first 8 weeks after surgery, which generated luminal DNA neutrophil extracellular traps. Cytological evidence of restoration of the epithelium was not evident until 1 year. The graft did not have biomechanical strength focally until 18 months, but the patient has not needed any medical intervention since then. 18 months after surgery, he had a normal chest CT scan and ventilation-perfusion scan and had grown 11 cm in height since the operation. At 2 years follow-up, he had a functional airway and had returned to school.

INTERPRETATION

Follow-up of the first paediatric, stem-cell-based, tissue-engineered transplant shows potential for this technology but also highlights the need for further research.

FUNDING

Great Ormond Street Hospital NHS Trust, The Royal Free Hampstead NHS Trust, University College Hospital NHS Foundation Trust, and Region of Tuscany.

Surgical management of pulmonary artery sling in children

OBJECTIVES

Pulmonary artery (PA) sling is a rare vascular anomaly associated with congenital tracheal stenosis. The natural history is poor and these patients often require early surgical intervention. We describe our experience with repair of this condition.

METHODS

From 1984 to 2011, 21 patients with PA sling underwent repair at the Royal Children's Hospital (median age, 5.9 months). PA sling was associated with compression of the trachea in all patients. Tracheal surgery was required in 12 (57.1%) patients. All patients had an echocardiogram, and concomitant repair of coexisting cardiac anomalies was performed in 6 (28.6%, 6/21) patients.

RESULTS

Operative mortality was 14.3% (3/21), occurring at 19 days, 4.4 months, and 5 months after surgery. Operative mortality for the first 10 years was 22.2% (1984-1993; 2/9), the next 10 years was 14.3% (1994-2003; 1/7), and 0% for the most recent 7 years (2004-2011; 0/5). All deaths occurred in patients requiring tracheal repair (25%, 3/12). No deaths have occurred since 2004 with introduction of the slide tracheoplasty technique. One (5.6%, 1/18) late death occurred at 8 months after repair. After tracheal repair, intervention for excessive granulations and tracheomalacia was necessary in 6 (50%, 6/12) patients. Median follow-up was 8 years (mean, 8.6 ± 6.4 years; range, 5 months to 20.6 years), and all survivors (100%, 17/17) remain asymptomatic.

CONCLUSIONS

Children with PA sling who do not require tracheal surgery have excellent outcomes. Mortality is determined by the need for tracheal surgery. However, with the advent of the slide tracheoplasty technique, mortality can be reduced. Survival beyond 1 year after surgery offers excellent prognosis.