Carinal stabilization technique in severe tracheobronchial malacia after slide tracheoplasty

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.

Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults

OBJECTIVE

To emphasize the importance of a careful clinical evaluation to prevent unnecessary interventions and treatments.

CLINICAL PRESENTATION AND INTERVENTION

A 76-year-old female patient had been diagnosed with asthma during previous admissions to different hospitals. She had also undergone fiberoptic bronchoscopy (FOB) on 2 occasions for evaluation of right middle lobe atelectasis observed on computed tomography. A repeated FOB revealed tracheobronchomalacia and nodular bronchial amyloidosis. A silicone Y stent was inserted, but the dyspnea increased. Excessive granulation tissue developed, and the patient died despite ventilatory support.

CONCLUSION

The stenting technique used did not prevent the development of respiratory failure and death in this patient. Hence, a surgical procedure could be considered as an alternative to stenting in such cases.

Fontan completion after external stenting of the left bronchus and intrapulmonary artery septation for left pulmonary artery hypoplasia

Tracheobronchial obstruction and unilateral hypoplasia of the pulmonary artery are serious barriers to successful Fontan completion. We describe a 5-year old girl with left bronchial obstruction, hypoplasia of the left pulmonary artery and a single ventricle (double inlet left ventricle). She had undergone external stenting to treat left bronchial stenosis at 3 years of age, bidirectional cavopulmonary anastomosis and Damus-Kaye-Stansel anastomosis at 4 years of age, intrapulmonary artery septation 1 year later and, finally, completion of the Fontan operation with excellent postoperative haemodynamics.

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.

Aortopexy with tracheal reconstruction for postoperative tracheomalacia in congenital tracheal stenosis

PURPOSE

Congenital tracheal stenosis is a rare condition and can be difficult to manage. One source of difficulty is postoperative tracheomalacia requiring long-term tracheal stenting. To prevent symptomatic postoperative tracheomalacia, we have been adding aortopexy to tracheal reconstruction since 2008. The aim of this study was to evaluate efficacy of aortopexy for preventing postoperative tracheomalacia after reconstruction of congenital tracheal stenosis.

METHODS

Retrospective chart review was conducted. From October 2003 to March 2011, 24 had tracheal reconstruction without aortopexy (group A) and 8 with aortopexy (group B). Statistical analysis was performed using Fisher's Exact test.

RESULTS

One had anastomotic leakage in group A, and 1, in group B (P = .44). Eleven patients required tracheostomy because of postoperative tracheomalacia confirmed by postoperative bronchoscopy in group A vs none in group B (P = .029).

CONCLUSIONS

We found that aortopexy with tracheal reconstruction reduced the need for postoperative tracheostomy in this patient group. Although there is a potential risk of anastomotic leakage because of the suspension suture on the anterior tracheal wall to aorta, we did not detect an increased incidence after aortopexy. Thus, aortic suspension may be a useful adjunct to prevent symptoms of tracheomalacia in these patients.