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Sumida W, Yasui A, Shirota C, Makita S, Okamoto M, Ogata S, Takimoto A, Takada S, Nakagawa Y, Kato D, Gohda Y, Amano H, Guo Y, Hinoki A, Uchida H. Update on aortopexy and posterior tracheopexy for tracheomalacia in patients with esophageal atresia. Surg Today 2024; 54:211-219. [PMID: 36729255 DOI: 10.1007/s00595-023-02652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/25/2022] [Indexed: 02/03/2023]
Abstract
Despite improving the survival after repair of esophageal atresia (EA), the morbidity of EA repair remains high. Specifically, tracheomalacia (TM) is one of the most frequent complications of EA repair. Continuous positive airway pressure is generally applied for the treatment of TM. However, surgical intervention is required against an apparent life-threatening event or inability to perform extubation for a long period. According to our review, most cases of TM showed symptom improvement after aortopexy. The ratio of the trachea's lateral and anterior-posterior diameter at the brachiocephalic artery crossing the trachea, which reflects the compression of the trachea by the brachiocephalic artery, is a good indicator of aortopexy. Our finding suggests that most TM cases associated with EA may not be caused by tracheal fragility alone, but may involve blood vessel compression. Posterior tracheopexy (PT) is also an effective treatment for TM. Recently, open or thoracoscopic PT was able to be performed simultaneously with EA repair. In many cases, aortopexy or PT is a safe and effective surgical treatment for TM with EA. Other surgical procedures, such as external stenting, should be considered for patients with diffuse-type TM for whom aortopexy and PT appear relatively ineffective.
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Affiliation(s)
- Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Seiya Ogata
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yaohui Guo
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Cao A, Swami P, Kaye R, Goldstein T, Grande DA, Smith LP. An Ex Vivo Model of Posterior Tracheomalacia With Evaluation of Potential Treatment Modalities. Laryngoscope 2023; 133:2000-2006. [PMID: 36073673 DOI: 10.1002/lary.30383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/27/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Posterior tracheomalacia (TM) is characterized by excessive intraluminal displacement of the tracheal membranous wall. Recently, novel surgical strategies for repair of posterior TM have been introduced. To our knowledge, these strategies have not been evaluated in a model of posterior TM. Thus, we sought to design an ex vivo mechanical model of posterior TM to evaluate potential repair interventions. METHODS A model for posterior TM was created with partial thickness longitudinal incisions to the posterior aspect of ex vivo porcine trachea. Three groups of tracheas were tested: (1) control (unmanipulated), (2) posterior TM (injury), and (3) intervention (repair). Interventions included external splinting with 0.3 and 0.5 mm bioresorbable plates, posterior tracheopexy, and injection tracheoplasty with calcium hydroxylapatite. An airtight tracheal system was created to measure tracheal wall collapse with changes in negative pressure. A bronchoscope and pressure transducer were connected to either end. Cross-sectional area of the tracheal lumen was analyzed using ImageJ software (National Institutes of Health, Bethesda, MD). RESULTS Average percent reduction in cross-sectional area of the tracheal lumen was compared using a two-tailed paired t-test. Significant differences were found between control and TM groups (p < 0.019). There was no significant difference between control and external splinting and posterior tracheopexy groups (p > 0.14). CONCLUSION We describe an ex vivo model for posterior TM that replicates airway collapse. External splinting and tracheopexy interventions showed recovery of the injured tracheal segment. Injection tracheoplasty did not improve the TM. LEVEL OF EVIDENCE N/A Laryngoscope, 133:2000-2006, 2023.
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Affiliation(s)
- Angela Cao
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein School of Medicine/Montefiore Medical Center, Bronx, New York, U.S.A
| | - Pooja Swami
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Rachel Kaye
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Todd Goldstein
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Daniel A Grande
- Department of Otolaryngology, The Feinstein Institute for Medical Research, Manhasset, New York, U.S.A
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
| | - Lee P Smith
- Department of Otolaryngology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Long Island Jewish Medical Center, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York, U.S.A
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Yu D, Peng W, Mo X, Zhang Y, Zhang X, He J. Personalized 3D-Printed Bioresorbable Airway External Splint for Tracheomalacia Combined With Congenital Heart Disease. Front Bioeng Biotechnol 2022; 10:859777. [PMID: 35620475 PMCID: PMC9127074 DOI: 10.3389/fbioe.2022.859777] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Severe tracheomalacia (TM) patients with respiratory symptoms need surgical intervention, including aortopexy, internal stents or external splint. While some patients continue to have respiratory symptoms after tracheal relief, and there is no evidence to support any one surgery therapy over another. Here we introduce a clinical safety and efficacy of the three-dimensional (3D)-printed bioresorbable airway external splints in treating congenital heart disease (CHD) patients with severe TM. From May 2019 to September 2020, nine patients with severe TM were enrolled. The median age was 5 months (range, 3–25 months), and the median weight was 7.5 kg (range, 3–15 kg). All patients had wheezing, and two patients were assisted by machine ventilation (MV) preoperatively. The median length of TM was 1.5 cm (range, 1.0–3.0 cm). All patients underwent suspension of a “C”-shaped lumen airway external splint, which were designed in SOLIDWORKS and made of polycaprolactone (PCL). The airway external splint could provided effective support for at least 6 months and was completely degraded into carbon dioxide and water within 2–3 years. The median time of postoperative machine assisted ventilation was 23.7 h (range, 3.3–223.4 h), and the median time of ICU stay was 9 days (range, 4–25 days). The median follow-up time was 18 months (range, 12–24 months). Respiratory symptoms were all relieved, and no external splint-associated complications occurred. The 3D computed tomography reconstruction showed no airway stenosis. Personalized 3D-printed bioresorbable airway external splint can not only limit external compression and prevent airway collapse but also ensure the growth potential of the airway, which is a safe, reliable and effective treatment for CHD with TM.
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Affiliation(s)
- Di Yu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Peng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuxi Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Zhang
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jiankang He
- State Key Laboratory for Manufacturing Systems Engineering, Xi'an Jiaotong University, Xi'an, China
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Wang JT, Peyton J, Hernandez MR. Anesthesia for pediatric rigid bronchoscopy and related airway surgery: Tips and tricks. Paediatr Anaesth 2022; 32:302-311. [PMID: 34877742 DOI: 10.1111/pan.14360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/29/2022]
Abstract
Bronchoscopy-guided diagnostic and interventional airway procedures are gaining in popularity and prominence in pediatric surgery. Many of these procedures have been used successfully in the adult population but have not been used in children due to a lack of appropriately sized instruments. Recent technological advances have led to the creation of instruments to enable many more diagnostic and therapeutic procedures to be done under bronchoscopic guidance. These procedures vary significantly in their length and invasiveness and require vastly different anesthetic plans that must be easily adapted to situational and procedural changes. In addition to close communication between the anesthesiology and procedural teams; an understanding of the type of procedure, anesthetic requirements, and potential patient risks is paramount to a successful anesthetic. This review will focus on new rigid bronchoscopic procedures, goals for their respective anesthetic management, and unique tips and trick for how to maintain adequate oxygenation and ventilation in each scenario.
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Affiliation(s)
- Jue T Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael R Hernandez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Kamran A, Smithers CJ, Baird CW, Jennings RW. Experience with bioresorbable splints for treatment of airway collapse in a pediatric population. JTCVS Tech 2021; 8:160-169. [PMID: 34401841 PMCID: PMC8350796 DOI: 10.1016/j.xjtc.2021.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Kamran
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Charles J. Smithers
- Department of General Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| | - Christopher W. Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Russell W. Jennings
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
- Address for reprints: Russell W. Jennings, MD, Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115.
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6
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Tambucci R, Wautelet O, Haenecour A, François G, Goubau C, Scheers I, Halut M, Menten R, Schmitz S, de Toeuf C, Pirotte T, D'hondt B, Reding R, Poncelet A. Esophageal Trachea, a Unique Foregut Malformation Requiring Multistage Surgical Reconstruction: Case Report. Front Pediatr 2020; 8:605143. [PMID: 33330293 PMCID: PMC7714922 DOI: 10.3389/fped.2020.605143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
Abnormal connections between the esophagus and low respiratory tract can result from embryological defects in foregut development. Beyond well-known malformations, including tracheo-esophageal fistula and laryngo-tracheo-esophageal cleft, rarer anomalies have also been reported, including communicating bronchopulmonary foregut malformations and tracheal atresia. Herein, we describe a case of what we have called "esophageal trachea," which, to our knowledge, has yet to be reported. A full-term neonate was born in our institution presenting with a foregut malformation involving both the middle esophagus and the distal trachea, which were found to be longitudinally merged into a common segment, 3 cm in length, located just above the carina and consisted of esophageal tissue without cartilaginous rings. At birth, the esophagus and trachea were surgically separated via right thoracotomy, the common segment kept on the tracheal side only, creating a residual long-gap esophageal atresia. The resulting severe tracheomalacia was treated via simultaneous posterior splinting of such diseased segment using an autologous pericardium patch, as well as by anterior aortopexy. Terminal esophagostomy and gastrostomy were created at that stage due to the long distance between esophageal segments. Between ages 18 and 24 months, the patient underwent native esophageal reconstruction using a multistage traction-and-growth surgical strategy that combined Kimura extra-thoracic esophageal elongations at the upper esophagus and Foker external traction at the distal esophagus. Ten months after esophageal reconstruction, prolonged, refractory, and severe tracheomalacia was further treated via anterior external stenting using a semitubular ringed Gore-Tex® prosthesis, through simultaneous median sternotomy and tracheoscopy. Currently, 2 years after the last surgery, respiratory stabilization, and full oral feeding were stably achieved. Multidisciplinary management was crucial for assuring lifesaving procedures, correctly assessing anatomy, and planning for multiple sequential surgical approaches that aimed to restore long-term respiratory and digestive functions.
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Affiliation(s)
- Roberto Tambucci
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Océane Wautelet
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Astrid Haenecour
- Pediatric Intensive Care Unit, Emergency Department, Saint-Luc University Clinics, Brussels, Belgium
| | - Geneviève François
- General Pediatric Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Christophe Goubau
- Pediatric Pneumology Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Isabelle Scheers
- Pediatric Gastroenterology and Hepatology Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Marin Halut
- Pediatric Radiology Unit, Department of Radiology, Saint-Luc University Clinics, Brussels, Belgium
| | - Renaud Menten
- Pediatric Radiology Unit, Department of Radiology, Saint-Luc University Clinics, Brussels, Belgium
| | - Sandra Schmitz
- Otolaryngology Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Caroline de Toeuf
- Otolaryngology Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Thierry Pirotte
- Pediatric Anesthesiology Unit, Emergency Department, Saint-Luc University Clinics, Brussels, Belgium
| | - Beelke D'hondt
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Raymond Reding
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Alain Poncelet
- Pediatric Cardiac and Thoracic Surgery Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
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Lawlor C, Smithers CJ, Hamilton T, Baird C, Rahbar R, Choi S, Jennings R. Innovative management of severe tracheobronchomalacia using anterior and posterior tracheobronchopexy. Laryngoscope 2019; 130:E65-E74. [PMID: 30908672 DOI: 10.1002/lary.27938] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/09/2019] [Accepted: 02/27/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Combined anterior and posterior tracheobronchopexy is a novel surgical approach for the management of severe tracheobronchomalacia (TBM). We present our institutional experience with this procedure. Our objective was to determine the utility and safety of anterior and posterior tracheopexy in the treatment of severe TBM. STUDY DESIGN Retrospective chart review. METHODS All patients who underwent anterior and posterior tracheopexy from January 2013 to July 2017 were retrospectively reviewed. Charts were reviewed for indications, preoperative work-up, tracheobronchomalacia classification and severity, procedure, associated syndromes, synchronous upper aerodigestive tract lesions, and aberrant thoracic vessels. Main outcomes measured included improvement in respiratory symptoms, successful extubation and/or decannulation, vocal fold immobility, and new tracheotomy placement. RESULTS Twenty-five patients underwent anterior and posterior tracheopexy at a mean age of 15.8 months (range, 2-209 months; mean, 31 months if 2 outliers of 206 and 209 months included). Mean length of follow-up was 26.8 months (range, 13-52 months). Indications for surgery included apneic events, ventilator dependence, need for positive pressure ventilation, tracheotomy dependence secondary to TBM, recurrent pneumonia, and exercise intolerance. Many patients had other underlying syndromes and synchronous upper aerodigestive tract lesions (8 VACTERL, 2 CHARGE, 1 trisomy 21, 1 Feingold syndrome, 17 esophageal atresia/tracheoesophageal fistula, 20 cardiac/great vessel anomalies, 1 subglottic stenosis, 1 laryngomalacia, 7 laryngeal cleft). At preoperative bronchoscopy, 21 of 25 patients had >90% collapse of at least one segment of their trachea, and the remaining four had 70% to 90% collapse. Following anterior and posterior tracheopexy, one patient developed new bilateral vocal-fold immobility; one patient with a preoperative left cord paralysis had a new right vocal-fold immobility. Postoperatively, most patients had significant improvement in their respiratory symptoms (21 of 25, 84%) at most recent follow-up. Three patients with preexisting tracheotomy were decannulated; two patients still had a tracheotomy at last follow-up. Two patients required new tracheotomy for bilateral vocal-fold immobility. CONCLUSIONS Combined anterior and posterior tracheopexy is a promising new technique for the surgical management of severe TBM. Further experience and longer follow-up are needed to validate this contemporary approach and to minimize the risk of recurrent laryngeal nerve injury. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E65-E74, 2020.
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Affiliation(s)
- Claire Lawlor
- Department of Otolaryngology, Children's National Medical Center, Washington, DC
| | | | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Reza Rahbar
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Russell Jennings
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
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8
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Les AS, Ohye RG, Filbrun AG, Ghadimi Mahani M, Flanagan CL, Daniels RC, Kidwell KM, Zopf DA, Hollister SJ, Green GE. 3D-printed, externally-implanted, bioresorbable airway splints for severe tracheobronchomalacia. Laryngoscope 2019; 129:1763-1771. [PMID: 30794335 DOI: 10.1002/lary.27863] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/17/2019] [Accepted: 01/22/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES/HYPOTHESIS To report the clinical safety and efficacy of three-dimensional (3D)-printed, patient-specific, bioresorbable airway splints in a cohort of critically ill children with severe tracheobronchomalacia. STUDY DESIGN Case series. METHODS From 2012 to 2018, 15 subjects received 29 splints on their trachea, right and/or left mainstem bronchi. The median age at implantation was 8 months (range, 3-25 months). Nine children were female. Five subjects had a history of extracorporeal membrane oxygenation (ECMO), and 11 required continuous sedation, six of whom required paralytics to maintain adequate ventilation. Thirteen were chronically hospitalized, unable to be discharged, and seven were hospitalized their entire lives. At the time of splint implantation, one subject required ECMO, one required positive airway pressure, and 13 subjects were tracheostomy and ventilator dependent, requiring a median positive end-expiratory pressure (PEEP) of 14 cm H2 O (range, 6-20 cm H2 0). Outcomes collected included level of respiratory support, disposition, and splint-related complications. RESULTS At the time of discharge from our institution, at a median of 28 days postimplantation (range, 10-56 days), the subject on ECMO was weaned from extracorporeal support, and the subjects who were ventilated via tracheostomy had a median change in PEEP (discharge-baseline) of -2.5 cm H2 O (range, -15 to 2 cm H2 O, P = .022). At median follow-up of 8.5 months (range, 0.3-77 months), all but one of the 12 surviving subjects lives at home. Of the 11 survivors who were tracheostomy dependent preoperatively, one is decannulated, one uses a speaking valve, six use a ventilator exclusively at night, and three remain ventilator dependent. CONCLUSIONS This case series demonstrates the initial clinical efficacy of the 3D-printed bioresorbable airway splint device in a cohort of critically ill children with severe tracheobronchomalacia. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1763-1771, 2019.
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Affiliation(s)
- Andrea S Les
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Amy G Filbrun
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan
| | | | - Colleen L Flanagan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rodney C Daniels
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - David A Zopf
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Scott J Hollister
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, U.S.A
| | - Glenn E Green
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
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Kamran A, Jennings RW. Tracheomalacia and Tracheobronchomalacia in Pediatrics: An Overview of Evaluation, Medical Management, and Surgical Treatment. Front Pediatr 2019; 7:512. [PMID: 31921725 PMCID: PMC6922019 DOI: 10.3389/fped.2019.00512] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/26/2019] [Indexed: 01/13/2023] Open
Abstract
Tracheobronchomalacia (TBM) refers to airway collapse due to typically excessive posterior membrane intrusion and often associated with anterior cartilage compression. TBM occurs either in isolation or in association with other congenital or acquired conditions. Patients with TM typically present non-specific respiratory symptoms, ranging from noisy breathing with a typical barking cough to respiratory distress episodes to acute life-threatening events and recurrent and/or prolonged respiratory infections. There are no definitive standardized guidelines for the evaluation, diagnosis, and treatment of TBM; therefore, patients may be initially misdiagnosed and incorrectly treated. Although milder cases of TBM may become asymptomatic as the diameter of the airway enlarges with the child, in cases of severe TBM, more aggressive management is warranted. This article is an overview of the clinical presentation, evaluation, diagnosis, medical management, and surgical treatment options in pediatric tracheomalacia.
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Affiliation(s)
- Ali Kamran
- Department of General Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Russell W Jennings
- Department of General Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
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10
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Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Baird CW, Jennings RW. Posterior Tracheopexy for Severe Tracheomalacia Associated with Esophageal Atresia (EA): Primary Treatment at the Time of Initial EA Repair versus Secondary Treatment. Front Surg 2018; 4:80. [PMID: 29379786 PMCID: PMC5775263 DOI: 10.3389/fsurg.2017.00080] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/26/2017] [Indexed: 11/27/2022] Open
Abstract
Purpose We review outcomes of posterior tracheopexy for tracheomalacia in esophageal atresia (EA) patients, comparing primary treatment at the time of initial EA repair versus secondary treatment. Methods All EA patients who underwent posterior tracheopexy from October 2012 to September 2016 were retrospectively reviewed. Clinical symptoms, tracheomalacia scores, and persistent airway intrusion were collected. Indication for posterior tracheopexy was the presence of clinical symptoms, in combination with severe tracheomalacia as identified on bronchoscopic evaluation, typically defined as coaptation in one or more regions of the trachea. Secondary cases were usually those with chronic respiratory symptoms who underwent bronchoscopic evaluation, whereas primary cases were those found to have severe tracheomalacia on routine preoperative dynamic tracheobronchoscopy at the time of initial EA repair. Results A total of 118 patients underwent posterior tracheopexy: 18 (15%) primary versus 100 (85%) secondary cases. Median (interquartile range) age was 2 months (1–4 months) for primary (22% type C) and 18 months (8–40 months) for secondary (87% type C) cases (p < 0.001). There were statistically significant improvements in most clinical symptoms postoperatively for primary and secondary cases, with no significant differences in any postoperative symptoms between the two groups (p > 0.1). Total tracheomalacia scores improved significantly in primary (p = 0.013) and secondary (p < 0.001) cases. Multivariable Cox regression analysis indicated no differences in persistent airway intrusion requiring reoperation between primary and secondary tracheopexy adjusting for imbalances in age and EA type (p = 0.67). Conclusion Posterior tracheopexy is effective in treating severe tracheomalacia with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy. With no significant differences in outcomes between primary and secondary treatment, posterior tracheopexy should be selectively considered at the time of initial EA repair.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - C Jason Smithers
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gary A Visner
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael A Manfredi
- Department of Gastroenterology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
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Shieh HF, Jennings RW. Three-dimensional printing of external airway splints for tracheomalacia. J Thorac Dis 2017; 9:414-416. [PMID: 28449431 DOI: 10.21037/jtd.2017.02.53] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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