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Ghezzi M, D’Auria E, Farolfi A, Calcaterra V, Zenga A, De Silvestri A, Pelizzo G, Zuccotti GV. Airway Malacia: Clinical Features and Surgical Related Issues, a Ten-Year Experience from a Tertiary Pediatric Hospital. CHILDREN-BASEL 2021; 8:children8070613. [PMID: 34356592 PMCID: PMC8307910 DOI: 10.3390/children8070613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Background: Few studies have been carried out with the aim of describing the clinical course and follow-up of patients with tracheomalacia. We aim to describe the symptoms at diagnosis and the post-treatment clinical course of patients affected by airway malacia. Methods: We retrospectively analyzed characteristics of pediatric patients with a diagnosis of airway malacia. Patients were classified into three groups: bronchomalacia (BM), tracheomalacia (TM) and tracheo-bronchomalacia (TBM). Demographic and clinical data, diagnostic work-up and surgical treatment were recorded. Results: 13/42 patients were affected by congenital syndromes (30.9%). Esophageal atresia with or without tracheal-esophageal fistula (EA/TEF) was detected in 7/42 patients (16.7%). Cardiovascular anomalies were found in 9/42 (21.4%) and idiopathic forms in 13/42 (30.9%). BM occurred in 7/42 (16.6%), TM in 23/42 (54.7%) and TBM in 12/42 (28.6%). At the diagnosis stage, a chronic cough was reported in 50% of cases with a higher prevalence in EA/TEF (p = 0.005). Surgery was performed in 16/42 (40%) of children. A chronic cough and acute respiratory failure were correlated to the need for surgery. During follow-up, there was no difference in persistence of symptoms between conservative vs surgical treatment (p = 0.47). Conclusion: the management of tracheomalacia remains a challenge for pediatricians. Clinical manifestations, such as a barking cough and acute respiratory failure may suggest the need for surgery. Follow-up is crucial, especially in those patients affected by comorbidities, so as to be able to manage effectively the possible persistence of symptoms, including those that may continue after surgical treatment.
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Affiliation(s)
- Michele Ghezzi
- Allergology and Pneumology Unit, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (E.D.); (A.F.); (A.Z.)
- Correspondence: ; Tel.: +039-02-6363-5797
| | - Enza D’Auria
- Allergology and Pneumology Unit, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (E.D.); (A.F.); (A.Z.)
| | - Andrea Farolfi
- Allergology and Pneumology Unit, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (E.D.); (A.F.); (A.Z.)
| | - Valeria Calcaterra
- Department of Pediatrics, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (V.C.); (G.V.Z.)
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Zenga
- Allergology and Pneumology Unit, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (E.D.); (A.F.); (A.Z.)
| | - Annalisa De Silvestri
- Biometry & Clinical Epidemiology, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Gloria Pelizzo
- Department of Pediatric Surgery, V. Buzzi Children’s Hospital, 20154 Milan, Italy;
- Department of Biomedical and Clinical Science “L. Sacco”, University of Milan, 20157 Milan, Italy
| | - Gian Vincenzo Zuccotti
- Department of Pediatrics, V. Buzzi Children’s Hospital, 20154 Milan, Italy; (V.C.); (G.V.Z.)
- Department of Biomedical and Clinical Science “L. Sacco”, University of Milan, 20157 Milan, Italy
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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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3
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Poore TS, Weinman JP, Handley E, Wine T, Helland S, Corbett B, Antoniolli N, Somme S, Friedlander J, Prager JD, DeBoer EM. Vascular and pulmonary comorbidities in children with congenital EA/TEF. Pediatr Pulmonol 2021; 56:571-577. [PMID: 33300304 DOI: 10.1002/ppul.25219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Esophageal atresia with tracheoesophageal fistula (EA/TEF) is associated with many congenital and vascular malformations; however, reports utilizing computed tomography (CT) and computed tomography angiography (CTA) are limited. The objective of this study is to review CT scans of the chest from patients with EA/TEF and report their pulmonary and vascular findings. METHODS We completed a retrospective chart review of children with congenital EA/TEF evaluated in the aerodigestive clinic at Children's Hospital Colorado. Results of the most recent CTA or CT of the chest were investigated. Demographics, medical conditions, and bronchoscopy findings were also recorded. The ratio of tracheal lumen area between inspiratory and expiratory CTA images was measured. RESULTS Of the patients with congenital EA/TEF seen in the program, 47 patients had a chest CT available for review. Eight patients (17%) had bronchiectasis. Of the contrast CT scans, 15 (58%) had a vascular abnormality and 16 (62%) demonstrated tracheal compression (38% at the level of the innominate artery, 35% from other structures). Nineteen of the CTAs had volumetric expiratory images of the trachea to evaluate tracheomalacia. The mean expiratory:inspiratory area was 0.57 (SD ± 0.23) at the level of the innominate. CONCLUSION Patients with EA/TEF frequently have vascular abnormalities that may alter airway mechanics as well as pulmonary comorbidities that may affect long-term management. For patients experiencing persistent respiratory symptoms, CTA of the chest should be considered adjunct to bronchoscopy to help with medical and surgical management of these children.
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Affiliation(s)
- Thomas S Poore
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jason P Weinman
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elyse Handley
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Todd Wine
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sparrow Helland
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Benjamin Corbett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Natalie Antoniolli
- Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Stig Somme
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joel Friedlander
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Gastroenterology, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Jeremy D Prager
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emily M DeBoer
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Section of Pulmonology and Sleep Medicine, The Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, USA
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Yu T, Sun L, Liu X, Zhu W. Silicon stent placement via rigid bronchoscopy for the treatment of central airway obstruction in infants: Case series. Medicine (Baltimore) 2021; 100:e24244. [PMID: 33466208 PMCID: PMC7808444 DOI: 10.1097/md.0000000000024244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/17/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Rigid bronchoscopy has been proven to be an excellent tool for the diagnosis and management of several causes of central airway obstruction (CAO). The invasive treatment of silicone bronchobrachial stenting has been performed in children and adults with CAO, and satisfying results were obtained in previous studies. However, there are few reports on infants with central airway obstruction treated with stenting via rigid bronchoscopy. This technique remains a challenge to pediatric thoracic surgeons, pediatric interventional pulmonologists, and otolaryngologists who struggle to treat airway obstruction disease. PATIENT CONCERNS Four patients were presented to our hospital with complaints of dyspnea for a period of time after their birth. DIAGNOSIS Three patients were diagnosed as tracheobronchomalacia, and tracheoesophageal fistula. INTERVENTIONS Four patients were treated with silicone stenting through rigid bronchoscopy. OUTCOMES Silicon stent was adequate for improving the obstruction of the tracheal tract. All the patients were followed-up longer than 6 months. Three patients could breathe normally; the stent migrated in only 1 patient. CONCLUSION Invasive silicone tracheobronchial stenting via rigid bronchoscopy is a viable option for infants with CAO. Choosing an appropriate size is a critical factor for success of stenting according to our experience.
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Rijnberg FM, Butler CR, Bieli C, Kumar S, Nouraei R, Asto J, McKavanagh E, de Coppi P, Muthialu N, Elliott MJ, Hewitt RJ. Aortopexy for the treatment of tracheobronchomalacia in 100 children: a 10-year single-centre experience. Eur J Cardiothorac Surg 2019. [PMID: 29514258 DOI: 10.1093/ejcts/ezy076] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children. METHODS Demographic data, characteristics and preoperative, operative and outcome details, including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016. RESULTS One hundred patients [median age 8.2 months, interquartile range (IQR) 3.3-26.0 months] underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012). CONCLUSIONS Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.
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Affiliation(s)
| | - Colin R Butler
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Otolaryngology, Great Ormond Street Hospital, London, UK.,Department of Academic Surgery, Institute of Child Health, UCL, London, UK
| | - Christian Bieli
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Respiratory Unit, University Children's Hospital, Zurich, Switzerland
| | - Sonia Kumar
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | - Reza Nouraei
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | - Joshua Asto
- Tracheal Team, Great Ormond Street Hospital, London, UK
| | | | - Paolo de Coppi
- Stem Cells & Regenerative Medicine Section, DBC, University College London, UK.,Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Nagarajan Muthialu
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Martin J Elliott
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Richard J Hewitt
- Tracheal Team, Great Ormond Street Hospital, London, UK.,Department of Otolaryngology, Great Ormond Street Hospital, London, UK
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6
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Gruszka A, Sachweh JS, Schnoering H, Tenbrock K, Muehler EG, Laschat M, Vazquez-Jimenez JF. Aortopexy offers surgical options for a variety of pathological tracheal conditions in paediatric patients. Interact Cardiovasc Thorac Surg 2017; 25:589-594. [DOI: 10.1093/icvts/ivx163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/12/2017] [Indexed: 11/12/2022] Open
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7
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Bergeron M, Cohen AP, Cotton RT. The Management of Cyanotic Spells in Children with Oesophageal Atresia. Front Pediatr 2017; 5:106. [PMID: 28555179 PMCID: PMC5430373 DOI: 10.3389/fped.2017.00106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/25/2017] [Indexed: 11/21/2022] Open
Abstract
Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation. Although this decrease may be transient and benign, it may also be indicative of a severe underlying problem that requires immediate intervention. Children with oesophageal atresia (OA) are at risk for a number of coexisting conditions that may trigger cyanotic spells. This current article will focus on the management of cyanotic spells both in children with innominate artery compression and those with tracheomalacia.
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Affiliation(s)
- Mathieu Bergeron
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aliza P Cohen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robin T Cotton
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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8
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Arcieri L, Serio P, Nenna R, Di Maurizio M, Baggi R, Assanta N, Moschetti R, Noccioli B, Mirabile L, Murzi B. The role of posterior aortopexy in the treatment of left mainstem bronchus compression. Interact Cardiovasc Thorac Surg 2016; 23:699-704. [DOI: 10.1093/icvts/ivw209] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 11/14/2022] Open
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Bairdain S, Zurakowski D, Baird CW, Jennings RW. Surgical Treatment of Tracheobronchomalacia: A novel approach. Paediatr Respir Rev 2016; 19:16-20. [PMID: 27237407 DOI: 10.1016/j.prrv.2016.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 04/13/2016] [Indexed: 11/19/2022]
Abstract
Tracheobronchomalacia, as a whole, is likely misdiagnosed and underestimated as a cause of respiratory compromise in pediatric patients. Currently, there is no standardized approach for the overall evaluation of pediatric tracheobronchomalacia (TBM) and the concept of excessive dynamic airway collapse (EDAC); no grading score for the evaluation of severity; nor a standardized means to successfully approach TBM and EDAC. This paper describes our experience standardizing the approach to these complex patients whose backgrounds include different disease etiologies, as well as a variety of comorbid conditions. Preoperative and postoperative evaluation of patients with severe TBM and EDAC, as well as concurrent development of a prospective grading scale, has allowed us to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments. Long-term, continued collection of patient characteristics, surgical technique, complications, and outcomes must be collected given the overall heterogeneity of this particular population.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115; Department of Anesthesia, Boston Children's Hospital, Boston MA 02115
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston MA 02115
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA 02115.
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10
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Bairdain S, Smithers CJ, Hamilton TE, Zurakowski D, Rhein L, Foker JE, Baird C, Jennings RW. Direct tracheobronchopexy to correct airway collapse due to severe tracheobronchomalacia: Short-term outcomes in a series of 20 patients. J Pediatr Surg 2015; 50:972-7. [PMID: 25824437 DOI: 10.1016/j.jpedsurg.2015.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Tracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea's anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM. METHODS The records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar's test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient. RESULTS Twenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5 months (range, 0.5-38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p=0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p=0.01), lower trachea (p<0.001), and right bronchus (p=0.04). CONCLUSION The use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Jason Smithers
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas E Hamilton
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lawrence Rhein
- Department of Pulmonology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Christopher Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell W Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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11
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Leung L, Chung PHY, Wong KKY, Tam PKH. Management of tracheobronchial obstruction in infants using metallic stents: long-term outcome. Pediatr Surg Int 2015; 31:249-54. [PMID: 25616564 DOI: 10.1007/s00383-015-3666-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Tracheobronchial obstruction, although uncommon in the pediatric age group, remains a challenging problem. We review the long-term outcome of endoscopic metallic stenting in infants with tracheobronchial obstruction. MATERIALS AND METHODS Medical records of all pediatric surgical patients who underwent tracheobronchial metallic stenting in our center were reviewed retrospectively from 1996 to 2014. Patients' demographic data, including etiology, associated anomalies and nature of obstruction were reviewed. Outcome measures include complications such as re-stenosis, granulation tissue, stent migration, fractured stent, maximal tracheal diameter achieved, weaning of ventilator and growth at interval follow-up. RESULTS Twelve balloon-expandable metallic stents were placed in the trachea (n = 10) and/or bronchi (n = 2) of 5 patients with a median age of 13 months (range 5-30 months). Etiology of the airway obstruction included congenital tracheal stenosis (n = 4), giant cervical and superior mediastinal lymphatic malformation with tracheobronchomalacia (n = 1). Seven complications were reported (3 patients developed granulation tissue, 2 patients had re-stenosis, 1 stent migrated, 1 stent fractured). All patients survived and were in good condition with a median follow-up of 16 years (range 11-18 years). Three patients weaned off ventilator and oxygen. CONCLUSIONS Endoscopic stenting with metallic stent has satisfactory long-term outcome in treating infants with tracheobronchial obstruction.
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Affiliation(s)
- Ling Leung
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, Hong Kong
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12
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Anterior Tracheal Suspension for Tracheobronchomalacia in Infants and Children. Ann Thorac Surg 2014; 98:1246-53. [DOI: 10.1016/j.athoracsur.2014.05.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/27/2014] [Accepted: 05/05/2014] [Indexed: 12/20/2022]
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13
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Arnaud AP, Rex D, Elliott MJ, Curry J, Kiely E, Pierro A, Cross K, Coppi PD. Early Experience of Thoracoscopic Aortopexy for Severe Tracheomalacia in Infants After Esophageal Atresia and Tracheo-esophageal Fistula Repair. J Laparoendosc Adv Surg Tech A 2014; 24:508-12. [DOI: 10.1089/lap.2013.0376] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexis P. Arnaud
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Dean Rex
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Martin J. Elliott
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Cardiothoracic Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Joe Curry
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Edward Kiely
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Agostino Pierro
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Surgery Unit, UCL Institute of Child Health, London, United Kingdom
| | - Kate Cross
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
| | - Paolo De Coppi
- General Paediatric Surgery Department, Great Ormond Street Hospital, NHS Foundation Trust, London, United Kingdom
- Surgery Unit, UCL Institute of Child Health, London, United Kingdom
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14
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Jennings RW, Hamilton TE, Smithers CJ, Ngerncham M, Feins N, Foker JE. Surgical approaches to aortopexy for severe tracheomalacia. J Pediatr Surg 2014; 49:66-70; discussion 70-1. [PMID: 24439583 DOI: 10.1016/j.jpedsurg.2013.09.036] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to determine the outcomes among three different surgical approaches for performing an aortopexy to treat severe tracheomalacia (STM). METHODS A retrospective review was performed for all patients who underwent an aortopexy by pediatric surgeons at a single institution during 1997-2012. Data collected included details of the operative approaches and clinical results. The data were analyzed using Chi-square and Fisher exact test. RESULTS Forty-one patients underwent an aortopexy. The operation was chosen by the surgeon and not randomized. Exposure was by partial sternotomy (PS) (20), open thoracotomy (12), or thoracoscopic approach (7). Only the PS approach was done by a single team. All groups showed improvement in work of breathing, prevention of severe respiratory distress, and acute life threatening events. These effects were more dramatic for the PS group, especially regarding oxygen and/or ventilator dependence and the ability to undergo tracheostomy decannulation. Among the sixteen patients with failure-to-thrive before successful aortopexy by any technique, ten demonstrated significant improvement in their growth (p=0.025). The recurrence rate for the thoracoscopic approach was 38%, and there were no recurrences in the partial sternotomy and the thoracotomy groups, 38% vs 0% vs 0%, p=0.005. Simultaneous bronchoscopy was utilized more commonly in the PS group compared to the thoracotomy and thoracoscopic group, 95% vs 62% vs 38%. CONCLUSIONS In this series, the partial sternotomy technique had the most reliable resolution of symptoms and no recurrence requiring reoperation. The PS approach to STM has the technical advantages of an improved exposure with equal access to the vessels over the right and left mainstem bronchi, as well as the trachea and a more specific elevation of the arteries, including suspension of the pulmonary arteries and trachea itself when desirable. Simultaneous bronchoscopy during aortopexy and an experienced team also likely contribute to improved outcomes. The variations in populations, follow-up, and use of continuous intraoperative bronchoscopy, however, make firm conclusions difficult.
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Affiliation(s)
- Russell W Jennings
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA.
| | - Thomas E Hamilton
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - C Jason Smithers
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Neil Feins
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - John E Foker
- Department of General Surgery and Esophageal Atresia Treatment Program, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA; University of Minnesota Medical School, Minneapolis, MN, USA
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Abstract
Tracheomalacia is a rare condition characterized by weakness of tracheobronchial cartilaginous bridges. Severe weakness results in tracheal collapse during inspiration, obstructing normal airflow. Tracheomalacia may also be associated with esophageal atresia, tracheoesophageal fistula, and gastroesophageal reflux. Aortopexy is an established surgical procedure for treatment of severe tracheomalacia. A 2-month-old boy was scheduled for aortopexy. He had already undergone repair of tracheoesophageal fistula and had failed multiple attempts at extubation. Intraoperative flexible fiberoptic bronchoscopy was performed to guide the amount and direction of aortopexy for assuring the most effective tracheal decompression. Since tracheomalacia is best assessed in a spontaneously breathing patient, it was an anesthetic challenge to maintain an adequate depth of anesthesia while allowing the patient to breathe spontaneously. Throughout the intraoperative period, SpO2 remained ≥96%. Following the procedure, the trachea was extubated and patient was able to breathe normally.
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Affiliation(s)
- Shruti Kumar
- Department of Anaesthesiology, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India
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Torre M, Carlucci M, Speggiorin S, Elliott MJ. Aortopexy for the treatment of tracheomalacia in children: review of the literature. Ital J Pediatr 2012; 38:62. [PMID: 23110796 PMCID: PMC3502176 DOI: 10.1186/1824-7288-38-62] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 10/04/2012] [Indexed: 11/10/2022] Open
Abstract
Abstract Severe tracheomalacia presents a significant challenge for Paediatricians, Intensivists, Respiratory Physicians, Otolaryngologists and Paediatric Surgeons. The treatment of tracheomacia remains controversial, but aortopexy is considered by most to be one of the best options. We conducted a review of the English literature relating to aortopexy. Among 125 papers, 40 have been included in this review. Among 758 patients (62% males) affected with tracheomalacia, 581 underwent aortopexy. Associated co-morbidities were reported in 659 patients. The most frequent association was with oesophageal atresia (44%), vascular ring or large vessel anomalies (18%) and innominate artery compression (16%); in 9% tracheomalacia was idiopathic. The symptoms reported were various, but the most important indication for aortopexy was an acute life-threatening event (ALTE), observed in 43% of patients. The main preoperative investigation was bronchoscopy. Surgical approach was through a left anterior thoracotomy in 72% of patients, while median approach was chosen in 14% and in 1.3% a thoracoscopic aortopexy was performed. At follow-up (median 47 months) more than 80% of the patients improved significantly, but 8% showed no improvement, 4% had a worsening of their symptoms and 6% died. Complications were observed in 15% of patients, in 1% a redo aortopexy was deemed necessary. In our review, we found a lack of general consensus about symptom description and evaluation, indications for surgery, though ALTE and bronchoscopy were considered by all an absolute indication to aortopexy and the gold standard for the diagnosis of tracheomalacia, respectively. Differences were reported also in surgical approaches and technical details, so that the same term “aortopexy” was used to describe different types of procedures. Whatever approach or technique was used, the efficacy of aortopexy was reported as high in the majority of cases (more than 80%). A subgroup of patients particularly delicate is represented by those with associated gastro-esophageal reflux, in whom a fundoplication should be performed. Other treatments of tracheomalacia, particularly tracheal stenting, were associated with a higher rate of failure, severe morbidity and mortality. Non english abstract La tracheomalacia severa rappresenta una sfida per Pediatri, Intensivisti, Pneumologi, Otorinolaringoiatri, Chirurghi Pediatri. Il trattamento della tracheomalacia è tuttora controverso. L’aortopessi è considerata da molti la migliore opzione terapeutica. Abbiamo condotto una revisione della letteratura di lingua inglese su tale argomento. Di 125 lavori, 40 sono stati inclusi nella revisione. Tra 758 pazienti (62% maschi) affetti da tracheomalacia, 581 sono stati sottoposti ad aortopessi tra il 1968 e il 2008. In 659 pazienti alcune comorbidità erano presenti. L’associazione più frequente era con l’atresia esofagea (44%), l’anello vascolare o un’anomalia dei grossi vasi (18%), la compressione da parte dell’arteria innominata (16%); nel 9% la tracheomalacia era idiopatica. I sintomi riportati sono stati variabili, ma l’indicazione più importante all’aortopessi sono stati eventi di ALTE, osservati nel 43% dei pazienti. Lo studio diagnostico preoperatorio principale è stato la broncoscopia. L’approccio chirurgico è avvenuto attraverso una toracotomia anteriore sinistra nel 72% dei pazienti, mentre un approccio mediano è stato scelto nel 14% e nell’1.3% dei casi è stato eseguito un approccio toracoscopico. Al follow-up (mediana di 47 mesi) la maggioranza dei pazienti sono migliorati significativamente, ma l’8% di essi non è migliorato, il 4% è peggiorato e il 6% è morto. Complicazioni sono state riportate nel 15% dei pazienti, nell’1% un nuovo intervento di aortopessi è stato necessario. In questa revisione abbiamo trovato che non c’è un consenso generale sulla valutazione e sulla descrizione dei sintomi, sulle indicazioni chirurgiche ed esami preoperatori, anche se le ALTE e la broncoscopia venivano considerate rispettivamente un’indicazione assoluta all’aortopessi e il “gold standard” diagnostico per la tracheomalacia. Venivano riportate differenze negli approcci chirurgici e nei dettagli tecnici, e lo stesso termine di aortopessi veniva usato per indicare diverse procedure chirurgiche. In ogni caso, indipendentemente dall’approccio o tecnica utilizzati, l’efficacia dell’aortopessi veniva riportata come elevata nella maggioranza dei casi (più dell’80%). Un sottogruppo di pazienti particolarmente delicato è rappresentato da quelli con reflusso gastroesofageo associato, nei quali sarebbe indicata una fundoplicatio. Altri trattamenti della tracheomalacia, quali stent tracheale, sembrano gravati da una maggiore percentuale di insuccessi, morbidità severa e mortalità.
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Affiliation(s)
- Michele Torre
- Paediatric Surgery, G, Gaslini Institute, Genova, Italy.
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17
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Abstract
BACKGROUND Tracheomalacia, a disorder of the large airways where the trachea is deformed or malformed during respiration, is commonly seen in tertiary paediatric practice. It is associated with a wide spectrum of respiratory symptoms from life-threatening recurrent apnoea to common respiratory symptoms such as chronic cough and wheeze. Current practice following diagnosis of tracheomalacia includes medical approaches aimed at reducing associated symptoms of tracheomalacia, ventilation modalities of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), and surgical approaches aimed at improving the calibre of the airway (airway stenting, aortopexy, tracheopexy). OBJECTIVES To evaluate the efficacy of medical and surgical therapies for children with intrinsic (primary) tracheomalacia. SEARCH METHODS The Cochrane Airways Group searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group's Specialised Register, MEDLINE and EMBASE databases. The Cochrane Airways Group performed the latest searches in March 2012. SELECTION CRITERIA All randomised controlled trials (RCTs) of therapies related to symptoms associated with primary or intrinsic tracheomalacia. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from the included study independently and resolved disagreements by consensus. MAIN RESULTS We included one RCT that compared nebulised recombinant human deoxyribonuclease (rhDNase) with placebo in 40 children with airway malacia and a respiratory tract infection. We assessed it to be a RCT with overall low risk of bias. Data analysed in this review showed that there was no significant difference between groups for the primary outcome of proportion cough-free at two weeks (odds ratio (OR) 1.38; 95% confidence interval (CI) 0.37 to 5.14). However, the mean change in night time cough diary scores significantly favoured the placebo group (mean difference (MD) 1.00; 95% CI 0.17 to 1.83, P = 0.02). The mean change in daytime cough diary scores from baseline was also better in the placebo group compared to those on nebulised rhDNase, but the difference between groups was not statistically significant (MD 0.70; 95% CI -0.19 to 1.59). Other outcomes (dyspnoea, and difficulty in expectorating sputum scores, and lung function tests at two weeks also favoured placebo over nebulised rhDNase but did not reach levels of significance. AUTHORS' CONCLUSIONS There is currently an absence of evidence to support any of the therapies currently utilised for management of intrinsic tracheomalacia. It remains inconclusive whether the use of nebulised rhDNase in children with airway malacia and a respiratory tract infection worsens recovery. It is unlikely that any RCT on surgically based management will ever be available for children with severe life-threatening illness associated with tracheomalacia. For those with less severe disease, RCTs on interventions such as antibiotics and chest physiotherapy are clearly needed. Outcomes of these RCTs should include measurements of the trachea and physiological outcomes in addition to clinical outcomes.
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Affiliation(s)
- Vikas Goyal
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane,
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18
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Aortopexy as treatment for tracheo-bronchomalacia in children: an 18-year single-center experience. Pediatr Crit Care Med 2011; 12:545-51. [PMID: 21263370 DOI: 10.1097/pcc.0b013e3182070f6f] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To define the factors influencing the outcome of aortopexy as management of tracheo-bronchomalacia. DESIGN A retrospective, single-center, observational, cohort study. SETTINGS Surgical services in a tertiary care hospital. PATIENTS One hundred five children who underwent an aortopexy for tracheo-bronchomalacia between 1990 and 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Comorbidity (categorized into three groups), surgical approach, and location of malacia were reviewed and analyzed in relation to mortality, need for a second intervention, complications, time to extubation after surgery, intensive care unit stay, and clinical improvement. Median age at surgery was 24 wks (1 wk-541 wks). Two surgical approaches were used: median sternotomy (n = 46) and left anterior parasternal (n = 59). Long-term (>2 yrs) follow-up was available for 73 patients (median = 7.0 yrs [2-18 yrs]); 73% were asymptomatic, 18% had minor symptoms, and 9% needed either ventilation or tracheostomy. The overall mortality rate was 9%, of which one-third was airway-related. Multivariable analysis revealed that major comorbidities were a significant risk factor both for mortality and the need for further procedures (re-do surgery, tracheostomy, internal stents) in contrast to surgical approach and involvement of the bronchus. Intensive care unit stay and days of ventilation after surgery were also significantly higher in patients with major comorbidities. CONCLUSIONS Aortopexy proved to be an effective treatment for most cases of tracheo-bronchomalacia, but major comorbidity was associated with an adverse outcome. Our data suggest that aortopexy should be considered in most cases of severe tracheo-bronchomalacia.
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20
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Fayon M, Donato L. Trachéobronchomalacie de l’enfant : de l’abstention à l’interventionnel. Arch Pediatr 2010; 17:97-104. [DOI: 10.1016/j.arcped.2009.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 09/01/2009] [Accepted: 09/22/2009] [Indexed: 11/30/2022]
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21
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Perger L, Kim HB, Jaksic T, Jennings RW, Linden BC. Thoracoscopic Aortopexy for Treatment of Tracheomalacia in Infants and Children. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S249-54. [DOI: 10.1089/lap.2008.0161.supp] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lena Perger
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Heung B. Kim
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Tom Jaksic
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Russell W. Jennings
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Bradley C. Linden
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
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22
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Abdel-Rahman U, Simon A, Ahrens P, Heller K, Moritz A, Fieguth HG. Aortopexy in Infants and Children—Long-term Follow-up in Twenty Patients. World J Surg 2007; 31:2255-9. [PMID: 17876663 DOI: 10.1007/s00268-007-9221-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Aortopexy has become an established surgical procedure for the treatment of tracheomalacia (TM) in infants and children. The aim of the present study was to evaluate the clinical outcome and respiratory function after aortopexy in the long term. METHODS Between 1992 and 2006, 20 patients (6 female, 14 male) with TM were treated by bronchoscopically monitored pexis of the aorta via a right anterior thoracotomy. Patient age ranged from 4 months to 11 years (mean: 29 months). Five infants had previous surgery of esophageal atresia or tracheo-esophageal fistulae, and five other patients were operated on for gastroesophageal reflux. Postoperative tidal expiratory flow (TEF25%) was compared to age-related values. RESULTS Mean follow-up was 7.8 years (range: 13 months to 10.7 years). There was no early or late mortality. Most patients (n = 16) showed immediate and permanent relief of symptoms. Compared to corresponding age groups, median TEF25% was slightly but not significantly decreased after aortopexy (p = 0.15). In one patient a re-aortopexy was necessary. Another patient experienced recurrent tracheo-esophageal fistula 3 years after aortopexy. CONCLUSIONS The bronchoscopically guided aortopexy is an efficient and simple method in the surgical treatment of TM in infants and children. The follow-up data in this series of 20 patients showed improvement of respiratory function and permanent relief of symptoms in the long term.
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Affiliation(s)
- Ulf Abdel-Rahman
- Department of Thoracic and Cardiovascular Surgery, Theodor-Stern-Kai 7, Johann Wolfgang Goethe-University, D-60590 Frankfurt/Main, Germany.
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23
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Abstract
PURPOSE Aortopexy is the accepted operative treatment for severe and localized tracheomalacia (TM). The standard surgical approach involves a left anterior thoracotomy, often under bronchoscopic control. We report the results of aortopexy in 28 children with severe and localized TM; 12 had a left lateral muscle-sparing approach and one had a thoracoscopic aortopexy. METHODS Retrospective review of patient notes was performed to note the indications, investigation findings, and postoperative course after aortopexy. RESULTS The median age at aortopexy was 5 months. The indications included acute life-threatening events in 22, failure to extubate in 5, and recurrent pneumonia in 1. Fifteen had associated esophageal atresia and 13 had primary TM. Symptoms of TM were abolished in 26 of the 28 patients after aortopexy. CONCLUSIONS Aortopexy is a safe and reliable procedure to treat localized intrathoracic TM presenting with acute life-threatening events. It is important to exclude associated problems such as vascular rings and to ensure that the tracheomalacic portion is segmental and does not significantly involve the main bronchi. The lateral muscle-sparing thoracotomy provides good access and is more cosmetic than the standard anterior approach. We would attempt the thoracoscopic approach in older infants and children.
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Affiliation(s)
- Sumit Dave
- Department of Paediatric Surgery, Sydney Children's Hospital, Randwick NSW 2031, Australia.
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24
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Abstract
BACKGROUND Tracheomalacia, a disorder of the large airways where the trachea is deformed or malformed during respiration is commonly seen in tertiary paediatric practice. It is associated with a wide spectrum of respiratory symptoms from life threatening recurrent apnea to common respiratory symptoms such as chronic cough and wheeze. Current practice following diagnosis of tracheomalacia include medical approaches aimed at reducing associated symptoms of tracheomalacia, ventilation modalities of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) and, surgical approaches aimed at improving the caliber of the airway (airway stenting, aortopexy, tracheopexy). OBJECTIVES To evaluate the efficacy of medical and surgical therapies for children with intrinsic (primary) tracheomalacia. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. The latest searches were performed in Feb 2005. SELECTION CRITERIA All randomised controlled trials of therapies related to symptoms associated with primary or intrinsic tracheomalacia. DATA COLLECTION AND ANALYSIS Results of searches were reviewed against pre-determined criteria for inclusion. No eligible trials were identified and thus no data were available for analysis. MAIN RESULTS No randomised controlled trials (RCTs) that examined therapies for intrinsic tracheomalacia were found. Eight of the more recent (last 11 years) non randomised controlled trials reported a benefit from the various surgical interventions. The success was however not universal and in some studies severe adverse events occurred. AUTHORS' CONCLUSIONS There is currently an absence of evidence to support any of the therapies currently utilised for management of intrinsic tracheomalacia. It is unlikely that any RCT on surgically based management will ever be available for children with severe life threatening illness associated with tracheomalacia. For those with less severe disease, RCTs are clearly needed. Outcomes of these RCTs should include measurements of the trachea and physiological outcomes in addition to clinical outcomes.
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Affiliation(s)
- I B Masters
- Royal Children's Hospital, Respiratory Medicine, Herston Rd, Herston, Brisbane, Queensland, Australia 4029.
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Weber TR, Keller MS, Fiore A. Aortic suspension (aortopexy) for severe tracheomalacia in infants and children. Am J Surg 2002; 184:573-7; discussion 577. [PMID: 12488172 DOI: 10.1016/s0002-9610(02)01054-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tracheomalacia with anterior great vessel compression is a common disorder in infants and children, which can lead to life-threatening airway occlusion. In this study, a large number of patients underwent anterior aortopexy to provide a more normal distal airway. METHODS Thirty-two infants and children with tracheomalacia associated with esophageal atresia-tracheoesophageal fistula (18), vascular ring (8), abnormal innominate artery takeoff (4), and primary (2) were evaluated with bronchoscopy, magnetic resonance imaging, and pulmonary functions. Aortopexy was accomplished through left thoracotomy and suture fixation of the aorta and innominate artery to the posterior sternum. RESULTS Intraoperative bronchoscopy showed marked improvement in airway caliber and rigidity, and no patients had further obstructive episodes. Forced expiratory volume improved from 52% +/- 4% of predicted to 82% +/- 3%. CONCLUSIONS Aortopexy is a simple procedure for the treatment of distal tracheomalacia that is immediately effective and provides permanent relief of obstructive episodes.
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Affiliation(s)
- Thomas R Weber
- Department of Surgery, Division of Pediatric Surgery and Pediatric Cardiovascular Surgery, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd., MO 63104, USA.
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26
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Abdel-Rahman U, Ahrens P, Fieguth HG, Kitz R, Heller K, Moritz A. Surgical treatment of tracheomalacia by bronchoscopic monitored aortopexy in infants and children. Ann Thorac Surg 2002; 74:315-9. [PMID: 12173806 DOI: 10.1016/s0003-4975(02)03642-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aortopexy has become an established surgical procedure for the treatment of severe tracheomalacia (TM) in infancy. However, postoperative outcome may be improved by intraoperative bronchoscopic control of the aortopexy. METHODS Between 1992 and 2000, 16 infants and children (2 female, 14 male) with TM were treated by pexis of the aorta via a right (15 patients) or left (1 patient) anterior thoracotomy. Patients age ranged from 4 to 122 months (mean, 26 mon). Three infants had previous surgery for esophagus atresia and tracheoesophageal fistula. Another four patients were operated for gastroesophageal reflux. In all cases, the aortopexy was monitored intraoperatively by bronchoscopy. Respiratory function was verified for each patient by comparing pre- and postoperative tidal expiratory flow values (TEF 25% in ml/sec). RESULTS Mean follow-up was 36 months (range, 2 to 60 mo). There was no intraoperative or postoperative mortality. 13 patients showed permanent relief of symptoms. Postoperative median TEF 25% increased significantly compared with preoperative values (81 ml/sec vs. 56 ml/sec; p = 0.016). In one patient repeat aortopexy was necessary. CONCLUSIONS Aortopexy through a right anterior thoracotomy is an efficient and feasible method in the surgical treatment of TM in infancy and, therefore, can improve postoperative respiratory function. Intraoperative bronchoscopy is advantageous.
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Affiliation(s)
- Ulf Abdel-Rahman
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany.
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