Repair of congenital tracheal stenosis

Slide tracheoplasty for congenital tracheal stenosis: A systematic review

INTRODUCTION

Slide tracheoplasty has become the gold standard surgery for congenital tracheal stenosis (CTS). This condition is rare and the surgery can be challenging and is performed by experienced surgeons in tertiary centers. A few reports involving relatively small cohorts have been published. The aim of this review is to evaluate the post-operative mortality and morbidity of pediatric slide tracheoplasty for CTS.

METHODS

A systematic literature review was performed according to PRISMA guidelines. The Medline and EMBASE databases were screened using a search strategy defined in collaboration with a librarian. We included articles reporting the post-operative mortality rate of slide tracheoplasties for treatment of CTS in children, when at least 10 patients were included.

RESULTS

A total of 932 articles were reviewed, and 15 studies were eligible with a total of 845 patients. The overall post-operative mortality rate was 9.3 %, and most deaths were airway related. The open revision surgery rate after surgery was 2.8 % and the endoscopic revision rate was 27.6 %.

DISCUSSION

This study highlights key factors to consider before the surgery and helps anticipate post-operative follow-up considerations for children with CTS. Several factors were identified as predictors of mortality including young age, weight at the time of surgery and association with lung hypoplasia or aplasia.

CONCLUSION

Although slide tracheoplasty has gained popularity in recent years due to better outcomes, it remains a major surgery with mortality risk and the need for multidisciplinary management.

Impact of Tracheal Arborization and Lung Hypoplasia in Repair of Pulmonary Artery Sling in Combination With Long-Segment Tracheal Stenosis

Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been our standard approach of care for patients with pulmonary artery sling (PAS) and tracheal stenosis. We present our experience, with emphasis on tracheal arborization and hypoplastic lungs; and their impact on long-term outcome of children with PAS and tracheal stenosis. Methods: It is a retrospective comparative study. Data were classified and analyzed based on the type of tracheobronchial arborization and normal versus hypoplastic lungs. Results: Seventy-five children operated between January 1994 and December 2019 (67 with normal lungs and 8 with lung hypoplasia/agenesis) were included. Patients with hypoplastic lungs had higher rates of preoperative ventilation (87.5%), postoperative ventilation (10 vs 8 days, P = .621), and mortality (50% vs 9%, P = .009) compared with those with normal lungs. Nineteen patients had tracheal bronchus (TB) variety and 30 patients had congenital long-segment tracheal stenosis (CLSTS) variety of tracheobronchial arborization. Endoscopic intervention was needed in 47.4% of patients with TB type and 60% with CLSTS type. CLSTS patients had higher rates of preoperative ventilation (60% vs 47.4%, P = .386), longer periods of postoperative ventilation (13 vs 6.5 days, P = .006), and ICU stay (15 vs 11 days, P = .714) compared with TB type. Conclusion: Surgical repair of PAS with tracheal stenosis has good long-term outcomes. All variations of tracheal anatomy can be managed with slide tracheoplasty. Persistence of airway problems requires intervention during follow-up as tracheal stenosis continues to be the Achilles heel.

Pulmonary artery sling: An overview

Pulmonary artery sling is a rare childhood vascular tracheobronchial compression syndrome that is frequently associated with tracheal stenosis. Consequently, neonates or infants may present with critical airway obstruction if there is long segment airway narrowing and complete rings. Rapid diagnosis of this cardiac vascular malformation and evaluation of the extent and severity of airway involvement is essential to plan surgery, typically a slide tracheoplasty to relieve critical airway obstruction. Long term outcome can be excellent following surgical repair of the stenosed airway and reimplantation of the left pulmonary artery. In this review we focus on the embryology, diagnostic workup, airway investigations and management for this rare but challenging congenital condition.

[Tracheobronchial stenting in patients with non-resectable tumors complicated by airway stenosis]

OBJECTIVE

To study the results and efficiency of tracheobronchial stenting in patients with unresectable tumors complicated by stenosis of central airways.

MATERIAL AND METHODS

We analyzed the results of tracheobronchial stenting in 23 patients with unresectable tumors complicated by stenosis of central airways between 2016 and 2021.

RESULTS

Technical and clinical success rate was 100%. No intraoperative complications were noted. Dyspnea regressed in all patients in early postoperative period. Moreover, there was objective improvement in lung ventilation with increase in lung capacity (from 2.1±0.4 to 2.7±0.5 l; p<0.05), forced expiratory volume (from 1.2±0.5 to 1.8±0.4 l; p<0.05), partial pressure of oxygen in arterial blood (from 47±7.4 to 85±6.3 mm Hg; p<0.05) and arterial oxygen saturation (from 86.1±8.2 to 93.1±5.1%; p<0.05). One patient developed massive bleeding due to tumor decay on the 3^rd day after surgery. In 2 patients, stent obturation with a «mucus plug» was observed after 2-3 postoperative days. In 3 months after surgery, 21.8% of patients had disturbances of external respiration accompanied by mild dyspnea due to granulation tissue growth. Stent migration in 3 months after endoscopic stenting was recorded in 1 patient. Three-month mortality was 26.1%.

CONCLUSION

Tracheobronchial stenting is a safe and effective minimally invasive surgical intervention. As a part of palliative care, this procedure improves functional and clinical parameters of pulmonary ventilation and reduces the incidence of complications. Thus, quality of life in patients with unresectable tumors complicated by airway stenosis is improved.

Experimental Tracheal Replacement: Angiogenesis and Null Apoptosis Promote Stenosis

Background

Tracheal replacement is a challenge for thoracic surgeons due to stenosis in the trachea-prosthesis anastomosis. We propose that stenosis occurs due to fibrosis as a result of an abnormal healing process, characterized by an increased expression of wound healing growth factors (vascular endothelial growth factor [VEGF], survivin, and CD31), which promote angiogenesis and decrease apoptosis. We analyzed the immunoreactivity of VEGF, survivin, CD31, and caspase-3 in the development of fibrotic stenosis in prosthetic tracheal replacement.

Methods

Fourteen dogs were operated on group I (n=7) received a 6-ring cervical tracheal segment autograft, while in group II (n=7), a 6-ring segment of the cervical trachea was resected and tracheal continuity was restored with a Dacron prosthesis. The follow-up was 3 months. Immunoreactivity studies for VEGF, survivin, CD31, and caspase-3 were performed. A statistical analysis was done using the Wilcoxon signed rank test.

Results

Four animals in group I were euthanized on the 10th postoperative day due to autograft necrosis. Three animals completed the study without anastomotic stenosis. Moderate expression of VEGF (p=0.038), survivin (p=0.038), and CD31 (p=0.038) was found. All group II animals developed stenosis in the trachea-prosthesis anastomotic sites. Microscopy showed abundant collagen and neovascularization vessels. Statistically significant immunoreactive expression of VEGF (p=0.015), survivin (p=0.017), and CD31 (p=0.011) was observed. No expression of caspase-3 was found.

Conclusion

We found a strong correlation between fibrosis in trachea-prosthesis anastomoses and excessive angiogenesis, moderate to intense VEGF, CD31, and survivin expression, and null apoptotic activity. These factors led to uncontrolled collagen production.

Reconstruction of the carina using bronchial autograft: an alternative approach

We report successful engraftment by autologous transplantation of the bronchial wall of the resected specimen in extensive tracheobronchial resection with left pneumonectomy. Since the adenoid cystic carcinoma had spread beyond the carina to the right bronchus, we resected three rings of tracheal cartilage and three rings of left main bronchus cartilage. Reconstruction was performed using the bronchial wall of the resected specimen to relieve tension on the anastomosis. No stricture or recurrence was observed four years after the operation. Further research relating to maximization of blood flow to the reconstructed tissue based on engraftment area and shape is required.

Diagnosis and management of complete tracheal rings with concurrent tracheoesophageal fistula

OBJECTIVE

Characterize patients with complete tracheal rings and tracheoesophageal fistula (TEF) and summarize management options.

METHODS

A systematic review of patients under 18 years of age with complete tracheal rings and TEF was conducted. Authors were contacted for additional patient information and new cases were added. Patients with iatrogenic TEF and tracheal stenosis due to other causes were excluded.

RESULTS

Sixteen patients with a median (IQR) follow-up of 10 months (3-12 months) were identified. All had a distal TEF with complete tracheal rings distal to the TEF. There were 10 (63%) type C esophageal atresia + TEF (EA/TEF), and 1 (6%) type D (5 missing data). Median (IQR) airway diameter was 2 mm (1.5-2.2 mm). Complete tracheal rings were diagnosed prior to TEF repair in 5 (31.3%) patients, after ≥1 failed extubation in 3 (12.5%) patients, and intra-operatively during respiratory distress in 1 patient. Ten patients (62.5%) were intubated with an endotracheal tube and one with a 6 Fr flexible aortic canula (5 missing data). Four patients with an endotracheal tube for TEF repair developed ventilatory problems. Complete tracheal rings were repaired in 9 (56%) patients (8 slide tracheoplasty, 1 pericardial patch) and followed conservatively in 3 (19%). One patient required tracheotomy. Four patients died.

CONCLUSIONS

Complete tracheal rings with concurrent TEF is a rare entity that pose challenges for ventilatory management during operative repair. Bronchoscopy prior to TEF repair is critical to allow for proper preoperative planning.

Congenital tracheal stenosis & associated cardiac anomalies: operative management & techniques

Congenital tracheal stenosis can lead to symptomatic airway obstruction in children and often mandates surgical correction. Over the past half-century, numerous tracheal reconstruction techniques have been developed, including tracheal resection with end-to-end anastomosis (for short-segment complete tracheal stenosis), patch tracheoplasty, slide tracheoplasty, and homograft and autograft augmentation repairs. However, operative management of congenital tracheal stenosis is often complicated by the presence of congenital heart disease, the most common of which is pulmonary artery sling. When present concomitantly, combined repair of both defects is feasible and is currently the preferred approach. Questions have been raised about the optimal timing and sequence of surgery, and some have advocated staged repair for patients with complex associated cardiac lesions. However, evidence from the past two decades suggests that concomitant repair can be performed with excellent results. The current standard of care involves the use of cardiopulmonary bypass to simultaneously repair the tracheal defect using slide tracheoplasty and all associated cardiac anomalies. Advances in operative techniques and extracorporeal circulation, progressive understanding of the pathological basis of combined congenital tracheal and cardiac disease, and a multidisciplinary approach to patient care have all contributed to the successful outcomes seen in the modern era. This article describes the combined surgical correction of tracheal stenosis and double-outlet right ventricle-tetralogy of Fallot type in an infant, provides a detailed step-by-step description for performing a slide tracheoplasty along with various other less favored tracheoplasty techniques, and reviews the current literature discussing such combined repairs.

Tracheal and bronchial stenoses and other obstructive conditions

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

Evolution of Surgical Approaches in the Management of Congenital Tracheal Stenosis

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Tracheobronchial issues in congenital heart disease

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

Management of congenital tracheal anomalies and laryngotracheoesophageal clefts

Congenital obstructions and anomalies of the pediatric airway are rare problems that may be associated with mild symptoms or critical stenoses that may be life threatening in the first few days of life. This review provides an overview of the embryologic development of the airway, different congenital anomalies associated with airway development, and surgical correction that may be associated with good long-term outcome.

Resection of the stenotic segment with individually tailored anastomosis for symptomatic congenital tracheal stenosis in infants

OBJECTIVES

To analyse retrospectively population-based results of congenital tracheal stenosis (CTS) repair in infants in Finland.

METHODS

Data on infants who were operated on for CTS in Helsinki Children's Hospital between August 1988 and May 2013 were analysed retrospectively. Fibreoptic bronchoscopy was performed perioperatively and in follow-up of all the surviving patients. The median follow-up time was 7 (range 1-20) years.

RESULTS

Thirteen infants were operated on for CTS. Resection of the stenotic segment with individually tailored anastomosis was used in 12 patients and slide tracheoplasty in 1 patient. The median age at the operation was 2.9 (range 0.2-19) months. Eight (62%) patients had associated cardiovascular defects, which were corrected during the same operation. The median length of stenosis was 35% (range 25-60%) of the total length of the trachea. The median length of time of postoperative mechanical ventilation was 10 (range 5-19) days. The median length of time of intensive care treatment was 15 (range 7-40) days. One patient died from hypoplastic lung tissue and fibrosis, and multiorgan failure. One patient required reoperation, and 3 other patients received balloon bronchodilatations postoperatively. There was no late mortality. All of the 12 survivors had a good outcome.

CONCLUSION

Resection with individually tailored anastomosis with up to 55% of the stenotic segment of the trachea presented a good long-term outcome.

Pulmonary artery sling with tracheal stenosis

Pulmonary artery sling (PAS) is a rare congenital heart disease in which the left pulmonary artery (LPA) originates from the right pulmonary artery (RPA) and encircles the distal trachea and right mainstem bronchus as it courses between the trachea and esophagus. Typically, patients with PAS have some respiratory symptoms, either due to external tracheal compression that can be corrected by relief of the sling mechanism, or due to severe diffuse tracheal stenosis with complete rings (ring-sling complex). The diagnosis of PAS is optimally made by echocardiography, while bronchoscopy is the key to the assessment of tracheal stenosis. Diagnosis is indication for surgery. Repair using a strategy of median sternotomy, cardiopulmonary bypass, division of the LPA and reimplantation into the main pulmonary artery (MPA), and simultaneous tracheal repair takes preference. Tracheal repair should be considered only in clinically symptomatic patients. The techniques of free tracheal autograft plasty or slide tracheoplasty offer promising results, and the choice of tracheal reconstruction should be guided by the clinical experience of the surgeon. Coexisting intracardiac pathologies are repaired at the same time. Postoperative care requires close multidisciplinary effort to achieve the best long-term result.

Univentricular heart with bridging bronchus and sling left pulmonary artery

A bridging bronchus (BB) is a rare congenital heart anomaly. Frequently, BB also is complicated with congenital cardiac malformation, especially with sling (retrotracheal) left pulmonary artery (SLPA). This report presents a patient who underwent a Norwood procedure for a complex congenital heart disease with BB and SLPA.

Anterior pericardial tracheoplasty for long-segment tracheal stenosis: long-term outcomes

OBJECTIVE

Although several techniques have been described for the treatment of tracheal stenosis, including slide tracheoplasty, tracheal autograft, rib grafting, and use of a pericardial patch, the optimal repair remains controversial because of a lack of long-term follow-up data. The purpose of this study is to examine the long-term results of anterior pericardial tracheoplasty.

METHODS

To assess the long-term outcomes of patients who underwent repair of tracheal stenosis with anterior pericardial tracheoplasty, we reviewed the case histories of 26 consecutive patients (1984-present). All but 5 had long-segment tracheal stenosis with more than 10 complete tracheal rings. Twenty-one had significant cardiac disease, and 10 had their cardiac lesions repaired at the time of their tracheoplasty. The median age was 6 months (range, 2 days-25 years). All patients underwent anterior pericardial tracheoplasty through a median sternotomy during normothermic cardiopulmonary bypass. We have previously described our tracheoplasty technique. An average of 14 tracheal rings (range, 5-22) was divided anteriorly, and a patch of fresh autologous pericardium was used to enlarge the trachea to 1.5 times the predicted diameter for age and weight.

RESULTS

There were 3 hospital deaths (at 1, 2, and 7 months, respectively) and 2 late deaths (at 2 and 13 years postoperatively, respectively). No deaths were related to airway obstruction. Two survivors required tracheostomy postoperatively, one after formation of granulation tissue and stenosis and the other after failure to wean from mechanical ventilation. All survivors remain asymptomatic, with minimal to no evidence of airway obstruction. Median follow-up is 11 years (range, 3 months-22 years).

CONCLUSION

Anterior pericardial tracheoplasty for tracheal stenosis provides excellent results in the majority of patients at long-term follow-up.

Perioperative extracorporeal membrane oxygenation support for critical pediatric airway surgery

Extracorporeal membrane oxygenation (ECMO) has been used for cardiopulmonary support in neonates, infants, and adults. We report the application of ECMO for critical airway surgery when mechanical ventilation cannot provide adequate gas exchange. Three pediatric patients underwent emergency ECMO establishment because of hypercapnia that could not be managed by conventional mechanical ventilation. The pathology included: (1) left pulmonary artery sling with long-segment tracheal stenosis; (2) absence of the right intermediate bronchus and abnormal origin of the right lower bronchus arising from the left main bronchus; (3) right-lung agenesis with long-segment tracheobronchial stenosis. Venoarterial ECMO was established. Before ECMO, the arterial pH values were 7.28, 7.0, and 7.08, and the PaCO2 values were 111.8, 112.0, and 208.7 mmHg for each patient, respectively. After ECMO support, respiratory acidosis was reversed. The patients then underwent surgical intervention. The surgical procedures included: (1) slide tracheoplasty and reimplantation of the left pulmonary artery; (2) resection of the stenotic tracheal segment and reconstruction of the bronchial tree; (3) tracheal dilatation and stent implantation. The ECMO durations were 11, 5, and 16 h, respectively. All patients were successfully weaned off ECMO without complications. In conclusion, ECMO provided adequate ventilation support for patients undergoing critical tracheobronchial reconstruction when conventional mechanical ventilation could not maintain adequate gas exchange.

Repair of long-segment congenital tracheal stenosis

Long-segment tracheal stenosis in infants and small children is difficult to manage and can be life-threatening. A retrospective review of 12 patients who underwent surgery for congenital tracheal stenosis between 1996 and 2004 was conducted. The patients' median age was 3.6 months. All patients had diffuse tracheal stenosis involving 40-61% (median, 50%) of the length of the trachea, which was suspected to be associated with complete tracheal ring. Five patients had proximal bronchial stenosis also. Ten patients had associated cardiac anomalies. Three different techniques were performed; pericardial patch tracheoplasty (n=4), tracheal autograft tracheoplasty (n=6), and slide tracheoplasty (n=2). After pericardial tracheoplasty, there were 2 early and 2 late deaths. All patients survived after autograft and slide tracheoplasty except one who died of pneumonia one year after the autograft tracheoplasty. The duration of ventilator support was 6-40 days after autograft and 6-7 days after slide tracheoplasty. The duration of hospital stay was 13-266 days after autograft and 19-21 days after slide tracheoplasty. Repeated bronchoscopic examinations were required after pericardial and autograft tracheoplasty. These data demonstrate that pericardial patch tracheoplasty show poor results, whereas autograft or slide tracheoplasty gives excellent short- and long-term results.

Management of pediatric tracheal stenosis and tracheomalacia

Tracheal stenosis and malacia are somewhat rare conditions encountered in children and are difficult management problems. Tracheal stenosis, when limited in length, is amenable to resection and re-anastomosis. However, long segment tracheal stenosis occurs most often in infants and often is associated with quite severe symptoms. A variety of surgical options are available for treatment depending, in part, on surgeon's preference and experience. Tracheomalacia is, in some ways, more frustrating to treat because it usually persists after the underlying cause, usually external compression, is eliminated. This chapter will discuss these issues in detail.

Management of congenital tracheal stenosis--using spontaneous ventilation to facilitate cardiopulmonary bypass

We present an unusual case of an infant with life-threatening tracheal stenosis scheduled for repair utilizing cardiopulmonary bypass. After repeated attempts at intubation endtidal CO2 was absent. The child was eventually managed with spontaneous breathing sevoflurane via a facemask. The possible causes of absent endtidal CO2 after intubation are discussed.

Surgical Treatment of Pulmonary Artery Sling and Tracheal Stenosis

BACKGROUND

Pulmonary artery sling is a rare vascular ring and is commonly associated with tracheal stenosis. Symptomatic newborns and infants with these complex lesions have a high mortality rate without surgical intervention. The ideal operation remains controversial, with debate focusing on the need for left pulmonary artery for reimplantation and the technique of tracheal reconstruction.

METHODS

From 1983 to 2003, 14 patients with pulmonary artery sling (mean age, 7 months; range, 6 days to 27 months) underwent repair of pulmonary artery sling alone (6 patients), tracheoplasty alone (1 patient), and pulmonary artery sling repair with tracheoplasty (7 patients). Preoperatively, 7 patients were intubated, 2 had VATER (vertebral, anal, tracheal, esophageal, and radial anomalies) syndrome, and 2 patients had agenesis of the right lung. The left pulmonary artery was reimplanted at the ductal insertion site in 13 patients. One patient had left pulmonary artery translocation. Tracheoplasty employing extracorporeal circulation consisted of autologous pericardial patch (6 patients) or slide tracheoplasty (2 patients). Six patients with pulmonary artery sling and mild tracheal stenosis required only left pulmonary artery reimplantation. Concomitant procedures included closure of atrial septal defect (4 patients), ventricular septal defect (4 patients), and shunt for Fallot's tetralogy (2 patients).

RESULTS

There were 2 hospital deaths (2 of 14;14%) from abdominal sepsis (1) and renal failure (1). Reoperations included diaphragm plication (2), tracheostomy (1), and bronchoscopy with laser resection of granulation tissue (5 patients: 2 slide, 3 pericardium). Follow-up was complete in all patients (mean, 42 months) with 1 late death from fungal sepsis. At follow-up, all left pulmonary artery anastomoses were patent by echocardiography, and no patient has required reoperation for trachea reconstruction.

CONCLUSIONS

These data demonstrate that tracheal repair is not always necessary in the presence of pulmonary artery sling; that agenesis of the right lung is not a contraindication to successful complete repair; and that simultaneous correction of intracardiac defects can be safely performed in selected patients. This study suggests that in newborns and infants, pericardial patch and slide tracheoplasty are effective methods for trachea reconstruction.

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

OBJECTIVE

Long-segment tracheal stenosis is rare, life-threatening, difficult, and expensive to treat. Management remains controversial. A multidisciplinary tracheal team was formed in 2000 to deal with a large number of children with airway problems referred for management. We review the effect of that service, comparing the era before and after the establishment of the multidisciplinary tracheal team.

METHODS

From January 1998 through January 2004, 34 patients with long-segment tracheal stenosis (21 patients with cardiovascular anomalies) underwent surgical intervention. Cardiopulmonary bypass was used in all operations. Before the multidisciplinary tracheal team, pericardial patch tracheoplasty with or without an autograft technique was the preferred method of repair. After the multidisciplinary tracheal team, an integrated care plan preferring slide tracheoplasty was initiated, correcting cardiac lesions simultaneously.

RESULTS

Before the establishment of the multidisciplinary tracheal team, pericardial patch tracheoplasty was performed in 15 of 19 patients. Twelve patients had a suspended pericardial patch tracheoplasty, 2 (17%) of whom died late after the operation. Of 3 patients who had had a simple unsuspended patch, 2 (67%) died early after the operation. Four patients were operated on with the tracheal autograft technique, 2 (50%) dying early in the postoperative period. After multidisciplinary tracheal team formation, in the era between 2001 and 2004, 15 patients were operated on with slide tracheoplasty, and there were 2 (13%) early postoperative deaths. A significant reduction in cost and duration of stay has been shown both in the intensive care unit and the hospital.

CONCLUSION

Our data suggest that a formalized multidisciplinary team approach and a policy of primary slide tracheoplasty are beneficial in the management of children with long-segment tracheal stenosis.

Endoscopy: a must in neonatal respiratory distress

Respiratory distress in a newborn presents both diagnostic and therapeutic dilemmas. Definitive treatment must be preceded by an accurate diagnosis other than in extremes. Complete tracheal rings are a very rare congenital cause of airway obstruction. Unlike other causes of upper airway obstruction, this cannot be relieved by tracheostomy, which may be counterproductive. We report the case of an 8-day-old female baby who presented with respiratory distress and was found to have complete tracheal rings and right pulmonary agenesis. The value of tracheo-bronchoscopy in this case cannot be overstressed.

Tracheal replacement in rabbits with a new composite silicone-metallic prosthesis

A new composite silicone-metallic prosthesis was tested, studying the potential for respiratory epithelial covering over the biocompatible inner lining, in a rabbit survival model. Seven New Zealand White rabbits underwent near-total excision of their trachea and implantation of a sterile prosthesis. After 2 months, they were sacrificed and the prostheses were retrieved. Specimens were fixed and histologically examined for tissue reaction around the prosthesis, at the anastomotic lines, and particularly for the presence or absence of epithelialization of the inner lumen over the biocompatible surface. All rabbits survived the operation. At 2 months, the outer layer of the prosthesis was consistently covered with fibrosis and neutrophils. The inner layer showed necrotic cells and scant re-epithelialization over the biocompatible lining, up to 5 mm beyond the anastomosis, with no evidence of organized respiratory epithelium in the middle sections. The new prosthesis is a viable temporary solution for airway replacement in rabbits. Granulation tissue was not observed at the anastomosis, and re-epithelialization did occur, but failed to achieve full-length luminal covering. The potential for granulation tissue does not yet make this an ideal long-term solution. Improvements in prosthesis design or biocompatibility are required, and need to be re-evaluated before applicability for chronic use.

The management of congenital tracheal stenosis

This paper reviews current concepts and results in the management of congenital tracheal stenosis (CTS). Diagnostic options are considered and the requirements for successful management defined. Chief amongst these is a multi-disciplinary approach with individualised patient management. Severe long-segment CTS represents the biggest challenge to clinicians and the worst problems for affected families. Near-death episodes are frequent in affected infants and some cannot be ventilated and require ECMO. Associated cardiovascular anomalies are frequent. Patients require immediate resuscitation and transfer to a specialist unit. After careful assessment, accurate diagnosis and discussion, primary resection and end-to-end repair with a slide technique should always be the first option, with concomitant repair of associated cardiac anomalies. If this is impossible because of the severity of the lesion, some form of patch tracheoplasty will be indicated. Cardiopulmonary bypass is often required. Patches include pericardium, autograft trachea, carotid artery, cartilage, and allograft trachea. Mortality ranges from 0 to 30% in the literature, which largely comprises single-centre long-term experience. Recurrence is common and can be managed by stenting and tracheal homograft implantation. Long-term quality of life of survivors is little reported but seems good. Physiological data are lacking. To improve results, we suggest a treatment algorithm to rationalise care.

Slide tracheoplasty for the management of complete tracheal rings

BACKGROUND/PURPOSE

Although rare, complete tracheal rings are the most common cause of congenital tracheal stenosis. The last 2 decades have seen an evolution in management, with increasing awareness of the potential advantages of slide tracheoplasty.

METHODS

Between March 2001 and August 2002, 11 children had complete tracheal rings corrected by slide tracheoplasty. Ages ranged from newborn to 15 years, and weight ranged from 1.8 to 57 kg. Length of stenosis ranged from 3 rings to virtually the whole length of the trachea. The most narrow point in the airway varied from less than 1.9 mm to 4.8 mm. Eight children had other congenital anomalies, severe in one child. Most children underwent repair on cardiopulmonary bypass.

RESULTS

Nine children are asymptomatic or minimally symptomatic, although 2 have endoscopic evidence of mild residual tracheal stenosis. One child, who had been unstable pre-operatively, died of multiple organ failure 7 weeks postoperatively. A second child required a tracheotomy for bronchomalacia at 6 months and died at 9 months with tracheotomy tube occlusion. Both children had adequate tracheal repairs. Complications have included lateral tracheal stenosis (the "Figure 8" trachea) and recurrent laryngeal nerve damage.

CONCLUSIONS

Our management of complete tracheal rings has evolved over the last decade, and slide tracheoplasty currently is our preferred surgical approach for tracheal stenosis regardless of the length of narrowing.