Clinical Experience with 30 Bridging Bronchus Patients with Airway Stenosis and Congenital Heart Disease

The indications and surgical techniques for airway stenosis (AS) repair among patients with bridging bronchus (BB) and congenital heart disease (CHD) have not been fully established. We sought to provide our experience with tracheobronchoplasty in a large series of BB patients with AS and CHD. Eligible patients were retrospectively enrolled from June 2013 to December 2017 and were followed up to December 2021. Epidemiological, demographic, clinical, imaging, surgical management, and outcome data were obtained. 5 tracheobronchoplasty techniques including 2 novel modified ones were performed. We included 30 BB patients with AS and CHD. Tracheobronchoplasty was indicated in them. 27 (90%) patients underwent tracheobronchoplasty. But 3 (10%) refused AS repair. 4 subtypes of the BB and 5 main sites of AS were identified. 6 (22.2%) cases, including one death, had severe postoperative complications associated with being underweight at surgery, preoperative mechanical ventilation, and more types of CHD. 3 cases were lost to follow-up. 18 (78.3%) of the survivors remained asymptomatic, and 5 (21.7%) had stridor, wheezing, or polypnea after exercise. 2 patients out of the three who did not undergo airway surgery died, and the one survivor had a poor quality of life. Good outcomes can be achieved in BB patients with AS and CHD who undergo proper tracheobronchoplasty techniques guided by specified criteria, but severe postoperative complications should be well managed.

Bronchoscopy findings in children with congenital lung and lower airway abnormalities

Congenital lung and lower airway abnormalities are rare, but they are an important differential diagnosis in children with respiratory diseases, especially if the disease is recurrent or does not resolve. The factors determining the time of presentation of congenital airway pathologies include the severity of narrowing, association with other lesions and the presence or absence of congenital heart disease (CHD). Bronchoscopy is required in these cases to assess the airway early after birth or when intubation and ventilation are difficult or not possible. Many of these conditions have associated abnormalities that must be diagnosed early, as this determines surgical interventions. It may be necessary to combine imaging and bronchoscopy findings in these children to determine the correct diagnosis as well as in operative management. Endoscopic interventional procedures may be needed in many of these conditions, ranging from intubation to balloon dilatations and aortopexy. This review will describe the bronchoscopic findings in children with congenital lung and lower airway abnormalities, illustrate how bronchoscopy can be used for diagnosis and highlight the role of interventional bronchoscopy in the management of these conditions.

Treatment of long-segment congenital tracheal stenosis with congenital cardiovascular defects in infancy

OBJECTIVES

This study aims to evaluate the outcomes of simultaneous repair for infants with long-segment congenital tracheal stenosis (LSCTS) with congenital cardiovascular defects (CCD).

METHODS

We retrospectively reviewed the clinical data of infants aged less than 1 year with LSCTS and CCD who underwent simultaneous repair at Children's Hospital of Chongqing Medical University from January 2020 to March 2023. A systematic search of PubMed, Embase, and Cochrane Library for the relevant published studies that reported the simultaneous repair of CTS and CCD in infancy was conducted in March 2023. The inverse variance method of DerSimonian-Laird (D + L) was used for estimate synthesis.

RESULTS

A total of thirteen infants with a mean age of 5.6 ± 3.1 months and a mean weight of 6.4 ± 0.9 Kg underwent slide tracheoplasty with modified procedures and cardiovascular operations. LSCTS was diagnosed in all thirteen patients. Nine infants were ventilator dependent, and four patients were operated on due to persistent wheezing and recurrent respiratory infections. Seven patients underwent pulmonary artery sling repair, and six underwent atrial septal defect repair. All infants were repaired utilizing cardiopulmonary bypass (CPB) support. Significant complications were recorded in three patients. In-hospital deaths were seen in one case. The median tracheal minimum diameter of hospital survivors was significantly larger than the preoperative minimum diameter (p < 0.001). The mean follow-up duration was 17.1 ± 7.1 months. There was no late mortality during the follow-up. Twelve studies were included based on our search strategy. The pooled estimate of mortality in the literature was 10.9% (95%CI, 5.3%-17.7%, I2 = 0). The pooled estimate of airway re-interventions was 28.8% (95%CI, 14.5%-43.2%, I2 = 74%).

CONCLUSIONS

Simultaneous repair of LSCTS and CCD in infancy is safe and effective. Slide tracheoplasty with appropriate technical modifications may be valid for LSCTS repair without significant restenosis and reinterventions.

Successful surgical treatment of congenital tracheal stenosis combined with tracheal bronchus and left pulmonary artery sling: a 10-year single-institution experience

PURPOSE

Radical surgery for congenital tracheal stenosis (CTS) is technically demanding. CTS combined with tracheal bronchus (TB) and pulmonary artery (PA) sling is a particularly challenging condition. We herein report our successfully modified surgical techniques for CTS combined with TB and PA sling.

METHODS

Nine patients treated at our institution from July 2010 to December 2020 for CTS with TB and PA sling were enrolled. The patients' characteristics, operative results, and clinical outcomes were reviewed and analyzed retrospectively.

RESULTS

The mean age at the operation and body weight were 8.0 ± 4.4 months old and 6.5 ± 0.8 kg, respectively. The mean tracheal diameter and length of the stenotic lesion were 3.2 ± 1.0 mm (mean stenosis rate 46.2%) and 25.4 ± 4.9 mm, respectively. All cases were complicated with PA sling at bifurcation stenosis with tracheobronchomalacia. All patients underwent modified posterior-anterior slide tracheoplasty with an inverted Y-shaped incision at the bifurcation and repositioning of the PA. The mean postoperative intubation period was 25.0 ± 32.1 days. There were no major intraoperative or postoperative complications, including hypoxic-ischemic encephalopathy. The mean hospital stay was 92.2 ± 73.4 days. All patients were discharged home without tracheostomy or oxygen support.

CONCLUSION

Our slide tracheoplasty technique for CTS with TB and PA sling achieved excellent outcomes.

LEVEL OF EVIDENCE

Level IV.

Tracheal bronchus and associated pathologies detected by multidetector-row computed tomography in the Vietnamese population

Tracheal bronchus (TB) is a very rare condition, which is often associated with some other pathologies. This study was designed to characterize the morphology of tracheal bronchus and associated pathologies in Vietnamese individuals using multidetector-row computed tomography (MDCT). From August 2016 to February 2021, 16, 64-, and 128-detector-row computed tomography scanners were used to perform chest scans of 3663 patients, of whom 32 had tracheal bronchus and associated pathologies. The prevalence of tracheal bronchus was 0.9%, of which 0.6% were male and 0.3% were female. We found that one patient had bilateral tracheal bronchus (3.1%) and 31 patients (96.9%) had right-sided tracheal bronchus. Most patients (75.1%) had type II tracheal bronchus, whereas 15.6% and 6.2% had type III and type I tracheal bronchus, respectively. The average distance from the tracheal bronchus to the carina was 6.6 ± 6.4 mm. The average diameter of the tracheal bronchus was 4.4 ± 2.2 mm; the group with 2–4-mm tracheal bronchus accounted for the highest proportion (46.9%). Associated pathologies included congenital heart diseases (i.e., valvular heart disease, tetralogy of Fallot, cyanotic congenital heart disease-APSO, and aortic coarctation) (43.7%), stenosis of the bilateral pulmonary arteries (15.6%), absent left pulmonary artery (6.2%), stenosis of the right pulmonary artery (3.1%), anomalous pulmonary venous connection (3.1%), stenosis of the trachea (3.1%), stenosis of the left main bronchus (3.1%), bronchogenic cyst (3.1%), and bronchial atresia (3.1%), and the remaining 12.5% had no abnormalities. tracheal bronchus is a very rare abnormality among Vietnamese and is often accompanied by other pathologies. MDCT with a high spatial resolution and a good tissue contrast, along with contrast agent and appropriate scanning protocols, is efficient in detecting tracheal bronchus and associated pathologies.

A case of successful slide tracheoplasty for long-segment congenital tracheal stenosis in a neonate with a congenital diaphragmatic hernia and Fallot's tetralogy

Background

Congenital tracheal stenosis (CTS) is a rare and life-threatening airway disorder, which is often associated with cardiac malformations. Among them, neonatal symptomatic CTS with cardiac malformations has an extremely poor prognosis. In contrast to cardiac malformation, congenital diaphragmatic hernia (CDH) has rarely been associated with CTS. We report a neonatal case in which slide tracheoplasty and intracardiac repair were performed simultaneously for CTS and Fallot’s tetralogy (TOF).

Case presentation

An infant with left CDH and Fallot's tetralogy (TOF) was born by cesarean section at 38 weeks of gestation. At the time of resuscitation, a 2.5 mm (ID) endotracheal tube could only be inserted just below the vocal cords. After repairing the CDH at 3 days of age, planned extubation was performed at 7 days of age. However, the patient required re-intubation due to life-threatening episodes after 2 days of the extubation. Enhanced CT revealed a long segment CTS from the upper trachea to the right bronchus (length of stenosis: 40 mm, minimum inner diameter: 2 mm). At 24 days of age, veno-arterial extracorporeal membrane oxygenation (ECMO) was introduced due to severe respiratory failure. At 28 days of age, slide tracheoplasty and palliative right ventricular outflow tract reconstruction (RVOTR) was performed with cardiopulmonary bypass (CPB). After tracheoplasty, a 3.5 mm tracheal (ID) tube could be placed in the reconstructed trachea in a patient with CTS. ECMO was completed 7 days after the operation. On the 17th day after the operation, he was extubated successfully. He was discharged 5 months after birth with home oxygenation therapy.

Conclusions

We reported the successful simultaneous correction of slide tracheoplasty and palliative RVOTR for a neonate with CDH. ECMO was used for respiratory management before and after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-022-01422-9.

Reconstruction of the trachea and carina: Surgical reconstruction, autologous tissue transplantation, allograft transplantation, and bioengineering

There have been significant advancements in medical techniques in the present epoch, with the emergence of some novel operative substitutes. However, the treatment of tracheal defects still faces tremendous challenges and there is, as yet, no consensus on tracheal and carinal reconstruction. In addition, surgical outcomes vary in different individuals, which results in an ambiguous future for tracheal surgery. Although transplantation was once an effective and promising method, it is limited by a shortage of donors and immune rejection. The development of bioengineering has provided an alternative for the treatment of tracheal defects, but this discipline is full of ethical controversy and hindered by limited cognition in this area. Meanwhile, progression of this technique is blocked by a deficiency in ideal materials. The trachea together with the carina is still the last unpaired organ in thoracic surgery and propososal of a favorable scheme to remove this dilemma is urgently required. In this review, four main tracheal reconstruction methods, especially surgical techniques, are evaluated, and a thorough interpretation conducted.

Decellularized tracheal scaffolds in tracheal reconstruction: An evaluation of different techniques

In humans, the trachea is a conduit for ventilation connecting the throat and lungs. However, certain congenital or acquired diseases may cause long-term tracheal defects that require replacement. Tissue engineering is considered a promising method to reconstruct long-segment tracheal lesions and restore the structure and function of the trachea. Decellularization technology retains the natural structure of the trachea, has good biocompatibility and mechanical properties, and is currently a hotspot in tissue engineering studies. This article lists various recent representative protocols for the generation of decellularized tracheal scaffolds (DTSs), as well as their validity and limitations. Based on the advancements in decellularization methods, we discussed the impact and importance of mechanical properties, revascularization, recellularization, and biocompatibility in the production and implantation of DTS. This review provides a basis for future research on DTS and its application in clinical therapy.

Surgical management strategy of slide tracheoplasty for infants with congenital tracheal stenosis

OBJECTIVE

The study objective was to evaluate the outcomes of slide tracheoplasty in infancy and identify predictors of adverse outcomes.

METHODS

We retrospectively reviewed the clinical data of infants aged less than 1 year with congenital tracheal stenosis who underwent slide tracheoplasty at a single center from April 2010 to September 2020.

RESULTS

Of 120 infants, 71.7% (86/120) had a pulmonary artery sling and 37.5% (45/120) had simultaneous intracardiac repairs. Additionally, 52.5% (63/120) of the patients had anomalous tracheobronchial arborization, and 17.5% (21/120) had diffuse tracheal stenosis. Six airway reoperations (5%) and 6 deaths (5%) occurred, and the mortality decreased annually. Multivariate analysis revealed that a low body weight, cardiovascular anomalies, and normal tracheobronchial arborization predicted a longer intubation duration. Univariate analysis revealed that a low body weight, preoperative invasive ventilation, a long cardiopulmonary bypass time, and granulation tissue were associated with death. After surgery, 26 patients had dysphagia, 24 of whom resumed oral feeding during follow-up. Ninety-two patients underwent chest computed tomography reexamination, and the trachea diameter had increased significantly from 2.32 ± 0.72 mm to 5.46 ± 1.24 mm. Nineteen and 29 patients underwent spirometry before and after surgery, respectively, and showed improvements in ventilation function, with the ratio of time to peak tidal expiratory flow to total expiratory time and ratio of volume to peak tidal expiratory flow to total expiratory volume values significantly improved from 19.80% (interquartile range, 16.90-23.80) and 23.10% (interquartile range, 21.10-25.90) to 26.80% (interquartile range, 21.20-34.40) and 30.20% (interquartile range, 25.00-34.50), respectively (P < .05).

CONCLUSIONS

A tailored individual management strategy of slide tracheoplasty in infancy facilitates favorable clinical outcomes. Close postoperative follow-up and long-term functional evaluations including clinical symptoms and pulmonary function are still needed.

Combination of slide tracheoplasty and side-to-side bronchoplasty for complex congenital tracheobronchial stenosis

Congenital tracheal stenosis is a rare but serious condition with high mortality and morbidity. We present a 6-month-old patient with complex congenital tracheal stenosis involving the trachea, carina and right bronchus intermedius, which was corrected with a combination of slide tracheoplasty and side-to-side bronchoplasty.

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.

Outcome of congenital tracheal stenosis in children over two decades in a national cardiothoracic surgical unit

OBJECTIVE

To assess the outcomes of congenital tracheal stenosis among children.

MATERIALS AND METHODS

A retrospective review of all children who underwent surgical repair of congenital tracheal stenosis reviewing charts, operative notes, echocardiograms, CT and MRI data from January 2002 to February 2019.

RESULTS

Twenty-six children underwent surgical treatment for tracheal stenosis. The median age was 3 months (range 0.3-35 months) and the median weight was 4.7 kg (range 2.5-13 kg) at the time of surgical intervention. Stridor was the most common presenting symptom in 17 patients (65% of patients). Twenty-one patients (81%) had concurrent cardiac anomalies, with pulmonary arterial sling being the most common, present in nine patients (34%). Extracorporeal life support was utilised in seven patients (27%) pre-operatively. Laryngeal release was required in 16 patients. In 7 patients an end-to-end anastomosis was performed, in 18 patients slide tracheoplasty, and 1 patient had a double slide tracheoplasty. The median cardiopulmonary bypass time was 106 minutes (range 25-255 minutes). The median cross-clamp time was 30 minutes (range 5-67 minutes). The median post-operative duration of ventilation was 5 days (range 0.5-16 days). The median ICU length of stay was 12.5 days (range 2-60 days). There were three hospital mortalities with 88% survival. One patient only required reintervention with balloon dilation. Twenty-two patients (85%) remained symptom-free on median follow-up at 7.6 years (range 0.2-17 years). Two patients since 2017 had 3D printed tracheas produced from CT imaging to assist surgical planning.

CONCLUSION

Congenital tracheal stenosis can be managed effectively with excellent outcomes and 3D printed models assist in planning the optimal surgical intervention.

The bridging bronchus: A comprehensive review of a rare, potentially life-threatening congenital airway anomaly associated with cardiovascular defects

The bridging bronchus is a rare congenital airway anomaly in which the right upper lobe of the lung is supplied by the right main bronchus while the right lower lobe, and often the right middle lobe is supplied by an aberrant bronchus arising from the left main bronchus. The aberrant bronchus crosses (bridges) the lower part of the mediastinum, hence the term bridging bronchus (BB). This potentially life-threatening condition, usually accompanied by diffuse or focal airway stenosis, commonly presents with signs and symptoms related to large airway obstruction, such as respiratory distress, apnea, wheezing, stridor, and recurrent respiratory tract infections. Diagnosis of the BB is often challenging because the associated signs and symptoms mimic those of common conditions such as bacterial and viral bronchiolitis, bronchial asthma, cystic fibrosis, and foreign body aspiration. The BB is also often accompanied by congenital cardiovascular anomalies, including left pulmonary artery sling, atrial, and ventricular septal defects, tetralogy of Fallot, patent ductus arteriosus, and coarctation of the aorta. Patients presenting with the above signs and symptoms who are not responsive to standard treatment modalities, and have accompanying cardiovascular congenital anomalies should, therefore, be investigated for the BB. Herein, we review the anatomy, embryology, clinical presentation, differential diagnosis, imaging techniques and surgical management of the BB.

Spanish multicentre study on morbidity and pathogenicity of tracheal bronchus in children

Tracheal bronchus (TRB) has been generally considered an anatomical variant of the tracheobronchial tree without a precise pathological effect. Its prevalence is estimated to be between 0.2% to 3% of all children undergoing bronchoscopy and scientific information has been limited to case reports or small case series. Our working hypothesis was that TRB could trigger by itself recurrent or persistent respiratory symptoms. The objective of this retrospective and multicentre study of children with a diagnosis of TRB, coming from the main paediatric pulmonology units of Spain, was to determine the anatomical and clinical characteristics, including comorbidities, of TRB in childhood and their impact in the patients' clinical outcomes. One hundred thirty-three patients from 13 institutions were included in the study. Mean diagnostic age was 3.4 years and flexible bronchoscopy was the initial diagnostic method in 85% of cases. All TRB were located on the right wall of the trachea: 76% in the lower third and 24% in the carina. The most common clinical manifestations were obstructive bronchitis (53.3%) and recurrent pneumonia (46.6%), usually affecting the right upper lobe. Regarding associated anomalies, 33% had tracheomalacia, 32% congenital cardiovascular malformations, 28% gastroesophageal reflux, 22.5% congenital tracheal stenosis, and 8.3% Down syndrome. This series appears to be the most extensive published to date addressing this topic and, according to our data, TRB does not appear to be a mere incidental finding but is more likely linked to a wide range of congenital anomalies and contributes by itself to the recurrent respiratory symptomatology that these children exhibit.

3D-bioprinted tracheal reconstruction: an overview

Congenital tracheomalacia and tracheal stenosis are commonly seen in premature infants. In adulthood, are typically related with chronic obstructive pulmonary disease, and can occur secondarily from tracheostomy, prolong intubation, trauma, infection and tumors. Both conditions are life-threatening when not managed properly. There are still some surgical limitations for certain pathologies, however tissue engineering is a promising approach to treat massive airway dysfunctions. 3D-bioprinting have contributed to current preclinical and clinical efforts in airway reconstruction. Several strategies have been used to overcome the difficulty of airway reconstruction such as scaffold materials, construct designs, cellular types, biologic components, hydrogels and animal models used in tracheal reconstruction. Nevertheless, additional long-term in vivo studies need to be performed to assess the efficacy and safety of tissue-engineered tracheal grafts in terms of mechanical properties, behavior and, the possibility of further stenosis development.

Tracheal Stenosis and Congenital Heart Disease in Trisomy 21

Tracheal rings (TR) are rare, congenital cartilaginous defect of the upper airway and are usually due to complete or near complete circumferential cartilaginous tracheal rings, with variable degrees of tracheal stenosis (TS) and shortening. Chromosomal anomalies like trisomy 21 are characteristically associated with a wide range of upper airway anomalies including TS and congenital heart disease (CHD). However, the overall prevalence of severe forms of TS is rare and reported in 1.2% of all CHD patients. Herein, we present a rare association of severe TS due to complete tracheal rings in a trisomy 21 patient with CHD and the challenges in the management.

Clinical outcomes after tracheoplasty in patients with congenital tracheal stenosis in 1997-2014

BACKGROUND

Mortality and morbidity of congenital tracheal stenosis (CTS) remain high. The aim of this study was to determine the factors predicting 12-month survival and 2-month successful extubation after tracheoplasty in patients with CTS.

METHODS

Retrospective chart reviews were conducted in patients with CTS undergoing tracheoplasty at a single institution between 1997 and 2014. Patients' characteristics at disease onset and tracheoplasty were summarized. Twelve-month survival rate and 2-month extubation rate without tracheotomy after tracheoplasty were analyzed.

RESULTS

We reviewed 81 patients' records. Multivariate analysis for 12-month survival revealed that older age (>2 months, hazard ratio [HR]: 0.08, 95% confidence interval [CI]: 0.02-0.36) or heavier body weight (>4.4 kg, HR: 0.13, 95% CI: 0.02-0.73) at tracheoplasty was a predictive factor for survival. Body weight at tracheoplasty (>8.2 kg, HR: 3.83, 95% CI: 1.88-7.79), preoperative balloon dilatation (HR: 0.30, 95% CI: 0.12-0.78), and carina involvement (HR: 0.36, 95% CI: 0.19-0.69) were predictive factors for successful extubation.

CONCLUSIONS

Although CTS management is individualized, age or body weight at tracheoplasty needs to be considered and assessed for survival, as well as preoperative balloon dilatation, and carina involvement for successful extubation.

LEVELS OF EVIDENCE

Level III.

Selection of cuffed endotracheal tube for children with congenital heart disease based on an ultrasound-based linear regression formula

It remains to be discovered whether a formula predicting the subglottic transverse diameter measured by ultrasound (SGD_formula) for the selection of an appropriate endotracheal tube (ETT) for children without congenital heart disease (CHD) is useful for children with CHD. A formula for predicting SGD was established after assessing 60 children ≤ 8 years without CHD and validated on 60 children with CHD. We selected the cuffed ETT size based on the SGD by ultrasound (SGD_ultra). Subsequently, the fit of the ETT cuff in 60 children with CHD was examined via air-leak test. The maximum allowed difference between the SGD_formula and the ETT size that fit was 0.2 mm. The agreement among and accuracy of SGD_ultra, SGD_formula, and the ETT used in children was analyzed. For children without CHD, we adopted a linear formula, given by SGD_formula (mm) = 0.4 × age + 5.3. For children with CHD, allometric formula was adopted, given by SGD_formula (mm) = 5.4 × age^0.18. A stronger agreement exists between SGD_ultra and ETT size compared to that between SGD_formula and ETT size. And the mean bias (SGD_formula-ETT size and SGD_ultra-ETT size) was 0.21 mm (95% confidence interval, - 0.59 to 1.01 mm) and 0.00 mm (- 0.79 to 0.84 mm). For the CHD group, the ultrasound-based method yielded a 78% success rate of ETT size choice, while the formula-based method permitted an appropriate ETT size in only 32% of subjects (P < 0.001). Our analysis showed that measuring the SGD_ultra was more accurate in predicting the correct OD of the ETT in children with CHD undergoing cardiovascular surgery, based on the correlation and agreement with ETT OD.

Restoring tracheal defects in a rabbit model with tissue engineered patches based on TGF-β3-encapsulating electrospun poly(l-lactic acid-co-ε-caprolactone)/collagen scaffolds

Long segment tracheal stenosis often has a poor prognosis due to the limited availability of materials for tracheal reconstruction. Tissue engineered tracheal patches based on electrospun scaffolds and stem cells present ideal solutions to this medical challenge. However, the established engineering process is inefficient and time-consuming. In our research, to optimize the engineering process, core-shell nanofilms encapsulating TGF-β3 were fabricated as scaffolds for tracheal patches. The morphological and mechanical characteristics, degradation and biocompatibility of poly(l-lactic acid-co-ε-caprolactone)/collagen (PLCL/collagen) scaffolds with different compositions (PLCL:collagen 75:25, 50:50 and 25:75, respectively) were comparatively evaluated to determine the preferable compositional ratio. Then the chondrogenesis-inducing potential is investigated, and tracheal patches based on electrospun scaffolds and bone marrow mesenchymal stem cells (BMSCs) were constructed to restore tracheal defects in rabbit models. The results indicated that core-shell scaffolds with a PLCL/collagen proportion of 75:25 were eligible for tracheal patches. The stable and sustained release of TGF-β3 from scaffolds could efficiently promote the chondrogenic differentiation of BMSCs and shorten the incubation time. Tracheal integrity was well maintained for 2 months after restoration; meanwhile, re-epithelialization also achieved. In conclusion, TGF-β3-encapsulating core-shell electrospun scaffolds with a PLCL/collagen proportion of 75:25 could be used to optimize engineering process of tracheal patches.

Bronchial Mismatch as a Predictor of Respiratory Failure After Congenital Tracheal Stenosis Repair

BACKGROUND

The purpose of this study was to identify predictors of postoperative respiratory failure after surgical tracheoplasty for congenital tracheal stenosis.

METHODS

Between February 2011 and April 2017, 16 infants underwent congenital tracheal stenosis repair. Preoperative computed tomography evaluation of the trachea and mainstem bronchi was performed. The primary outcome was midterm freedom from postoperative respiratory failure defined as persistent need for mechanical ventilation or surgical tracheobronchial reoperation. Bronchial mismatch, defined as [1 - (smaller bronchus diameter / larger bronchus diameter)] × 100, was analyzed in relation to the primary outcome.

RESULTS

Median age was 106 days (range, 1 to 406) and median weight was 5.3 kg (range, 2.6 to 8 kg). Four patients were neonates (25%) and 6 had genetic abnormalities (37.5%). There were no early nor late deaths. Median ventilation time was 5.5 days (range, 3 to 45). Mean follow-up time was 2.2 years (range, 0.1 to 4.5). Four patients with bronchial mismatch greater than 20% had postoperative respiratory failure (p = 0.002). Two of them underwent tracheostomy and were discharged with ventilation home care support. One underwent successful reoperation consisting of bilateral bronchial plasty with autologous cartilage rib grafts, and the other underwent successful right bronchial and tracheal reconstruction. One patient with bilateral bronchial hypoplasia underwent slide tracheoplasty associated with preemptive bilateral bronchial plasty and made a full recovery.

CONCLUSIONS

Surgical treatment of congenital tracheal stenosis in neonates and infants portends a good outcome. Bronchial mismatch greater than 20% can identify a subset of patients at increased risk for surgical reintervention and chronic respiratory failure. Slide tracheoplasty with preemptive bronchial reconstruction may prevent postoperative respiratory failure.

Tissue-engineered trachea from a 3D-printed scaffold enhances whole-segment tracheal repair

Long segmental repair of trachea stenosis is an intractable condition in the clinic. The reconstruction of an artificial substitute by tissue engineering is a promising approach to solve this unmet clinical need. 3D printing technology provides an infinite possibility for engineering a trachea. Here, we 3D printed a biodegradable reticular polycaprolactone (PCL) scaffold with similar morphology to the whole segment of rabbits' native trachea. The 3D-printed scaffold was suspended in culture with chondrocytes for 2 (Group I) or 4 (Group II) weeks, respectively. This in vitro suspension produced a more successful reconstruction of a tissue-engineered trachea (TET), which enhanced the overall support function of the replaced tracheal segment. After implantation of the chondrocyte-treated scaffold into the subcutaneous tissue of nude mice, the TET presented properties of mature cartilage tissue. To further evaluate the feasibility of repairing whole segment tracheal defects, replacement surgery of rabbits' native trachea by TET was performed. Following postoperative care, mean survival time in Group I was 14.38 ± 5.42 days, and in Group II was 22.58 ± 16.10 days, with the longest survival time being 10 weeks in Group II. In conclusion, we demonstrate the feasibility of repairing whole segment tracheal defects with 3D printed TET.

Surgical intervention strategies for congenital tracheal stenosis associated with a tracheal bronchus based on the location of stenosis

PURPOSE

The aim of this study was to determine the appropriate surgical intervention strategies for congenital tracheal stenosis (CTS) associated with a tracheal bronchus based on the location of stenosis.

METHODS

The medical records of 13 pediatric patients with CTS associated with a tracheal bronchus at a single institution between January 2006 and December 2015 were retrospectively reviewed.

RESULTS

Type 1: tracheal stenosis above the right upper lobe bronchus (RULB) (n = 1). One patient underwent slide tracheoplasty and was successfully extubated. Type 2: tracheal stenosis below the RULB (n = 7). Tracheal end-to-end anastomosis was performed before 2014, and one patient failed to extubate. Posterior-anterior slide tracheoplasty was performed since 2014, and all three patients were successfully extubated. Type 3: tracheal stenosis above the RULB to the carina (n = 5). One patient underwent posterior-anterior slide tracheoplasty and was successfully extubated. Two patients with left-right slide tracheoplasty and another two patients with tracheal end-to-end anastomosis for the stenosis below the RULB could not be extubated.

CONCLUSION

Tracheal end-to-end anastomosis or slide tracheoplasty can be selected for tracheal stenosis above the RULB according to the length of stenosis. Posterior-anterior slide tracheoplasty appears feasible for tracheal stenosis below the RULB or above the RULB to the carina.