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Thierry B, Arakelian L, Denoyelle F, Larghero J, Wurtz A. Full circumferential human tracheal replacement: a systematic review. Eur J Cardiothorac Surg 2024; 66:ezae269. [PMID: 38984816 DOI: 10.1093/ejcts/ezae269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/14/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024] Open
Abstract
Full Circumferential Tracheal Replacement (FCTR) is a surgical challenge, indicated in rare cases of extensive tracheal resection, with no consensus on surgical technique or materials. A systematic review according to PRISMA guidelines was carried out from 2000 to 2022 to identify cases of FCTR, to compare surgical indications, the nature of the tracheal substitutes and their immunological characteristics, surgical replacement techniques and vascularization. Thirty-seven patients, including five children, underwent FCTR surgery using 4 different techniques: thyrotracheal complex allograft (n = 2), aorta (n = 12), autologous surgical reconstruction (n = 19), tissue-engineered decellularized trachea (n = 4). The mean follow-up was 4 years. Of the 15 deceased patients, 10 died of the progression of the initial pathology. For the majority of the teams, particular care was given to the vascularization of the substitute, in order to guarantee long-term biointegration. This included either direct vascularization via vascular anastomosis, or an indirect technique involving envelopment of the avascular substitute in a richly vascularized tissue. Stent placement was standard, except for autologous surgical reconstructions where tracheal caliber was stable. Internal stents were frequently complicated by granulation and stenosis. Although epithelial coverage is essential to limit endoluminal proliferation and act as a barrier, fully functional ciliated airway epithelium did not seem to be necessary. In order to facilitate future comparisons, a standardized clinical trial, respecting regulatory constraints, including routine follow-up with tracheal biomechanics assessment and scheduled biopsies could be proposed. It would help collecting information such as dynamics and mechanisms of tracheal bio-integration and regeneration.
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Affiliation(s)
- Briac Thierry
- Department of Paediatric Otolaryngology - Head and Neck Surgery, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
- Department of biotherapy clinical investigation, INSERM U976, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Lousineh Arakelian
- Department of biotherapy clinical investigation, INSERM U976, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
- Department of cell therapy, Hôpital St Louis, AP-HP, Paris, France
| | - Françoise Denoyelle
- Department of Paediatric Otolaryngology - Head and Neck Surgery, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Jérôme Larghero
- Department of biotherapy clinical investigation, INSERM U976, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
- Department of cell therapy, Hôpital St Louis, AP-HP, Paris, France
| | - Alain Wurtz
- Emis Platform, Limoges University Hospital, Limoges, France
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Tseng WH, Liu EW, Cheng KY, Wee SJ, Lee JJ, Chen HC. Tracheal Replacement Techniques and Associated Mortality: A Systematic Review. Laryngoscope 2024; 134:1517-1522. [PMID: 37916766 DOI: 10.1002/lary.31100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Tracheal replacement is a crucial operation to enhance the quality of life for patients with extensive tracheal lesions. The most suitable surgical techniques for different clinical conditions remain a topic of debate. Through a reviewing of the relevant literature, this study investigated the association between surgical techniques and mortality rate. DATA SOURCES Studies were collected from PubMed, Embase, the Web of Science, the Cochrane Center Register of Controlled Trials, and ClinicalTrials.gov. METHODS This systematic review encompassed literature from the inception of each database to May 10, 2023, focusing on tracheal replacement for patients who underwent circumferential resection of the trachea or partial resection with preservation of the posterior membranous wall. Non-human and non-clinical studies were excluded. RESULTS About 31 studies were included in the assessment comprising a combination of case reports and case series, and 118 patients underwent tracheal replacement through four underlying methodologies, including tracheal allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, or tissue engineering surgery. Each modality exhibits unique advantages and disadvantages, leading to variable outcomes in clinical application. CONCLUSION Tracheal replacement is challenging due to the absence of an ideal substitution or graft material. Despite limited clinical successes observed across various modalities, we believe autologous tissue reconstruction for tracheal replacement has the advantage of broadest indications, low rejection rate, and avoidance of immunosuppressive agents. Future research should focus on achieving tracheal replacement that preserves mucociliary clearance, lateral rigidity, and longitudinal flexibility. LEVEL OF EVIDENCE NA Laryngoscope, 134:1517-1522, 2024.
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Affiliation(s)
- Wen-Hui Tseng
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
| | - En-Wei Liu
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
| | - Kai-Yuan Cheng
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
| | - Shyun-Jing Wee
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
| | - Jian-Jr Lee
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
- College of Medicine, China Medical University, Taichung City, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung City, Taiwan
- College of Medicine, China Medical University, Taichung City, Taiwan
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de Frémicourt K, Wurtz A, Georgescu D, Sarsam M. Extended autologous tracheal replacement by a novel pedicled thoraco-chondro-costal flap: a cadaveric proof of concept. Eur J Cardiothorac Surg 2024; 65:ezae063. [PMID: 38400739 DOI: 10.1093/ejcts/ezae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/21/2023] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES Our aim was to report an anatomic model of an autologous flap based on the internal thoracic blood supply: the pedicled thoraco-chondro-costal flap; and establish the feasibility of various types of extended tracheal replacement with this novel flap, according to a newly proposed topographic classification. METHODS In a cadaveric model, a cervicotomy combined with median sternotomy was performed. The incision was extended laterally to expose the chest wall. The internal thoracic pedicle was freed from its origin down to the upper limit of the delineated flap to be elevated. The perichondria and adjacent periostea were incised longitudinally to remove cartilages and adjacent rib segments, preserving perichondria and periostea. A full-thickness quadrangular chest wall flap pedicled on internal thoracic vessels was then elevated and shaped into a neo conduit to replace the trachea with the pleura as an inner lining. RESULTS Various types of extended non-circumferential and full-circumferential tracheal replacements were achieved with this composite flap. No anastomosis tension was noticed despite the absence of release manoeuvres. CONCLUSIONS This model could represent a suitable autologous tracheal substitute, which is long, longitudinally flexible and eventually transversely rigid. No microsurgical vascular anastomoses are required. The technique is reproducible. The perichondria and periostea would regenerate vascularized neo-cartilaginous rings, potentially decreasing the need for long-term stenting. The inner pleural lining could potentially transform into ciliated epithelium as shown in previous preclinical studies.
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Affiliation(s)
- Kim de Frémicourt
- Department of ENT and Oncological Surgery, Henri Becquerel Anticancer Center, Rouen, 1 Rue d'Amiens, 76038, Rouen, France
| | - Alain Wurtz
- Lille University, 1 Pl. de Verdun, Lille, 59000, France
| | - Dragos Georgescu
- Department of ENT and Oncological Surgery, Henri Becquerel Anticancer Center, Rouen, 1 Rue d'Amiens, 76038, Rouen, France
| | - Matthieu Sarsam
- Department of Thoracic and Cardiac Surgery, Rouen University Hospital, 37 Bd Gambetta, 76000, Rouen, France
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Perryman MC, Kraft SM, Kavookjian HL. Laryngotracheal Reconstruction for Subglottic and Tracheal Stenosis. Otolaryngol Clin North Am 2023:S0030-6665(23)00075-0. [PMID: 37268515 DOI: 10.1016/j.otc.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Laryngotracheal stenosis is the common endpoint for any process that results in the narrowing of the airway at the level of the glottis, subglottis, or trachea. Although endoscopic procedures are effective in opening the airway lumen, open resection and reconstruction can be necessary to reconstitute a functional airway. When resection and anastomosis are insufficient due to extensive length or location of the stenosis, autologous grafts can be used to expand the airway. Future directions in airway reconstruction include tissue engineering and allotransplantation.
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Affiliation(s)
- Mollie C Perryman
- Department of Otolaryngology-Head & Neck Surgery, University of Kansas, The University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3010, Kansas City, KS 66160, USA
| | - Shannon M Kraft
- Department of Otolaryngology-Head & Neck Surgery, University of Kansas, The University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3010, Kansas City, KS 66160, USA
| | - Hannah L Kavookjian
- Department of Otolaryngology-Head & Neck Surgery, University of Kansas, The University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3010, Kansas City, KS 66160, USA.
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Adamo D, Galaverni G, Genna VG, Lococo F, Pellegrini G. The Growing Medical Need for Tracheal Replacement: Reconstructive Strategies Should Overcome Their Limits. Front Bioeng Biotechnol 2022; 10:846632. [PMID: 35646864 PMCID: PMC9132048 DOI: 10.3389/fbioe.2022.846632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
Breathing, being predominantly an automatic action, is often taken for granted. However, respiratory diseases affect millions of people globally, emerging as one of the major causes of disability and death overall. Among the respiratory dysfunctions, tracheal alterations have always represented a primary challenge for clinicians, biologists, and engineers. Indeed, in the case of wide structural alterations involving more than 50% of the tracheal length in adults or 30% in children, the available medical treatments are ineffective or inapplicable. So far, a plethora of reconstructive approaches have been proposed and clinically applied to face this growing, unmet medical need. Unfortunately, none of them has become a well-established and routinely applied clinical procedure to date. This review summarizes the main clinical reconstructive attempts and classifies them as non-tissue engineering and tissue engineering strategies. The analysis of the achievements and the main difficulties that still hinder this field, together with the evaluation of the forefront preclinical experiences in tracheal repair/replacement, is functional to promote a safer and more effective clinical translation in the near future.
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Affiliation(s)
- Davide Adamo
- Interdepartmental Centre for Regenerative Medicine “Stefano Ferrari”, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Galaverni
- Interdepartmental Centre for Regenerative Medicine “Stefano Ferrari”, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Filippo Lococo
- Università Cattolica del Sacro Cuore, Rome, Italy
- Thoracic Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Graziella Pellegrini
- Interdepartmental Centre for Regenerative Medicine “Stefano Ferrari”, University of Modena and Reggio Emilia, Modena, Italy
- Holostem Terapie Avanzate S.r.l., Modena, Italy
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Vernon D, Eytan DF, Hillel A, Boahene K. Vascularized Prelaminated Thermoplastic Bioabsorbable Scaffold in Tracheal Reconstruction. Laryngoscope 2021; 132:550-553. [PMID: 34355794 DOI: 10.1002/lary.29759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/24/2021] [Accepted: 07/10/2021] [Indexed: 11/10/2022]
Abstract
Successful tracheal reconstruction remains a challenging task for the reconstructive surgeon. A variety of techniques have been previously employed, using both autografts and allografts. The authors present a novel method for tracheal reconstruction utilizing a prelaminated fascial flap in conjunction with a bioabsorbable scaffold. Laryngoscope, 2021.
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Affiliation(s)
- Dominic Vernon
- Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Danielle F Eytan
- Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Alexander Hillel
- Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Kofi Boahene
- Department of Otolaryngology and Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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7
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Greaney AM, Niklason LE. The History of Engineered Tracheal Replacements: Interpreting the Past and Guiding the Future. TISSUE ENGINEERING. PART B, REVIEWS 2021; 27:341-352. [PMID: 33045942 PMCID: PMC8390779 DOI: 10.1089/ten.teb.2020.0238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022]
Abstract
The development of a tracheal graft to replace long-segment defects has thwarted clinicians and engineers alike for over 100 years. To better understand the challenges facing this field today, we have consolidated all published reports of engineered tracheal grafts used to repair long-segment circumferential defects in humans, from the first in 1898 to the most recent in 2018, totaling 290 clinical cases. Distinct trends emerge in the types of grafts used over time, including repair using autologous fascia, rigid tubes of various inert materials, and pretreated cadaveric allografts. Our analysis of maximum clinical follow-up, as a proxy for graft performance, revealed that the Leuven protocol has a significantly longer clinical follow-up time than all other methods of airway reconstruction. This method involves transplanting a cadaveric tracheal allograft that is first prevascularized heterotopically in the recipient. We further quantified graft-related causes of mortality, revealing failure modes that have been resolved, and those that remain a hurdle, such as graft mechanics. Finally, we briefly summarize recent preclinical work in tracheal graft development. In conclusion, we synthesized top clinical care priorities and design criteria to inform and inspire collaboration between engineers and clinicians toward the development of a functional tracheal replacement graft. Impact statement The field of tracheal engineering has floundered in recent years due to multiple article retractions. However, with recent advances in biofabrication and tissue analysis techniques, the field remains ripe for advancement through collaboration between engineers and clinicians. With a long history of clinical application of tracheal replacements, engineered tracheas are arguably the regenerative technology with the greatest potential for translation. This work describes the many phases of engineered tracheal replacements that have been applied in human patients over the past 100 years with the goal of carrying forward critical lessons into development of the next generation of engineered tracheal graft.
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Affiliation(s)
- Allison M. Greaney
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Laura E. Niklason
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
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8
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Biswas G, Panchal KB, Jain PV, Manikantan K, Sharan R, Arun P. Fabricating Flaps in the Forearm Prior to Tracheal Reconstruction. Indian J Plast Surg 2020; 54:53-57. [PMID: 33814742 PMCID: PMC8012785 DOI: 10.1055/s-0040-1721522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background The process of reconstruction of tracheal defects is complex and still not optimum. Options range from using staged reconstructions, combining flaps with autologous or alloplastic implants, as well as use of tissue-engineered constructs combined with vascularized tissues which are lined with cell cultures. Staged reconstructions using prelaminated epithelium, and prefabricated flaps, help in reconstruction of this complex structure. Prefabricating the flap at a different site allows for integration of the tissues prior to its transfer. Method This article reports two patients planned for tracheal reconstruction for the purpose of advanced papillary carcinoma of the thyroid invading the trachea. Staged reconstruction using a prefabricated radial artery forearm flap (RAFF) and split rib cartilage was performed. In the second patient, a young girl, a similar construct of the RAFF, prelaminated with buccal mucosa, was performed. However, in the latter case, an intraoperative decision by the head and neck team to limit excision of the trachea sparing the mucosa was taken; the reconstruct in the forearm was redundant and needed to be discarded, replacing the defect with a free superficial circumflex iliac artery perforator (SCIP) flap. Result At 3 years follow-up, both the patients are free of disease, with the construct serving its purpose in the older female.
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Affiliation(s)
- Gautam Biswas
- Department of Plastic and Reconstructive Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Karnav Bharat Panchal
- Department of Plastic and Reconstructive Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Prateek V Jain
- Department of Head and Neck Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Kapila Manikantan
- Department of Head and Neck Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Rajeev Sharan
- Department of Head and Neck Surgery, TATA Medical Center, Kolkata, West Bengal, India
| | - Pattatheyil Arun
- Department of Head and Neck Surgery, TATA Medical Center, Kolkata, West Bengal, India
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Cheng SF, Wu S, Li QP, Sang HY, Fan ZY. Airway reconstruction using decellularized aortic xenografts in a dog model. Organogenesis 2020; 16:73-82. [PMID: 32674702 DOI: 10.1080/15476278.2020.1790273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Tracheal reconstruction after extensive resection remains a challenge in thoracic surgery. Aortic allograft has been proposed to be a potential tracheal substitute. However, clinically, its application is limited for the shortage of autologous aortic segment. Whether xenogeneic aortic biosheets can be used as tracheal substitutes remains unknown. In the present study, we investigated the possibility in dog model. The results show that all dogs were survived without airway symptoms at 6 months after tracheal reconstruction with gently decellularized bovine carotid arteries. In the interior of engrafted areas, grafted patch integrated tightly with the residual native tracheal tissues and tracheal defects in the lumen were repaired smoothly without obvious inflammation, granulation, anastomotic leakage, or stenosis. In addition, histological and scanning electron microscopy examination showed that grafted patches were covered with ciliated columnar epithelium similar to epithelium in native trachea, which indicated successfully re-epithelialization of decellularized bovine carotid arteries in dogs. These findings provide preclinical investigation of xenogeneic aortic biosheets in serving as tracheal substitute in a dog model, which proposes that decellularized biosheets of bovine carotid may be a potential material for bioartificial tracheal graft.
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Affiliation(s)
- Shao-Fei Cheng
- Department of Thoracic-cardiovascular Surgery, Shanghai Jiaotong University Affiliated Sixth Hospital , Shanghai, China
| | - Song Wu
- Department of Thoracic-cardiovascular Surgery, Shanghai Jiaotong University Affiliated Sixth Hospital , Shanghai, China
| | - Qian-Ping Li
- Department of Thoracic-cardiovascular Surgery, Shanghai Jiaotong University Affiliated Sixth Hospital , Shanghai, China
| | - Hong-Yang Sang
- Department of Thoracic-cardiovascular Surgery, Shanghai Jiaotong University Affiliated Sixth Hospital , Shanghai, China
| | - Zheng-Yang Fan
- Department of Thoracic-cardiovascular Surgery, Shanghai Jiaotong University Affiliated Sixth Hospital , Shanghai, China
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Long-Segment Tracheal Reconstruction With Free Radial Forearm Flap Reinforced by Rib Cartilage. Ann Plast Surg 2019; 80:525-528. [PMID: 29489542 DOI: 10.1097/sap.0000000000001399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Long-segment tracheal reconstruction remains a challenge. The ideal tracheal substitute should be an epithelialized tube to prevent stenosis and sufficiently rigid to maintain airflow patency. An autologous technique using a radial forearm free flap reinforced by rib cartilage has been recently described for tracheal reconstruction. We report here two cases of complex tracheal reconstruction with a modification of this technique, which consists of the creation of two independent skin paddles to allow the reconstruction of the trachea and a second adjacent defect (eg, cervical skin, esophagus). Airway patency was achieved with no stenosis, prolonged stenting, fistula, or necrosis after 26 and 44 months, respectively. We suggest that the satisfactory outcome obtained with this modified technique is a valuable option for tracheal and adjacent defect reconstruction without the need for a second flap.
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11
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Jacobson AS, Roden DF, Lee EQ, Most A, Meyers A, Liu C, Levine J. Tracheal replacement revisited: Use of a vascularized tracheal transplant in a porcine model. Laryngoscope 2018; 128 Suppl 6:S1-S9. [DOI: 10.1002/lary.27671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Adam S. Jacobson
- Department of Otolaryngology-Head and Neck Surgery; New York University Langone Medical Center; New York New York
| | - Dylan F. Roden
- Department of Otolaryngology-Head and Neck Surgery; New York University Langone Medical Center; New York New York
| | - Eric Q. Lee
- Department of Otolaryngology-Head and Neck Surgery; New York University Langone Medical Center; New York New York
| | - Allison Most
- Department of Otolaryngology-Head and Neck Surgery; New York University Langone Medical Center; New York New York
| | - Adrienne Meyers
- Cardiovascular Research Foundation; Orangeburg, New York U.S.A
| | - Cheng Liu
- Department of Pathology; New York University Langone Medical Center; New York New York
| | - Jamie Levine
- Department of Plastic and Reconstructive Surgery; New York University Langone Medical Center; New York New York
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12
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Reconstruction of Ovine Trachea with a Biomimetic Composite Biomaterial. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2610637. [PMID: 30417010 PMCID: PMC6207889 DOI: 10.1155/2018/2610637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/08/2018] [Indexed: 02/02/2023]
Abstract
The aim of this study was to evaluate a novel composite material for tracheal reconstruction in an ovine model. A polymer containing various forms of carbon fibers (roving, woven, and nonwoven fabric) impregnated with polysulfone (PSU) was used to create cylindrical tracheal implants, 3 cm in length and 2.5 cm in diameter. Each implant, reinforced with five rings made of PSU-impregnated carbon-fiber roving, had three external layers made of carbon-fiber woven fabric and the inner layer formed of carbon-fiber nonwoven fabric. The inner surface of five implants was additionally coated with polyurethane (PU), to promote migration of respiratory epithelium. The implants were used to repair tracheal defects (involving four tracheal rings) in 10 sheep (9-12 months of age; 40-50 kg body weight). Macroscopic and microscopic characteristics of the implants and tracheal anastomoses were examined 4 and 24 weeks after implantation. At the end of the follow-up period, outer surfaces of the implants were covered with the tissue which to various degree resembled histological structure of normal tracheal wall. In turn, inner surfaces of the prostheses were covered only with vascularized connective tissue. Inner polyurethane coating did not improve the outcomes of tracheal reconstruction and promoted excessive granulation, which contributed to moderate to severe stenosis at the tracheal anastomoses. The hereby presented preliminary findings constitute a valuable source of data for future research on a tracheal implant being optimally adjusted for medical needs.
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13
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Siddiqi S, de Wit R, van der Heide S, Oosterwijk E, Verhagen A. Aortic allografts: final destination?-a summary of clinical tracheal substitutes. J Thorac Dis 2018; 10:5149-5153. [PMID: 30233891 DOI: 10.21037/jtd.2018.07.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The patient population in desperate need for an airway substitute are individuals with long segment tracheal defects that are considered, technically, inoperable. Regardless of the underlying etiology, benign or malignant growing processes, this patient category enters a palliative setting or require tracheal transplantation. Different airway substitutes have been categorized by Grillo as follows; tracheal transplantation, autogenous tissue, non-viable tissue, tissue-engineering and foreign materials. These fields have been explored in the past in animal models and in clinical patients. Research on airway replacement has been exposed to a level of controversies in the past years. The field has been turbulent and apocryphal. In particular, the area of tissue-engineering using stem cells has suffered from a major set-back leaving scientists, clinicians and ethical committees skeptical. Recently, a hopeful study emerged using aortic allografts as tracheal substitutes in patients with airway defects. The initial results seem promising and reliable. The developments of the field at this point seem striking and hopeful. The focus of this review is to shed light on developments in the field of aortic allografts as substitute for tracheal replacement.
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Affiliation(s)
- Sailay Siddiqi
- Department of Cardiothoracic Surgery, Radboud Medical Center, Nijmegen, The Netherlands
| | - Rayna de Wit
- Department of Cardiothoracic Surgery, Radboud Medical Center, Nijmegen, The Netherlands
| | - Stefan van der Heide
- Department of Cardiothoracic Surgery, Radboud Medical Center, Nijmegen, The Netherlands
| | - Egbert Oosterwijk
- Department of Urology, Radboud Medical Center, Nijmegen, The Netherlands
| | - Ad Verhagen
- Department of Cardiothoracic Surgery, Radboud Medical Center, Nijmegen, The Netherlands
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14
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Udelsman B, Mathisen DJ, Ott HC. A reassessment of tracheal substitutes-a systematic review. Ann Cardiothorac Surg 2018. [PMID: 29707495 DOI: 10.21037/acs.2018.01.17.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tracheal substitutes remain an active area of research. For rare patients with large or complex defects that cannot be repaired primarily, replacement of the airway may represent the only treatment option. The present systematic review aims to assess the clinical successes and setbacks of current methods of airway replacement. Methods Systematic review using Medline and PubMed from 01 January 2000 to 01 October 2017 focusing on clinical translation of circumferential or near circumferential (>270°) tracheal substitutes. Studies were identified using key phrases including terms such as "tracheal replacement", "tracheal regeneration", "tracheal transplant", "tracheal tissue engineering", and "tracheal substitution". Animal or non-clinical studies were excluded. Reviews were included if they contained clinical updates. Results Twenty-one studies were included in assessment comprising a mix of case reports, case studies, and a single review with clinical updates on prior studies. Since 2001, 41 patients have undergone a reported circumferential or near circumferential tracheal substitution through four underlying methodologies including allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, and tissue engineered reconstruction. Each modality has unique advantages and disadvantages with varying success in clinical application. Conclusions The need for tracheal substitution remains a difficult clinical problem without an ideal prosthetic or graft material. While various modalities have had limited clinical success, further laboratory work is necessary before tracheal substitutes can become widely adopted, especially in the case of tissue engineered conduits, which have been setback by premature clinical translation.
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Affiliation(s)
- Brooks Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald C Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Udelsman B, Mathisen DJ, Ott HC. A reassessment of tracheal substitutes-a systematic review. Ann Cardiothorac Surg 2018; 7:175-182. [PMID: 29707495 DOI: 10.21037/acs.2018.01.17] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Tracheal substitutes remain an active area of research. For rare patients with large or complex defects that cannot be repaired primarily, replacement of the airway may represent the only treatment option. The present systematic review aims to assess the clinical successes and setbacks of current methods of airway replacement. Methods Systematic review using Medline and PubMed from 01 January 2000 to 01 October 2017 focusing on clinical translation of circumferential or near circumferential (>270°) tracheal substitutes. Studies were identified using key phrases including terms such as "tracheal replacement", "tracheal regeneration", "tracheal transplant", "tracheal tissue engineering", and "tracheal substitution". Animal or non-clinical studies were excluded. Reviews were included if they contained clinical updates. Results Twenty-one studies were included in assessment comprising a mix of case reports, case studies, and a single review with clinical updates on prior studies. Since 2001, 41 patients have undergone a reported circumferential or near circumferential tracheal substitution through four underlying methodologies including allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, and tissue engineered reconstruction. Each modality has unique advantages and disadvantages with varying success in clinical application. Conclusions The need for tracheal substitution remains a difficult clinical problem without an ideal prosthetic or graft material. While various modalities have had limited clinical success, further laboratory work is necessary before tracheal substitutes can become widely adopted, especially in the case of tissue engineered conduits, which have been setback by premature clinical translation.
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Affiliation(s)
- Brooks Udelsman
- Division of General Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harald C Ott
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Baujat B, Struk S, Lesnik M, de Crouy Chanel O, Barbut J, Lefevre M, Périé S, Lacau St. Guily J. Fascia Temporalis Free Flap for Cricotracheal Reconstruction: A Novel Approach. Ann Thorac Surg 2017; 104:1040-1046. [DOI: 10.1016/j.athoracsur.2017.02.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/20/2017] [Accepted: 02/24/2017] [Indexed: 11/16/2022]
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Circumferential tracheal replacement: do the benefits warrant the risks? Ann Thorac Surg 2014; 97:1480. [PMID: 24694441 DOI: 10.1016/j.athoracsur.2013.09.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 09/18/2013] [Accepted: 09/30/2013] [Indexed: 11/21/2022]
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Fukunaga Y, Sakuraba M, Miyamoto S, Kayano S, Kurosawa K, Fujiki M, Sakisaka M, Yoshimoto S. One-stage reconstruction of a tracheal defect with a free radial forearm flap and free costal cartilage grafts. J Plast Reconstr Aesthet Surg 2014; 67:857-9. [PMID: 24476705 DOI: 10.1016/j.bjps.2013.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/15/2013] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
Abstract
Reconstructing the trachea is challenging because of its multilayer structure and airway function; multiple procedures are often required. We report a case of one-stage reconstruction for a tracheal defect. The surgery was performed with a free radial forearm flap and free costal cartilage grafts. Air leakage occurred postoperatively but healed without additional surgery. The reconstructed trachea has retained its shape, diameter and airway function for 14 months despite the patient's history of radiotherapy. This one-stage procedure with well-vascularised tissue was successfully used to reconstruct a stable, well-functioning trachea.
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Affiliation(s)
- Yutaka Fukunaga
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan.
| | - Minoru Sakuraba
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan; Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Shimpei Miyamoto
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Shuji Kayano
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Koreyuki Kurosawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Masahide Fujiki
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
| | - Masanobu Sakisaka
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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Prasad KG, Varvares MA, Odell MJ. Single-stage repair of subglottic stenosis using the radial forearm free flap as a vascularized carrier. Head Neck 2011; 32:1579-83. [PMID: 20146329 DOI: 10.1002/hed.21231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We present a case report of a patient with history of subglottic carcinoma who underwent chemoradiation and subsequently developed subglottic stenosis (SGS). METHODS AND RESULTS She was treated with an anterior cricoid split maintained by septal cartilage wrapped in a partially deepithelialized radial forearm free flap (RFFF). To date, with a follow-up of 6 months, the patient has been fully decannulated and has not experienced airway collapse or any other complications. CONCLUSIONS Upper airway reconstruction using a single-stage autogenous cartilage graft wrapped in a vascularized carrier is a real option for those patients with extensive SGS in the setting of an irradiated and devascularized tissue bed.
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Affiliation(s)
- Kumar G Prasad
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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Janssen LM, van Osch GJVM, Li JP, Kops N, de Groot K, Feenstra L, Hardillo JAU. Laryngotracheal reconstruction with porous titanium in rabbits: are vascular carriers and mucosal grafts really necessary? J Tissue Eng Regen Med 2010; 4:395-403. [DOI: 10.1002/term.254] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Remplacement de trachée par reconstructions chirurgicales : état actuel de la recherche. ACTA ACUST UNITED AC 2009; 126:272-7. [DOI: 10.1016/j.aorl.2009.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 10/07/2009] [Indexed: 12/21/2022]
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Fabre D, Singhal S, De Montpreville V, Decante B, Mussot S, Chataigner O, Mercier O, Kolb F, Dartevelle PG, Fadel E. Composite cervical skin and cartilage flap provides a novel large airway substitute after long-segment tracheal resection. J Thorac Cardiovasc Surg 2009; 138:32-9. [DOI: 10.1016/j.jtcvs.2008.11.071] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2008] [Revised: 10/01/2008] [Accepted: 11/09/2008] [Indexed: 10/20/2022]
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Fujiwara T, Nishino K, Numajiri T. Tracheal reconstruction with a prefabricated and double-folded radial forearm free flap. J Plast Reconstr Aesthet Surg 2009; 62:790-4. [DOI: 10.1016/j.bjps.2007.09.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 09/05/2007] [Indexed: 11/27/2022]
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Li X, Wang J, Ni Y, Yan X, Lu Q, Xu H, Cheng Q, Liu K. Bone morphogenetic protein-2 stimulation of cartilage regeneration in canine tracheal graft. J Heart Lung Transplant 2009; 28:285-9. [PMID: 19285622 DOI: 10.1016/j.healun.2008.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 07/16/2008] [Accepted: 12/01/2008] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Graft stenosis is among the most serious post-surgical complications that can occur after tracheal transplantation. Typically, stenosis is caused by resorption of tracheal cartilage. Bone morphogenetic protein-2 (BMP-2) is efficient at stimulating bone or cartilage regeneration. In this study, BMP-2 is tested for its effects on stimulation of cartilage regeneration in tracheal transplantation. METHODS For tracheal autotransplantation, 24 mongrel dogs were divided equally into four groups and BMP-2 was injected between the cartilage rings at doses of 1, 3, 5 or 7 mg. For tracheal allotransplantation, 12 mongrel dogs were divided equally into two groups. One group received 5 mg of BMP-2 per graft, and the other received collagen only as a control. The grafts were harvested after 4 weeks and subjected to pathologic analysis. The diameter of the graft lumen and areas of new cartilage regeneration were measured. RESULTS Regenerated cartilage areas were found in both the injected area and around the perichondrium. The areas of regenerated cartilage, as well as the diameter of the tracheal lumen, increased significantly with increasing concentrations of BMP-2. Five milligrams per milliliter was the most effective dose of BMP-2 in this study. CONCLUSIONS BMP-2 can significantly stimulate cartilage regeneration in tracheal grafts and also can be used to prevent stenosis after tracheal transplantation.
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Affiliation(s)
- Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China.
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Abstract
In this review, we summarize the history of tracheal reconstruction and replacement as well as progress in current tracheal substitutes. In Part 1, we cover the historical highlights of grafts, flaps, tube construction, and tissue transplants and address the progress made in tracheal stenting as a means of temporary tracheal support. This is followed in Part 2 by an analysis of solid and porous tracheal prostheses in experimental and clinical trials. We conclude Part 2 with a summary of recent efforts toward generating a bioengineered trachea. Finally, we provide an algorithm on the spectrum of options available for tracheal replacement.
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Affiliation(s)
- Kristin A Kucera
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas 77555, USA
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Webb BD, Walsh GL, Roberts DB, Sturgis EM. Primary Tracheal Malignant Neoplasms: The University of Texas MD Anderson Cancer Center Experience. J Am Coll Surg 2006; 202:237-46. [PMID: 16427548 DOI: 10.1016/j.jamcollsurg.2005.09.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 09/15/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary malignant neoplasms of the trachea are very rare and data relating to them are limited. This study was conducted to review the presentation, management, and outcomes of primary tracheal cancers at our institution, a large multidisciplinary cancer center. STUDY DESIGN Retrospective chart review was conducted for all patients found to have a pathologic diagnosis of primary tracheal malignancy. RESULTS Since 1945, 74 patients were diagnosed with primary tracheal cancers. Among these, 34 (45.9%) were squamous cell carcinomas, 19 (25.7%) were adenoid cystic carcinomas, and 21 (28.4%) were of other histologic types. Presenting symptoms were most frequently dyspnea (55.4%), hemoptysis (48.6%), cough (41.9%), and hoarseness (35.1%). Most patients (77.3%) were former or current smokers, particularly those with squamous cell carcinoma (93.3%). For the entire group of 74 patients, the 5-year disease-specific mortality rate was 72.9% and the 5-year all-cause mortality rate was 79.3%. Patients who had adenoid cystic carcinoma and those with cervical primaries had better rates of disease-specific and overall survival than others (p = 0.036 and 0.006 for the former patient group and p = 0.006 and 0.030 for the latter patient group). Among patients with incident disease treated at our institution (n = 45), those undergoing primary operation with adjuvant radiotherapy appeared to have better disease-specific and overall survival rates compared with those undergoing primary radiotherapy with or without chemotherapy (p = 0.0002 and 0.0003, respectively). Although those undergoing operation and receiving radiotherapy did better than those undergoing operation alone, the difference was not statistically significant. CONCLUSIONS Primary tracheal cancers are very rare, and our results should be viewed with caution, given that our population comprised a small heterogeneous group treated over a 60-year period. Although squamous cell carcinoma was the most common pathology in smokers, adenoid cystic carcinoma was more prevalent among nonsmokers. Operation with adjuvant postoperative radiotherapy is recommended for most patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Adenoid Cystic/epidemiology
- Carcinoma, Adenoid Cystic/mortality
- Carcinoma, Adenoid Cystic/pathology
- Carcinoma, Adenoid Cystic/therapy
- Carcinoma, Squamous Cell/epidemiology
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/therapy
- Combined Modality Therapy
- Comorbidity
- Female
- Humans
- Male
- Middle Aged
- Neoplasm Staging
- Radiotherapy Dosage
- Radiotherapy, Adjuvant
- Retrospective Studies
- Smoking/epidemiology
- Survival Analysis
- Tracheal Neoplasms/epidemiology
- Tracheal Neoplasms/mortality
- Tracheal Neoplasms/pathology
- Tracheal Neoplasms/therapy
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Affiliation(s)
- Benjamin D Webb
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Ruszymah BHI, Chua K, Latif MA, Hussein FN, Saim AB. Formation of in vivo tissue engineered human hyaline cartilage in the shape of a trachea with internal support. Int J Pediatr Otorhinolaryngol 2005; 69:1489-95. [PMID: 15941595 DOI: 10.1016/j.ijporl.2005.04.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2005] [Accepted: 04/12/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Treatment and management of congenital as well as post-traumatic trachea stenosis remains a challenge in pediatric surgery. The aim of this study was to reconstruct a trachea with human nasal septum chondrocytes by using the combination of biodegradable hydrogel and non-biodegradable high-density polyethylene (HDP) as the internal predetermined shape scaffold. METHODS Human nasal septum cartilage was harvested as excessive tissue after elective septoplasty and digested in 0.6% collagenase II. Chondrocytes were cultured in an equal volume mix of Ham's F12 medium and Dulbecco's modified eagle medium added with 10% fetal bovine serum and basic fibroblast growth factor. After two passages, the cultured chondrocytes were trypsinized and mixed with biodegradable hydrogel Pluronic F127. The chondrocytes-hydrogel admixture was then painted over the HDP as the internal support in a predetermined trachea shape. The composite was then implanted subcutaneously in athymic mice. RESULTS After 8 weeks of in vivo implantation, the tissue engineered trachea constructs were harvested. Macroscopic appearance of the tissue engineered trachea constructs demonstrated that the HDP were 80-90% covered with yellowish glistering cartilage like tissue without any sign of inflammation. The tissue engineered trachea cartilage consisted of evenly spaced lacunae embedded in basophilic matrix and stained red with Safranin-O staining denoting abundant proteoglycans production. Type II collagen gene which was expressed in native cartilage was highly expressed in this tissue engineered trachea cartilage. CONCLUSION We have successfully reconstructed a trachea in vivo with human nasal septum chondrocytes using HDP as the internal support. This construct has the advantage of bio-inert and strength in which both are important properties in tracheal reconstruction.
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Affiliation(s)
- Binti Haji Idrus Ruszymah
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia.
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Laser literature watch. Photomed Laser Surg 2005; 23:233-42. [PMID: 15910194 DOI: 10.1089/pho.2005.23.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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