Elective extracorporeal support for complex tracheal reconstruction in neonates

Abstract

Background Congenital obstructive anomalies of the trachea present unique challenges in reconstruction and perioperative airway management. Complications include anastomotic breakdown, leak and granulation formation related to the complexity of the repair, and difficulties with perioperative airway management. We describe our technique of elective intraoperative and postoperative extracorporeal support to improve surgical exposure and postoperative healing. Methods We have performed complex tracheal reconstructions in 4 newborns (2.2 to 4.3 kg) for long segment tracheal stenosis and complete tracheal rings, diagnosed with bronchoscopy and computerized tomography. Three of the 4 infants had other significant anomalies including complex congenital heart disease, hydrocephalus, encephalomalacia, left lung agenesis, facial anomalies, vertebral anomalies, and hand and hip anomalies. The repairs were performed through a median sternotomy using an extracorporeal membrane oxygenation circuit for support. Venoarterial support was used for the sliding tracheoplasty reconstruction. Extracorporeal membrane oxygenation was converted to venovenous for postoperative “airway rest.” After diuresis, the lungs were reexpanded and the 4 patients were ventilated and removed from extracorporeal membrane oxygenation at 4, 5, 8, and 9 days postoperatively. Bronchoscopy was performed to evaluate the airway. Results All patients had excellent healing of the trachea without granulation tissue. There were no complications of extracorporeal membrane oxygenation support or bleeding issues. All 4 patients survived the surgery and immediate postoperative period with 2 late deaths. The child with congenital heart disease expired after 8 weeks after having hepatorenal failure develop. The child with Goldenhar’s syndrome and a single left lung died after 5 months in the hospital. The other 2 patients survived. Two of the infants required late tracheostomy for facial and laryngeal anomalies. Conclusions Extracorporeal membrane oxygenation provides an excellent environment for complex tracheal reconstruction and promotes postoperative healing by minimizing trauma to the reconstructed airway.