Large Tracheal Defects Research Articles

Application of modified spiral tracheoplasty in thyroid carcinoma with trachea invasion: a retrospective analysis of 15 cases

BackgroundTo describe the indications, techniques and preliminary experience of modified spiral tracheoplasty in the reconstruction of large tracheal defect after thyroidectomy.MethodsThe medical records of patients who underwent tracheal torsion to repair large tracheal defects after thyroid carcinoma surgery from January 2019 to January 2022 were retrospectively reviewed. The extent of tracheal defect, duration of tracheal reconstruction, postoperative complications and surgery results were analyzed.ResultsThe duration of tracheal reconstruction was 30–60 min. No postoperative bleeding, incision infection, tracheostomy stenosis occurred. Recurrent laryngeal nerve palsy occurred in 5 patients. All patients were followed up for 24 to 60 months. The 2-year overall survival rate was 100%, the 2-year local control rate of trachea was 100%, and the 2-year tumor-free survival rate was 81.8%.ConclusionThe modified spiral tracheoplasty is a safe and effective method to repair the large defect of trachea after thyroid carcinoma invading the trachea.

Pedicled pericardial patch in tracheal reconstruction in children – Novel technique to provide vascularized tissue for salvaging difficult airways

BackgroundManagement of large central airway defects are often complex. Children who present with these defects have multiple co-morbidities or have had previous surgeries. Surgical options include various tissue cover for these defects without longer term benefits. Vascularized autologous pericardial patch offers a better solution to these defects by providing vascularity and potential for remodelling in future. Methods41 children (M:F of 24:17) were operated for large trachea-bronchial defects between January 2015 and August 2022. The median age of was 12 months with median weight of 8.9 kg (IQR 3.3 kg–17.7 kg) Causes leading to the central tracheal defect include failed repair of previous trachea-oesophageal fistula (TOF) (n = 21) and acquired fistula due to button battery injury (n = 11). Surgical repair consisted of autologous pedicled pericardial patch repair for the airway defect under cardiopulmonary bypass. ResultsThere were two operative deaths related to extensive sepsis and necrosis of reconstructed trachea. Four children had further reoperation with additional patch. Bronchoscopy was used as surveillance in all these children, with use of airway stents (biodegradable stent) in 9 children. The median ventilation time was 8 days, with tracheostomy being needed in 5 for long term support. ConclusionsAutologous pericardial patch is a versatile technique and can be used to salvage large tracheal defects when other method have failed or not feasible. Tracheomalacia at the site of repair could be managed with biodegradable stents. Vascularity and ciliary function of the patch still needs to be evaluated.

Development of tissue-engineered tracheal scaffold with refined mechanical properties and vascularisation for tracheal regeneration.

Introduction: Attempted tracheal replacement efforts thus far have had very little success. Major limiting factors have been the inability to efficiently re-vascularise and mimic the mechanical properties of native tissue. The major objective of this study was to optimise a previously developed collagen-hyaluronic acid scaffold (CHyA-B), which has shown to facilitate the growth of respiratory cells in distinct regions, as a potential tracheal replacement device. Methods: A biodegradable thermoplastic polymer was 3D-printed into different designs and underwent multi-modal mechanical assessment. The 3D-printed constructs were incorporated into the CHyA-B scaffolds and subjected to in vitro and ex vivo vascularisation. Results: The polymeric backbone provided sufficient strength to the CHyA-B scaffold, with yield loads of 1.31-5.17N/mm and flexural moduli of 0.13-0.26MPa. Angiogenic growth factor release (VEGF and bFGF) and angiogenic gene upregulation (KDR, TEK-2 and ANG-1) was detected in composite scaffolds and remained sustainable up to 14 days. Confocal microscopy and histological sectioning confirmed the presence of infiltrating blood vessel throughout composite scaffolds both in vitro and ex vivo. Discussion: By addressing both the mechanical and physiological requirements of tracheal scaffolds, this work has begun to pave the way for a new therapeutic option for large tracheal defects.

Partial decellularization eliminates immunogenicity in tracheal allografts.

There is currently no suitable autologous tissue to bridge large tracheal defects. As a result, no standard of care exists for long-segment tracheal reconstruction. Tissue engineering has the potential to create a scaffold from allografts or xenografts that can support neotissue regeneration identical to the native trachea. Recent advances in tissue engineering have led to the idea of partial decellularization that allows for the creation of tracheal scaffolds that supports tracheal epithelial formation while preserving mechanical properties. However, the ability of partial decellularization to eliminate graft immunogenicity remains unknown, and understanding the immunogenic properties of partially decellularized tracheal grafts (PDTG) is a critical step toward clinical translation. Here, we determined that tracheal allograft immunogenicity results in epithelial cell sloughing and replacement with dysplastic columnar epithelium and that partial decellularization creates grafts that are able to support an epithelium without histologic signs of rejection. Moreover, allograft implantation elicits CD8+ T-cell infiltration, a mediator of rejection, while PDTG did not. Hence, we establish that partial decellularization eliminates allograft immunogenicity while creating a scaffold for implantation that can support spatially appropriate airway regeneration.

Surgical correction of a percutaneous dilatational tracheostomy: A case report.

Introduction and importancePercutaneous dilatational tracheostomy (PDT) has become a routine procedure in intensive care, because of its multiple advantages over surgical tracheostomy (ST).Case presentationWe present the case of a 72-year-old patient with SARS-CoV-2 pneumonia, who received a PDT in the 6th tracheal ring with a lateral puncture of the trachea. This atypical placement of tracheostomy was due to a massive left-pronounced goiter, causing a tracheal shift to the right. To avoid dislocation of the tracheal cannula and prevent recurrent bleeding, surgical revision was decided. After left hemithyroidectomy, oral intubation was temporarily necessary, in order to remove the old tracheostomy. Then suturing of the left lateral tracheal defect and standard ST in the 2nd tracheal cartilage was performed. The patient was successfully weaned and decannulated and his swallowing function remained intact.Clinical discussionIn our case left hemithyroidectomy was necessary, in order to enable an optimal surgical tracheostomy in the 2nd tracheal cartilage. Because mechanical ventilation was carried out proximal to the large tracheal defect after PCT, a secondary closing approach was not an option. The endotracheal cuff was placed above the defect, in order to prevent acute or chronic intraluminal pressure trauma. Postoperative x-ray and bronchoscopy insured the sufficient sealing of the tracheal suturing.ConclusionWe describe an unusual placement of percutaneous dilatational tracheostomy through a thyroid goiter and our approach to perform a correction surgical tracheostomy.

Successful tracheal necrosis management using a pedicle pectoralis flap: A case report

Thyroidectomy is considered an overall low-risk procedure. However, severe life-threatening complications, including tracheal necrosis may occur postoperatively. A 45-year-old male patient was referred to our clinic for papillary thyroid carcinoma surgery. The patient had mediastinitis signs and symptoms seven days after total thyroidectomy. Subsequent imaging demonstrated air leak and with mediastinitis as the primary diagnosis, and the patient underwent reoperation. During the operation, four necrotic tracheal rings were found to be the source of air leak. Due to tissue inflammation and infection, neither primary repair with tracheal resection and anastomosis, nor strap muscle plugging procedure were feasible. Therefore, a pedicle flap derived from the right pectoralis major muscle was transferred to the necrotic trachea. The patient"s clinical condition improved after the operation and subsequent bronchoscopies confirmed healing of trachea. During six-month follow-up, no complications were observed. In conclusion, the technique discussed in the current report shows promising outcomes for reconstructing large tracheal defects in inflammatory conditions where primary repair techniques are not suitable.

A novel reconstruction technique of a tracheal defect in the emergent setting using a thymus flap in a patient with tracheoinnominate artery fistula

BackgroundThere is a very high mortality associated with a tracheoinnominate artery fistula; however, when patients survive, they often require reconstruction of the eroded tracheal defect after the bleeding has been controlled.Case presentationThis is the case of an 83-year-old male with a tracheoinnominate artery fistula who was stabilized in the operating room and underwent repair of his trachea. A novel technique of using the thymus gland as a pedicled flap to repair a large tracheal defect was executed after achieving hemostasis. The patient’s defect was repaired successfully following control of the fistula.ConclusionsWe have shown that the thymus gland can be used successfully as a pedicled flap for repair of a tracheal defect in the setting of a tracheoinnominate artery fistula.

De-epithelialization of porcine tracheal allografts as an approach for tracheal tissue engineering

Replacement of large tracheal defects remains an unmet clinical need. While recellularization of acellular tracheal grafts appeared to be a viable pathway, evidence from the clinic suggests otherwise. In hindsight, complete removal of chondrocytes and repopulation of the tracheal chondroid matrix to achieve functional tracheal cartilage may have been unrealistic. In contrast, the concept of a hybrid graft whereby the epithelium is removed and the immune-privileged cartilage is preserved is a radically different path with initial reports indicating potential clinical success. Here, we present a novel approach using a double-chamber bioreactor to de-epithelialize tracheal grafts and subsequently repopulate the grafts with exogenous cells. A 3 h treatment with sodium dodecyl sulfate perfused through the inner chamber efficiently removes the majority of the tracheal epithelium while the outer chamber, perfused with growth media, keeps most (68.6 ± 7.3%) of the chondrocyte population viable. De-epithelialized grafts support human bronchial epithelial cell (BEAS-2B) attachment, viability and growth over 7 days. While not without limitations, our approach suggests value in the ultimate use of a chimeric allograft with intact donor cartilage re-epithelialized with recipient-derived epithelium. By adopting a brief and partial decellularization approach, specifically removing the epithelium, we avoid the need for cartilage regeneration.

Clinical practice of repair of large tracheal defects with local tension free flaps

Objective: To investigate a simple and practical method for the repair of large tracheal defects. Methods: From April 2015 to October 2017, 10 patients with large tracheal wall defects after thyroid carcinoma underwent two phase repair with cervical tension free flap with modified design. In the longitudinal direction of the leakage, design two pieces of random flap outside the top angle of 45°, respectively, and the side turn double flip flap to repair the leak, outward and upward forming tension, avoid collapse after healing. Results: Large tracheal wall defects in 10 cases were successfully repaired, and normal respiration and language functions were recovered quickly.With following-up of 6-30 months(the medran was 12 months), the airway kept normal ventilation, no recurrence, and 1 patient with pulmonary metastasis had a stable condition. Conclusion: The modified tension free flap can be used for the repair of large defects of trachea with a good efficacy.

A Modular Strategy to Engineer Complex Tissues and Organs.

Currently, there are no synthetic or biologic materials suitable for long‐term treatment of large tracheal defects. A successful tracheal replacement must (1) have radial rigidity to prevent airway collapse during respiration, (2) contain an immunoprotective respiratory epithelium, and (3) integrate with the host vasculature to support epithelium viability. Herein, biopolymer microspheres are used to deliver chondrogenic growth factors to human mesenchymal stem cells (hMSCs) seeded in a custom mold that self‐assemble into cartilage rings, which can be fused into tubes. These rings and tubes can be fabricated with tunable wall thicknesses and lumen diameters with promising mechanical properties for airway collapse prevention. Epithelialized cartilage is developed by establishing a spatially defined composite tissue composed of human epithelial cells on the surface of an hMSC‐derived cartilage sheet. Prevascular rings comprised of human umbilical vein endothelial cells and hMSCs are fused with cartilage rings to form prevascular–cartilage composite tubes, which are then coated with human epithelial cells, forming a tri‐tissue construct. When prevascular– cartilage tubes are implanted subcutaneously in mice, the prevascular structures anastomose with host vasculature, demonstrated by their ability to be perfused. This microparticle–cell self‐assembly strategy is promising for engineering complex tissues such as a multi‐tissue composite trachea.

Tissue engineering of a composite trachea construct using autologous rabbit chondrocytes.

The repair of large tracheal segmental defects remains an unsolved problem. The goal of this study is to apply tissue engineering principles for the fabrication of large segmental trachea replacements. Engineered tracheal replacements composed of autologous cells (neotracheas) were tested in a New Zealand White rabbit model. Neotracheas were formed in the rabbit neck by wrapping a silicone tube with consecutive layers of skin epithelium, platysma muscle, and an engineered cartilage sheet and allowing the construct to mature for 8-12weeks. In total, 28 rabbits were implanted and the neotracheas assessed for tissue morphology. In 11 cases, neotracheas deemed sufficiently strong were used to repair segmental tracheal defects. Initially, the success rate of producing structurally sound neotracheas was impeded by physical disruption of the cartilage sheets during animal handling, but by the end of the study, 15 of 18 neotracheas (83.3%) were structurally sound. Of the 15 structurally sound neotracheas, 11 were used for segmental reconstruction and were left in place for up to 21days. Histological examination showed the presence of variable amounts of viable epithelium, a vascularized platysma flap, and a layer of safranin O-positive cartilage along with evidence of endochondral ossification. Rabbits that had undergone segmental reconstruction showed good tracheal integration, had a viable epithelium with vascular support, and the cartilage was sufficiently strong to maintain a lumen when palpated. The results demonstrated that viable, trilayered, scaffold-free neotracheas could be constructed from autologous cells and could be integrated into native trachea to repair a segmental defect.

Fascia Temporalis Free Flap for Cricotracheal Reconstruction: A Novel Approach

The aim of tracheal reconstruction is to provide an airtight and noncollapsible airway covered with a suitable epithelial lining. To date, no ideal treatment is available for large tracheal defects. We report 4 patients who underwent one-stage reconstruction for a cricotracheal stenosis with a free temporoparietal fascia flap and costal cartilage grafts. Closure of tracheostoma was achieved for all patients. The main advantage of this flap compared with the free radial forearm flap is that it supplies a more suitable lining allowing the reepithelialization process with respiratory epithelium. This one-stage procedure provides a reliable construct to substitute for large tracheal defects, even in areas previously exposed to an operation or radiotherapy.

Repair of large airway defects with bioprosthetic materials

ObjectivePatients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects. MethodsRetrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix. ResultsEight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%). ConclusionsBioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.

Treatment of large tracheal defects after resection: Laryngotracheal release and tracheal replacement.

Resection with direct tracheal or laryngotracheal anastomosis is the standard procedure employed for treatment of benign stenosis or occasionally primary or secondary tracheal malignancy. Literature review. A tracheal anastomosis usually heals without complications provided that the ends being joined are adequately supplied with blood, an atraumatic suturing technique is used, and the anastomosis does not become infected. It is especially important that the anastomosis is not subjected to tension. Various techniques of laryngeal and tracheal release serve to reduce the tension on the anastomosis by mobilizing and reducing the distance between the two segments to be approximated. These techniques can be used in different combinations depending on situation encountered during surgery. In cases where more than 50% of the tracheal length must be excised, prosthetic replacements, autologous tissue transfer and allografts are required. All present various problems. The use of tissue-engineering techniques utilizing autologous stem cells has opened new perspectives for tracheal replacement. Such procedures are still in an experimental state.

Pedicled pericardial patch tracheoplasty as a last-resort repair for acquired and recurrent long-segment tracheal stenosis through resternotomy without CPB

Long-segment stenotic tracheal rings represent a rare but life-threatening cause of respiratory distress. Surgery may be required in an emergency setting, using established techniques and repair materials. In an adult with long-segment tracheal stenosis whose extent was underestimated by conventional diagnostic workup, standard repair materials were unavailable in emergency setting. This case report illustrates a usual surgical technique in a bail out situation, using autologous Pericardium to patch a large tracheal defect. Although several techniques have been described for the treatment of tracheal stenosis, including slide tracheoplasty, tracheal autograft and rib cartilage grafting, here we used a pedicled pericardial patch. The purpose of this case report is to augment pericardial tracheoplasty.

A Large Tracheal Defect Is Not a Contraindication to an Eloesser Flap

A Large Tracheal Defect Is Not a Contraindication to an Eloesser Flap

Replacement of the complete posterior tracheal wall with autologous pericardium and latissimus dorsi flap after esophageal acid burn

Introduction: Reconstruction of large tracheal defects are complex, simply because there are no artificial materials for replacement and autologous tissues have distinctive limitations.

Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae

Tracheo-oesophageal fistula (TOF) is a rare, life-threatening condition. We report our results of surgical treatment and evaluation of the outcome of acquired non-malignant TOF. Twenty-five patients (aged 49 ± 21 years) with TOF were operated on between 2001 and 2011. Tracheo-oesophageal fistula was due to prolonged intubation/tracheostomy (84%), was secondary to other surgery (8%) or trauma (4%) or was idiopathic (4%). The tracheal defect was 2.4 ± 1.3 cm long and was associated with tracheal stenosis in seven (28%) patients. Surgical treatment consisted of direct suturing of the oesophageal defect in two layers (or end-to-end oesophageal resection and anastomosis in one case) associated with tracheal suturing (n = 15; 60%), tracheal resection and anastomosis (n = 8; 32%) or covering of a large tracheal defect by an intercostal muscle flap or by a resorbable patch with muscle apposition (n = 2; 8%). The surgical approach was cervicotomy (n = 14; 56%), cervicotomy plus median sternotomy or split (n = 6; 24%), thoracotomy (n = 4; 16%) or cervicotomy plus sternal spit plus thoracotomy (n = 1; 4%). In 18 (72%) cases a muscular flap was used and in six (24%) a protective tracheostomy was performed. No perioperative deaths occurred. Morbidity occurred in eight (32%) patients; none of them required a second surgical look. At median follow-up of 41 months, the outcome was excellent or good for 22 patients (88%), two (8%) are still dependent on jejunostomy and tracheostomy for neurological diseases and one (4%) is under mechanical ventilation for end-stage respiratory failure. Surgical treatment of TOF is associated with good results in terms of control of acute symptoms and long-term outcome, particularly concerning oral intake and spontaneous breathing.

Reconstruction of a Large Tracheal Defect Using Gore-Tex and External Wire Stent

Reconstruction of a tracheal defect remains to be one of the biggest challenges in thoracic surgery. We present a case in which we used Gore-Tex and an external wire stent to reconstruct 7 cm of the trachea and obtained satisfactory outcomes. Gore-Tex appears to be a biocompatible, stable, and reversible material that can be safely used to reconstruct tracheal defects.

Tracheoplasty using a metallic fusiform centrally-doubled coiled stent for a major tracheal defect in rabbits

Background/PurposeThe long-term survival rate of rabbits treated with a fusiform metallic coil for a large tracheal wall defect is 60%. In the present study, the central half of a simple coil was covered by a double coil to prevent the ingrowth of the surrounding connective tissue and to provide a sutureless fixation of the coil to obtain a further increase in the survival rate. Study DesignThe anterior half of the tracheal wall was removed for a longitudinal length of 6 tracheal rings to make a large tracheal defect. Metallic coils were placed into the tracheal lumen through the wall defect. The doubly-coiled portion was designed to fit the length of the defect to eliminate the need for suture fixation. The survival at two months after the operation, endoscopic findings and histological changes were evaluated. ResultsAll 6 rabbits treated with a centrally-doubled coiled stent survived without major respiratory trouble for at least 2months. Endoscopic examinations performed 1month after the operation revealed an irregular coating of reddish granulation tissue inside the coil, and a wet portion was aspirated. The tracheal defect was replaced with fibrous tissue, but neither a complete epithelialization nor cartilage formation was observed. ConclusionThese results suggest that the metallic coil was useful to obtain an improvement in the survival of rabbits with a large tracheal wall defect. Therefore, this new coil might be indicated for the treatment of tracheal wall defects.