Management Of Congenital Tracheal Stenosis Research Articles

Surgical management of congenital tracheal stenosis associated with complex cardiovascular anomalies.

Although surgical outcomes have improved in patients with congenital tracheal stenosis (CTS), the management of such patients with complex cardiovascular anomalies (CVAs) remains a challenge. This study aimed to clarify the clinical features of this combination. Medical records of 14 patients with complex CVAs who had undergone slide tracheoplasty for CTS between May 2016 and February 2022 were retrospectively reviewed. Complex CVAs were defined as CVAs without left pulmonary artery sling and simple cardiac shunts. Data collected included age and body weight at tracheal reconstruction, preoperative respiratory support, surgery details, and mortality. The median age and body weight at tracheal reconstruction were 3.5 (range, 1-17)months and 4.7 (range, 2.3-8.2)kg, respectively. Simultaneous repair of CTS and CVAs was performed in eight patients and staged repair in six patients. Patients who underwent simultaneous repair required preoperative respiratory support more frequently than those who underwent staged repair (8/8 [100%] vs 2/6 [33.3%]; P = 0.015). No mortality occurred. Patients with complex CVAs often require tracheal reconstruction in early infancy. Surgical management strategy for this combination was generally decided on the basis of the severity of respiratory symptoms due to CTS.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Evaluation and management of congenital tracheal stenosis

ObjectivesTo outline an expert-based consensus of recommendations for the diagnosis and management of pediatric patients with congenital tracheal stenosis. MethodsExpert opinions were sought from members of the International Pediatric Otolaryngology Group (IPOG) via completion of an 18-item survey utilizing an iterative Delphi method and review of the literature. ResultsForty-three members completed the survey providing recommendations regarding the initial history, clinical evaluation, diagnostic evaluation, temporizing measures, definitive repair, and post-repair care of children with congenital tracheal stenosis. ConclusionThese recommendations are intended to be used to support clinical decision-making regarding the evaluation and management of children with congenital tracheal stenosis. Responses highlight the diverse management strategies and the importance of a multidisciplinary approach to care of these patients.

Closed-PICU perioperative management of congenital tracheal stenosis.

Perioperative management of congenital tracheal stenosis (CTS) is challenging. In the present study, compared the effect of closed-pediatric intensive care unit (PICU) perioperative management by pediatric intensivists and open-PICU management by surgeons. Outcomes in terms of ventilator-free days (VFD) and length of postoperative PICU stay in children with CTS were evaluated. This retrospective cohort study was conducted in a PICU in Japan. Children with CTS who underwent slide tracheoplasty were grouped according to whether they were perioperatively managed in an open (January 2015 to April 2016) or a closed (May 2016 to August 2019) PICU. Data were extracted from patients' medical records. In total, 13 and 38 patients were included in the open- and closed-PICU groups, respectively. Compared to the open-PICU group, the closed-PICU group had shorter duration of muscle relaxant administration (median 4 vs 5 days; P < 0.001), earlier enteral nutrition (34/38 [90%] vs 1/13 [8%]; P < 0.001), more 28-day VFD (median 21 vs 20 days; P = 0.04), and shorter duration of postoperative PICU stay (median 16 vs 36 days; P = 0.002), but mortality did not differ significantly between the two groups (0/38 [0%] vs 1/13 [8%]; P = 0.25). Closed-PICU perioperative management with pediatric intensivists' participation significantly increased 28-day VFD and reduced the length of postoperative PICU stay in patients with congenital tracheal stenosis.

先天性気管狭窄症を合併した先天性心疾患とその周術期管理

先天性気管狭窄症を合併した先天性心疾患とその周術期管理

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.

Management of congenital tracheal stenosis and tracheomalacia in infants and children

Management of congenital tracheal stenosis and tracheomalacia in infants and children

Non-operative management of congenital tracheal stenosis: criteria by computed tomography.

Whether to perform surgical or conservative treatment for congenital tracheal stenosis (CTS) is controversial. Thus, the computed tomography (CT) criteria for conservative treatment of CTS were investigated. From 2005 to 2017, 28 CTS cases were included. The operative cases and preoperative death cases constituted the required intervention group (group I), and the non-operative surviving cases constituted the observation group (group O). The diameter of the tracheal narrowest part (DTNP) on CT was evaluated as a criterion for non-operative follow-up. Chest CT was performed 19 times in 19 group I cases and 18 times in 9 group O cases. The median age of the patients that underwent CT scan examinations was 3.4months (range 0-25months) in group I and 22months (range 0-60months) in group O. The cut-off values of the non-operative criteria were 40.8% (AUC: 0.82, p < .01) normal for age of the trachea's narrowest part, and 41.6% normal for body weight (AUC: 0.92, p < .01), respectively. DTNP is 40% and more of the normal diameter appears necessary for non-surgical management. The present study suggests that the criteria for conservative management of CTS are that the DTNP is not less than 40% of the normal tracheal diameter, with a few symptoms.

Pitfalls in the management of congenital tracheal stenosis: is conservative management feasible?

Congenital tracheal stenosis (CTS) is rare and challenging. Complete tracheal rings cause a wide spectrum of airway-obstructing lesions and varying degrees of respiratory distress. Although surgical reconstruction is the primary option for symptomatic CTS, sometimes an appropriate management strategy may be difficult due to other anomalies. We aimed to identify pitfalls in the management of CTS. We retrospectively reviewed the records of patients with CTS during the last 10years in our institution. Sixteen pediatric patients were diagnosed with CTS. Of the 16 patients, 12 (75.0%) had cardiovascular anomalies including seven left pulmonary artery sling. Six patients with dyspnoea caused by CTS and three patients with difficult intubations due to CTS underwent tracheoplasty. Four patients underwent only cardiovascular surgery without tracheoplasty. Three asymptomatic patients were followed up without undergoing any surgical procedure. We repeatedly discussed management of four patients with especially complex pathophysiology at multidisciplinary meetings. Right ventricular outflow tract obstruction, tracheobronchial malacia, increased pulmonary blood flow, and pulmonary aspiration due to gastroesophageal reflux presumably accounted for their severe respiratory distress, and we forewent their tracheal reconstruction. The management of CTS should be individualized, and conservative management is a feasible option in selected cases.

Revision thoracic slide tracheoplasty: Outcomes following unsuccessful tracheal reconstruction.

Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report was to describe our experience with revision TST following unsuccessful prior tracheal reconstruction. Retrospective analysis at an academic children's hospital. Patients undergoing TST on cardiopulmonary bypass between January 2005 and May 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated and compared between patients undergoing revision slide tracheoplasty (RTST) and a control group of 26 matched patients undergoing primary surgery TST. Twenty-six revision patients (25 referrals, one primary patient) of 162 patients reviewed over the study period met inclusion criteria. Twenty-three patients had a history of complete tracheal rings, and three patients had cartilaginous deficiency. A total of 41 airway reconstruction procedures had been performed prior to RTST. When compared to primary TST, patients undergoing RTST required fewer cardiac procedures intraoperatively, and fewer mean ventilator hours (P = .01) postoperatively. There was no significant difference in the median length of stay, requirement of >48 hours ventilation, or postoperative complications between groups. There was one nonsurgical postoperative mortality following RTST. Despite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes. 4. Laryngoscope, 128:2181-2186, 2018.

Management of congenital tracheal stenosis in the neonatal period.

Few reports have focused on the management of congenital tracheal stenosis (CTS) in the neonatal period. The aim of this study was to determine appropriate management strategies for CTS in the neonatal period. The medical records of eight neonatal patients with CTS at a single institution between January 2007 and December 2016 were retrospectively reviewed. Three patients with frequent ventilatory insufficiency despite assisted ventilation underwent surgical intervention (balloon tracheoplasty: n=1, slide tracheoplasty: n=2). Ventilatory insufficiency improved after surgery in all three patients. One patient who underwent slide tracheoplasty died due to non-airway-related causes. Observation or conservative management was performed in five patients with minimal respiratory symptoms or stable ventilation under assisted ventilation. All five patients were safely managed non-operatively in the neonatal period. Depending on the severity of ventilatory insufficiency, there are two management strategies for CTS in the neonatal period. Surgical intervention, such as balloon tracheoplasty or slide tracheoplasty, is indicated for patients with unstable ventilatory status despite assisted ventilation. Observation or conservative management is a more suitable option for neonates with stable ventilation.

Emergency management for congenital tracheal stenosis with endoluminal stenting in pediatric intensive care units.

The objective of this study was to share our experience in the management of congenital tracheal stenosis (CTS) using self-expanding intraluminal stents in infants. From January 2010 to August 2012, 31 infants with CTS treated using stents by bronchoscope in pediatric intensive care units (PICUs) were recruited for this study. Among the 31 patients, 17 were male and 14 were female with their ages ranging from 55 days to 22 months. CTS was associated with congenital heart disease (CHD) in 22 patients. There were no immediate stent-related airway complications. A significant and immediate improvement of respiratory obstruction following stent placement in all 31 patients led to successful weaning from the breathing machine and extubation. Granulation tissue formation as a complication was observed in three (9.7%) patients, but all were successfully managed using cryotherapy. During follow up (up to 24 months), stents in 29 infants remained functional. In seven cases, stents were retrieved under bronchoscope (the same day to 10 months), and three cases required stent replacement (each of the three cases had the stent replaced three times). Nine infants died after stenting due to other causes and two infants abandoned treatment. Airway stenting may provide an important therapeutic option in infants with CTS.

Evolution of Surgical Approaches in the Management of Congenital Tracheal Stenosis: Single-Center Experience.

Congenital tracheal stenosis (CTS) is a serious and rare condition that often presents a complex surgical challenge. We reviewed the evolution of surgical approaches to the management of CTS at a single institution. We conducted a retrospective clinical review of all patients who underwent surgical repair of CTS at our institution. From January 1992 to January 2014, a total of 30 patients (median age 92 days; range 3 days-1.7 years) underwent surgery for CTS at our institution. Techniques included slide tracheoplasty (n = 16), tracheal resection (n = 10), pericardial patch tracheoplasty (n = 3), and costal cartilage tracheoplasty (n = 1). Twenty-two (73%) patients had associated intracardiac or great vessel anomalies, including 18 (60%) with left pulmonary artery sling. Five (17%) patients had associated single lung malformation. All procedures were performed via a median sternotomy with cardiopulmonary bypass. Median postoperative length of stay was 25 days (range, 5-431 days). Late airway reintervention was required in seven (26%), including two (15%) infants after slide tracheoplasty, two (22%) posttracheal resection, and two (100%) post pericardial patch tracheoplasty. The one patient who underwent costal cartilage tracheoplasty required multiple reinterventions. Overall mortality was 13% (n = 4), two deaths occurred post slide tracheoplasty, one death occurred after tracheal resection, and one after pericardial patch tracheoplasty, respectively. Slide tracheoplasty is the procedure of choice for repair of CTS, while tracheal resection is a viable option for patients with discreet, short-segment stenosis.

Surgical management of congenital tracheal stenosis associated with tracheal bronchus and congenital heart disease.

Congenital tracheal stenosis (CTS) is variable in patients with tracheal bronchus and congenital heart disease (CHD). Tracheoplasty remains a high-risk surgical treatment. From January 2007 to December 2014, 24 CTS patients (10 males and 14 females; age 20.6 ± 13.6 months) with tracheal bronchus and CHD underwent one-stage surgical correction. Clinical features of all patients included dyspnoea, or recurrent pulmonary infections. There was long-segment CTS in 13 cases (54%), and 4 cases were associated with a bridging bronchus. Less than 50% of normal tracheal size was identified in 21 cases. Complete tracheal or bronchial rings were identified in all cases. Operative techniques included: tracheal end-to-end anastomosis in 11 cases and slide tracheoplasty in 13 cases, which included 11 cases of right upper lobe bronchus (RULB) opposite side-slide tracheoplasty. There were 2 operative deaths, due to postoperative tracheomalacia or residual main bronchial stenosis. The duration of postoperative hospital stay was 7-59 days, with an average of 19 days. Follow-up was completed in 19 cases. The follow-up duration was from 1 month to 7 years. Tracheal granulation occurred in 1 case. Clinical symptoms were significantly improved in the remaining patients. Tracheal bronchi have special anatomical features. The techniques of tracheal end-to-end anastomosis or side-slide tracheoplasty can be used to correct tracheal stenosis with satisfactory outcomes.

Management of Congenital Tracheal Stenosis.

Congenital tracheal stenosis (CTS) is a serious and rare condition. In most cases, stenotic lesions are composed of complete tracheal rings of cartilage.The severity of symptoms correlates with the length of affected trachea, the presence of concomitant respiratory conditions, degree of luminal narrowing,and any bronchial involvement. Critically, CTS is a disorder that can lead to life-threatening respiratory insufficiency in children. Thus, it is a clinical entity that demands timely diagnosis and treatment. This review will firstly discuss the anatomy and pathophysiology of CTS and outline the various clinical presentations associated with the disorder. In addition, methods of diagnosis and treatment strategies will be reviewed, with a focus on contemporary surgical techniques. Finally, postoperative care of patients with CTS will be reviewed, and a contemporary multidisciplinary management approach will be presented.

気管狭窄症の病態とその治療

気管狭窄症の病態とその治療

Revision Thoracic Slide Tracheoplasty for Congenital Tracheal Stenosis: Outcomes following Unsuccessful Prior Tracheal Reconstruction

Objectives: Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report is to (1) describe our experience with revision TST following unsuccessful prior tracheal reconstruction and (2) compare our outcomes with primary TST. Methods: Patients undergoing TST on cardiopulmonary bypass between January 2005 and 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated. Results: A total of 108 patients were reviewed over the study period. Twenty-two revision patients (20 referrals, 2 primary patients) met inclusion criteria. Eighteen patients had a history of complete tracheal rings and 4 patients had cartilaginous deficiency. A total of 35 tracheoplasties (rib graft = 6; slide tracheoplasty = 5; pericardial patch = 4; homograft = 3;resection = 1; cricoid split = 1; combined tracheal reconstruction = 15) had been performed prior to revision TST. Following revision TST, additional endoscopic interventions were required in 5 patients (23%). Twelve balloon dilations (average 2.4 per child) and 4 endoscopic stent placements were performed in these 5 patients. The majority (68%) of children required &lt;48 hours of ventilator support following revision. There was one nonsurgical postoperative mortality. Conclusions: Despite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes.

Surgical management of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is a rare but life-threatening disorder, particularly in neonates and infants. The stenotic lesions are commonly composed of complete rings of cartilage varying in length, location, and severity. A definitive diagnosis of CTS may be delayed because of the rarity of this disorder and thus its unfamiliarity among physicians, its variable onset time, its various clinical symptoms, and the diversity of associated clinical conditions due to the cardiovascular disorders that may accompany it. More than half of the patients who manifest clinical symptoms during early infancy show a long-segment stenosis. Long-segment CTS is problematic and challenging to manage. Over the last two decades several surgical techniques for long-segment CTS have been devised and developed, but no definitively advantageous surgical procedure has been established because of insufficient experience and the lack of large-scale studies. Although rib cartilage tracheoplasty and pericardial patch tracheoplasty have provided limited early to midterm success for infants with long-segment CTS, these procedures are associated with early and late complications, including granulation tissue formation, patch collapse, and restenosis necessitating reintervention. By contrast, slide tracheoplasty has given rise to better surgical outcomes. This procedure enables reconstruction of the stenotic trachea using native tracheal walls with preserved blood supply. The trachea is foreshortened by only one-half of the original stenosis, resulting in reduced tension on the anastomosis. Consequently, the technique has several advantages, including less formation of granulation tissue, satisfactory subsequent growth, and infrequent reoperation for restenosis. Slide tracheoplasty is currently recognized as the preferred technique for long-segment CTS.

Alternative Approach to the Surgical Management of Congenital Tracheal Stenosis

Congenital tracheal stenosis is a serious disease associated with high operative mortality and morbidity, especially in the newborn period. Its surgical management involves either sliding tracheoplasty, which is associated with extensive dissection and recurrent stenosis, or with pericardial patch tracheoplasty that fails to address recoiling of the stenotic complete ring and collapse of the patch into the tracheal lumen. We report a modification of the latter technique, in which a half ring external stenting device is used to keep the rings from recoiling.

Slide cricotracheoplasty in an infant

Slide tracheoplasty was first described in 1989 by Tsang and colleagues and has now become the gold standard to treat long-segment tracheal stenosis. This technique presents several advantages: no graft material is required, it allows satisfactory enlargement of the trachea, and it does not hinder the functional growth of the trachea. 2,3 Recently, our team has reported the association of tracheal resection and slide tracheoplasty to manage an infant presenting with tracheal hypoplasia associated to a partial critical stenosis. 4 However, surgical management of a tracheal hyp oplasia extending up to the cricoid is still quite challenging. We therefore describe a variant of the slide tracheoplasty that allowed us to treat this difficult case.

Management of congenital tracheal stenosis in infancy☆

Congenital tracheal stenosis (CTS) is a very infrequent malformation. Till recently, the outlook for these patients was dismal because medical management was the only way of treatment. Surgical and endoscopical techniques developed in the last years have improved the prognosis. We review the short- and long-term outcomes of a single institution experience in the management of children with CTS, comparing different treatment modalities. Between 1991 and 2004, 19 cases of CTS have been managed in our Unit. Respiratory symptoms varied from mild stridor on exertion to severe distress. Bronchoscopy was performed for diagnostic purposes in all cases; other imaging techniques (computed tomography (CT), magnetic resonance imaging (MRI), bronchography, angiography, doppler-ultrasound) were performed on an individual basis. According to clinical and endoscopical features, patients were classified into three groups. The following data have been studied in each case: sex, age at diagnosis and treatment, anatomical type, associated anomalies, treatment modality, complications, outcome and time of follow-up. Ten boys and nine girls have been included in this study. Age at diagnosis ranged from 3 days to 7 years (median, 4 months) and 84% of cases showed associated anomalies. Five patients presented mild or no symptoms and have been managed expectantly. The other 14 cases were operated on because of persistent or severe clinical symptoms. The following procedures were performed: slide tracheoplasty (n = 7), costal cartilage tracheoplasty (n = 5), tracheal resection and reconstruction (n = 3), endoscopical dilatation (n = 3), stent placement (n = 1), and laser resection (n = 1). Three patients required two or more procedures and surgical survival rate is 78%. Overall mortality in the series is 21% and all survivors (15 patients) are asymptomatic or show mild symptoms with respiratory infections only. Follow-up is complete, ranging from 8 months to 12.3 years (mean, 5 years). Bronchoscopy is our preferred diagnostic tool. Selection of the type of treatment depends on the patient's clinical status and the anatomical pattern of the stenosis. In symptomatic cases with short-segment stenosis (<30% of total tracheal length), we prefer tracheal resection with end-to-end anastomosis; for long-segment stenosis (>30%), slide tracheoplasty is our procedure of choice.