Repair Of Congenital Tracheal Stenosis Research Articles

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

To assess the outcomes of congenital tracheal stenosis among children. A retrospective review of all children who underwent surgical repair of congenital tracheal stenosis reviewing charts, operative notes, echocardiograms, CT and MRI data from January 2002 to February 2019. Twenty-six children underwent surgical treatment for tracheal stenosis. The median age was 3 months (range 0.3-35 months) and the median weight was 4.7 kg (range 2.5-13 kg) at the time of surgical intervention. Stridor was the most common presenting symptom in 17 patients (65% of patients). Twenty-one patients (81%) had concurrent cardiac anomalies, with pulmonary arterial sling being the most common, present in nine patients (34%). Extracorporeal life support was utilised in seven patients (27%) pre-operatively. Laryngeal release was required in 16 patients. In 7 patients an end-to-end anastomosis was performed, in 18 patients slide tracheoplasty, and 1 patient had a double slide tracheoplasty. The median cardiopulmonary bypass time was 106 minutes (range 25-255 minutes). The median cross-clamp time was 30 minutes (range 5-67 minutes). The median post-operative duration of ventilation was 5 days (range 0.5-16 days). The median ICU length of stay was 12.5 days (range 2-60 days). There were three hospital mortalities with 88% survival. One patient only required reintervention with balloon dilation. Twenty-two patients (85%) remained symptom-free on median follow-up at 7.6 years (range 0.2-17 years). Two patients since 2017 had 3D printed tracheas produced from CT imaging to assist surgical planning. Congenital tracheal stenosis can be managed effectively with excellent outcomes and 3D printed models assist in planning the optimal surgical intervention.

Treatment of postoperative tracheal granulation tissue with inhaled budesonide in congenital tracheal stenosis

PurposeTracheal obstruction by granulation tissue can compromise the postoperative course in congenital tracheal stenosis (CTS). Balloon dilatation and stenting may be required. Budesonide is a corticosteroid with topical anti-inflammatory effects. In 2008, we used inhaled budesonide for treatment of postoperative granulation tissue for the first time in CTS, resulting in significant improvement. The aim of this study was to evaluate the efficacy of inhaled budesonide for treatment of postoperative granulation tissue in CTS. MethodsRetrospective chart review was conducted. From 2004 through 2011, we performed 39 tracheoplasties. Forced stenting±balloon dilatation (S/B) was required when airway obstruction with tissue granulation was life-threatening. We compared the requirement for S/B between the early group without budesonide (2004–Nov. 2008, Early) and the late group with budesonide (Dec. 2008–2011, Late). Statistical analysis was performed using Fisher’s Exact test. ResultsEleven of 22 in Early and 8 of 17 in Late were successfully extubated, never having had life-threatening tissue granulation. The remaining patients in each group (11 in Early and 9 in Late) required tracheostomies due to postoperative complication. Ten in Early and 5 in Late with tracheostomies developed granulation tissue. Of these patients, the 10 in Early required S/B, while none of the 5 in Late required S/B (P=.0003). Bronchoscopy demonstrated significant regression of granulation tissue in all cases treated with inhaled budesonide. ConclusionInhaled budesonide is effective for treatment of tracheal granulation tissue in patients with tracheostomies after repair of CTS.

Do Tracheas Grow After Slide Tracheoplasty?

Slide tracheoplasty has become the surgical technique of choice for repair of congenital tracheal stenosis. Despite the initial reluctance regarding the ability of this "reconstructed" trachea to grow, the reduced morbidity and mortality have allowed slide tracheoplasty to be widely adopted. The aim of this study was to evaluate tracheal growth after slide tracheoplasty. This was a retrospective study. In follow-up bronchography performed 1, 6, 12, 18, and 24 months after slide tracheoplasty, we measured the cross-sectional areas of the midtrachea and distal trachea at each investigation and correlated the measurements with the anthropomorphic factors (body weight, height, and body surface). Fourteen patients were enrolled in this study. The midtracheal and distal tracheal cross-sectional areas significantly increased with time (p ≤ 0.0001). The average rates of midtracheal growth were 21.0 mm(2)year in the first 6 months and 8.0 mm(2)/year in the first 2 years, and the distal trachea grew 18.5 mm(2)/year and 8.4 mm(2)/year, respectively. Regression analysis showed that both the midtrachea and the distal trachea increase significantly with weight (r(2) = 0.257, p ≤ 0.0001), height (r(2) = 0.376, p ≤ 0.0001), and body surface area (r(2) = 0.315, p ≤ 0.0001). Balloon dilation did not significantly alter the tracheal growth in the first 2 years after slide tracheoplasty. Slide tracheoplasty does not inhibit tracheal growth. The reconstructed trachea grows faster in the first 6 months and slows in the following 18 months. There is a positive correlation between tracheal cross-sectional area and weight, height, and body surface area.

Tratamento cirúrgico das estenoses traqueais congênitas

To analyze the outcomes of patients undergoing repair of congenital tracheal stenosis. This was a retrospective review of congenital tracheal stenosis patients treated between 2001 and 2007 at the University of São Paulo School of Medicine Hospital das Clínicas in São Paulo, Brazil. Six boys and one girl (age at diagnosis ranging from 28 days to 3 years) were included. Five of the patients also had cardiac or major vessel malformations. The stenosis length was short in three patients, medium in one and long in three. The techniques used were pericardial patch tracheoplasty in three patients, resection and anastomosis in two, slide tracheoplasty in one and vascular ring correction in one. One patient died during surgery due to hypoxia and hemodynamic instability, and one died from septic shock on postoperative day 11. Other complications included pneumonia, arrhythmia, stenosis at the anastomosis level, residual stenosis, granuloma formation and malacia. The mean follow-up period was 31 months; four patients were cured, and one required the use of a T tube to maintain airway patency. Congenital tracheal stenosis is a curable disease. However, its repair is complex and is associated with high rates of morbidity and mortality.

Simultaneous management of congenital tracheal stenosis and cardiac anomalies in infants

The present article aims to describe our experience with patients who underwent simultaneous repair of congenital tracheal stenosis and cardiac anomalies. Between January 2000 and December 2003, 9 infants underwent simultaneous surgical repair of a congenital tracheal stenosis and congenital heart disease. The intraoperative findings revealed localized tracheal stenosis in 3 patients. The funnel-type tracheal stenosis was present in 6 patients. Associated cardiac anomalies included ostium secundum atrial septal defect in 5 patients and ventricular septal defect in 2 patients, pulmonary artery sling in 4 patients, patent ductus arteriosus in 6 patients, atrioventricular septal defect in 1 patient, aortic arch hypoplasia in 1 patient, coarctation of the aorta in 1 patient, and partial anomalous pulmonary venous connection in 2 patients, one of them with "scimitar syndrome." Tracheal origin of the right upper lobe was diagnosed in 2 of the patients. A right aberrant subclavian artery (lusoria) was found in one patient. All patients were operated on through a median sternotomy and with cardiopulmonary bypass. Tracheal resection with direct end-to-end anastomosis was performed in all cases. There was no operative mortality. One patient died 6 weeks postoperatively. Eight patients were extubated between the 14th and 30th postoperative days under bronchoscopic monitoring. The extubation was performed after a stepwise respirator-weaning program. Postoperative endoscopic examination showed adequate airway dimensions and patency in every case. The midterm results after a mean follow-up of 37 months (range, 16-58 months) of the entire group demonstrate a stabile and complication-free clinical outcome. We advocate our current strategy for infants with congenital tracheal stenosis: resection with end-to-end anastomosis and simultaneous repair of associated intracardiac anomalies.

Repair of congenital tracheal stenosis

We have used six different techniques in 61 operations performed at Children's Memorial Hospital (Chicago, IL) between 1982 and 2001 on 54 infants with complete tracheal rings and primary or recurrent tracheal stenosis. Short-term and long-term outcomes are reviewed for all techniques including pericardial tracheoplasty, tracheal autograft, tracheal resection, cartilage tracheoplasty, slide tracheoplasty, and aortic homograft patch tracheoplasty. Patients' ages ranged from 7 days to 72 months; mean age at operation was 6 months. There were 33 boys and 21 girls. Associated pulmonary artery sling was present in 19 of 54 patients (35%). Significant associated intracardiac anomaly was present in 13 of 54 patients (24%). The number of complete tracheal rings involved ranged from two to 18 rings (mean, 14 ± 5). All procedures were performed with the use of cardiopulmonary bypass. Simultaneous repair of pulmonary artery sling and cardiac abnormalities was undertaken. There were three early deaths, two after pericardial tracheoplasty and one after tracheal autograft. There were eight late deaths, five after pericardial tracheoplasty, one after tracheal autograft, one after slide tracheoplasty, and one after tracheal resection. Median length of hospital stay was 60 days for pericardial tracheoplasty, 28 days for tracheal autograft, 14 days for tracheal resection, and 18 days for the slide tracheoplasty. Follow-up is complete in all patients. Tracheal autograft is currently our procedure of choice for patients with long-segment tracheal stenosis because of its use of all-autologous material, technical ease of performance, already-present epithelial lining of the autograft, intrinsic maintenance of the cartilage contour, potential for growth, and ready availability. We limit the use of tracheal resections to patients with eight or less rings of tracheal stenosis. Copyright © 2002 by W.B. Saunders Company

Healing of a free tracheal autograft is enhanced by topical vascular endothelial growth factor in an experimental rabbit model

Objective: In 1996, we introduced the free tracheal autograft technique for repair of congenital tracheal stenosis from complete tracheal rings in infants and children. Sources of possible concern with this procedure include the potential for autograft ischemia, patch dehiscence, and recurrent stenosis. Vascular endothelial growth factor is a potent angiogenic inducer (particularly in the setting of ischemia, hypoxia, or both) and is postulated to promote tissue healing. The purpose of this study was to test the hypothesis that pretreatment of tracheal autografts with topical vascular endothelial growth factor would enhance tracheal healing. Methods: In a rabbit model of tracheal reconstruction (n = 32), an elliptically shaped portion of the anterior tracheal wall was excised. The excised portion of trachea was one third of the tracheal circumference and 2 cm in length (6 tracheal rings). This portion of trachea (the autograft) was soaked in either vascular endothelial growth factor (5 μg/mL, n = 16) or normal saline solution (n = 16) for 15 minutes before being reimplanted in the resultant tracheal opening. Animals were killed and autografts were examined at 2 weeks, 1 month, and 2 months postoperatively for gross and microscopic characteristics. Results: By 2 weeks, and progressing through 1 and 2 months, autografts treated with vascular endothelial growth factor, as compared with control autografts, had reduced luminal stenosis, submucosal fibrosis, and inflammatory infiltrate ( P < .05). The autografts tended to become malaligned in control animals, whereas the tracheal architecture was preserved in rabbits treated with vascular endothelial growth factor. Microvascular vessel density was significantly greater in all vascular endothelial growth factor groups ( P < .05) at all time intervals. Conclusions: Topical treatment of free tracheal autografts with vascular endothelial growth factor in a rabbit tracheal reconstruction model enhanced healing, as evidenced by accelerated autograft revascularization, reduced submucosal fibrosis and inflammation, and preservation of the normal tracheal architecture. Topical vascular endothelial growth factor may improve future results of tracheal reconstruction.

Management of distal tracheal stenosis.

To evaluate the treatment, perioperative management, and outcome of infants who underwent repair of congenital tracheal stenosis. We hypothesized that early resection and tracheoplasty with early weaning of ventilatory support results in less mucosal injury, and thus better outcome. Retrospective study from 1986 to 1996. Tertiary care children's hospital. Seventeen consecutive infants with congenital tracheal stenosis, aged from birth to 16 months. Fifteen patients had complete tracheal rings, 6 of whom also had a left pulmonary artery sling. Fourteen patients underwent either tracheoplasty or resection and reanastomosis of the trachea, both facilitated by cardiopulmonary bypass. Six patients underwent resection and reanastomosis; 4 patients were extubated within 2 to 5 days without sequelae. There was 1 unrelated perioperative death. Two patients required reintubation. Eight patients required tracheoplasty due to severe tracheal stenosis and had variable postoperative courses. Seven of 14 patients required 0 to 1 postoperative bronchoscopies. Seven of 14 patients required 2 to 7 bronchoscopies for granulation tissue formation, cicatrix, graft collapse, and tracheitis. One patient required numerous procedures and revision tracheoplasty for cicatrix and stenosis. Correction of short-segment (<5 rings) tracheal stenosis by resection and reanastomosis of the trachea with the aid of cardiopulmonary bypass and early weaning of ventilatory support is recommended. Tracheoplasty using either the castellation technique or slide tracheoplasty is recommended in the treatment of infants with severe (long segment) tracheal stenosis.

Simple deep hypothermia for repair of congenital tracheal stenosis: a case report.

Simple deep hypothermia for repair of congenital tracheal stenosis: a case report.

Simple deep hypothermia for repair of congenital tracheal stenosis: a case report

Simple deep hypothermia for repair of congenital tracheal stenosis: a case report

Repair of congenital tracheal stenosis with a free tracheal autograft

Objectives: Evaluate the results of a technique for repair of congenital tracheal stenosis by use of a free tracheal autograft. Methods: Between January 1996 and July 1997, six infants with congenital tracheal stenosis resulting from complete tracheal rings underwent repair with a free tracheal autograft. Mean age at the time of repair was 4.9 months; mean weight was 5.4 kg. The approach was through a median sternotomy with cardiopulmonary bypass for respiratory support. The trachea was incised anteriorly through the area of stenosis, the midportion of the stenotic trachea was excised, and an end-to-end anastomosis was carried out posteriorly. The excised tracheal segment (1.3 to 2.2 cm long) was used as a free autograft to patch the lower trachea anteriorly. In four infants the autograft was augmented in the upper trachea with pericardium; in two patients with a shorter length of stenosis, the autograft completed the repair. Simultaneous pulmonary artery sling repair (4), ligation and division of patent ductus arteriosus (3), cricoid split (2), atrial and ventricular septal defect repair (1), and complete atrioventricular canal repair (1) were performed at the time of tracheal repair. Results: The infants were extubated and discharged at a mean of 13 and 23 days postoperatively, respectively. One infant had recurrent tracheal stenosis related to the pericardial patch and required a tracheal stent and tracheostomy 4 months postoperatively. Our mean follow-up is 11 months. Bronchoscopic findings currently show widely patent tracheal lumina in all infants. Conclusions: The technique of free tracheal autograft with and without pericardial augmentation was successful in opening the airway of six infants with congenital tracheal stenosis and is currently our procedure of choice for children with this diagnosis. (J Thorac Cardiovasc Surg 1998;115:869-74)

Rib-muscle pedicle flap for the repair of congenital tracheal stenosis.

Congenital tracheal stenosis (CTS) is an uncommon congenital anomaly that presents early in life with symptoms of biphasic stridor. Most cases require surgical correction. Techniques have included dilation, resection of the involved segment, and tracheoplasty. Today pericardium and costal cartilage are the most frequently used materials for tracheoplasty, but patients still often encounter problems with the graft, with the procedure, or with late complications. This preliminary study was undertaken to determine the feasibility of a rib-intercostal muscle pedicle flap for the treatment of CTS. Tracheoplasties were performed on seven 3.5- to 5.5-kg piglets with a pedicled segment of the right fourth rib via a lateral thoracotomy incision. The method was found to be technically feasible, and pedicles of greater than 2.5 cm were easily developed. The repair provided good structural support and an airtight seal at high ventilator pressures. Histologic examination after 2 weeks showed the flap to be incorporating into the native trachea and to be without degenerative changes. This "vital" composite flap has several real and theoretic advantages over current methods of repair and may prove to be valuable in the treatment of CTS. The clinical application of this myo-osseous pedicle graft in the treatment of patients with stenoses not amenable to surgical resection and primary anastomosis should be explored.

A new intratracheal stent made from nitinol, an alloy with “shape memory effect”

Temporary or permanent tracheal splinting in pediatric patients may be indicated in tracheomalacia or bronchomalacia, repair of congenital tracheal stenosis, and after tracheal resection. This study presents the results of the development of a new intraluminal airway stent made from titanium alloy, a metal with "shape memory effect". At low temperatures (martensitic state) the titanium alloy stent can be fashioned into a specific shape; then when heated to a higher temperature (austenitic state) the stent alters its shape, only to regain its original shape when recooled to the lower temperature. The stent, connected to a small electric power supply, was introduced into 20 young rabbits with the use of a 2.5 cm rigid bronchoscope. After implantation in the martensitic state the stent was warmed to 40 degrees C, the austenitic state, by an electric current of 1.5 to 3 ampere for 1 to 2 seconds. After a period of 8 to 10 weeks the stent was removed (in its martensitic state) through the same-sized bronchoscope after being cooled with 3 to 4 ml of 80% alcohol solution at 6 degrees C. No signs of airway obstruction developed in any of the animals after implantation or extraction of the stent. The biomechanical properties of the trachea, as shown by strain measurements with the use of incremental forces, showed significant differences between the stented and unstented segments (p < 0.005). The titanium alloy intratracheal stent adequately fulfilled the requirements of a temporary intraluminal airway splint, and because of its unique feature of shape memory effect the stent could be inserted, fixed, and removed easily, even in very small airways.

Concomitant repair of congenital tracheal stenosis and complex cardiac anomaly in small children

Severe obstructive lesion of the trachea combined with complex congenital cardiac anomaly has generally been regarded as a fatal disease. Herein we report the successful concomitant repair of severe tracheal stenosis and complex cardiac anomaly with the use of cardiopulmonary bypass in two cases. The first patient was a 5-year-old boy with tetralogy of Fallot associated with a localized intrathoracic tracheal stenosis caused by complete cartilaginous rings. Tracheal resection and end-to-end anastomosis combined with total correction of tetralogy of Fallot was performed with the aid of cardiopulmonary bypass. The second patient was a 5-month-old girl with a pulmonary artery sling, scimitar syndrome, and extensive tracheal stenosis. The patient underwent definitive correction of cardiac lesions and complete tracheal reconstruction with a cartilaginous graft with the aid of cardiopulmonary bypass. Utmost care was paid to avoid contamination during the operation. Both of the patients are doing well at present without any signs of complication, 2 years 5 months and 1 year 10 months after the operation, respectively. We advocate concomitant repair of both lesions, with cardiopulmonary bypass, in the surgical managements of infants and small children who have a difficult and otherwise fatal combination of complex congenital cardiac anomaly and severe intrathoracic tracheal stenosis.

Surgical repair of congenital tracheal stenosis in an infant

Congenital tracheal stenosis is a rare but treatable form of infant respiratory distress. Successful resection of approximately 50% of the tracheal length in a 4-month-old infant is described.