Slide Tracheoplasty Research Articles

Complex surgical treatment of congenital tracheal stenosis with associated unilateral lung agenesis

Abstract Background The combination of congenital tracheal stenosis (CTS) and unilateral pulmonary agenesis is rare and fatal. Especially, right lung agenesis is associated with dextrocardia and often causes tracheal alignment disorder. The mortality is estimated with 12.5–65%. Slide Tracheoplasty (ST) has been improved the prognosis, however, the postoperative course of CTS with single lung remains unclear. Here, we describe the postoperative challenging situation with bronchial intervention and other devices. Case presentation A 9-month-old girl with CTS, right lung agenesis, dextrocardia, and bilateral superior vena cava underwent ST anterior to the aortic arch. On postoperative day 50, tracheostomy was performed for long-term airway pressure support. Six months after the ST, she showed severe bronchomalacia at the bifurcation of the lobar bronchi, which was sandwiched between the descending aorta and left pulmonary artery. Direct bronchopexy and mobilization of left pulmonary artery resolved the severe bronchomalacia. Additionally, the kinked trachea caused a tracheal ulcer and frequent accidental decannulations. The ulcer was made above the aortic arch by contact with the tracheal cannula. The customized Montgomery T-tube solved both problems and enabled the stable management for airway. Her condition eventually improved, and she was discharged home after 14 months of hospitalization. Conclusion This case presented a very rare and critical condition. This is the first report to address the severe condition after ST anterior to the aortic arch. Surgical interventions or other devices for treatment are thought to be modified according to each condition.

Refashioned lamb tissue as an animal model for training complex techniques of laryngotracheal stenosis surgery.

Open reconstructive upper airway surgery for laryngotracheal stenosis (LTS), whether for subglottic or tracheal stenosis, constitutes a group of complex approaches. LTS requiring open reconstruction is overall rare and primarily performed at tertiary centres. This poses an obvious challenge for the acquisition and maintenance of surgical skills for this group of complex approaches. In this context, animal models provide a unique opportunity for open reconstructive airway surgery training. Such models ought to take into consideration ethical aspects, be easily available and easy to maintain, and have similar macroscopic anatomical features to the human laryngotracheal frame. Here, we provide a brief surgical guide for the use of refashioned lamb tissue as a training model for surgery of adult and pediatric reconstructive airway surgery. The techniques of laryngotracheal reconstruction, partial cricotracheal resection, tracheal resection with end-to-end anastomosis, and slide tracheoplasty are presented. Proper training in open LTS surgery is challenging, time consuming and its complexity further lengthens the learning curve. The lamb larynx and trachea model is an effective model for practising various airway reclaiming surgeries.

Slide tracheoplasty in 81 children: Improved outcomes with modified surgical technique and optimal surgical age.

The aim of this study was to evaluate the surgical outcome of slide tracheoplasty.Eighty-one patients who underwent slide tracheoplasty were retrospectively reviewed. Before and after operation, all patients were examined by computed tomography (CT) and bronchoscopy regularly.There were 8 deaths and the mortality was 9.9%. They all died of respiratory failure associated with the formation of granulation tissue in the airway postoperatively. The mortality was 15.8% from 2009 to 2012 and decreased to 8.1% from 2013 to 2016. The mortality of patients aged 10 to 24 months was 5.7%, which was significantly lower than those younger than 10 months and those older than 24 months. After surgery, 11 patients had granulation tissue growing at anastomosis edges and 8 of them died eventually. Twenty patients had mucosa varus at the site of anastomosis which mainly happened in the early time. Between different time periods and different age groups, there was significant difference in the incidence of granulation tissue and mucosa varus (P < .01). Clinical symptoms of tracheal stenosis disappeared and the results of CT were satisfactory after operation.Slide tracheoplasty is an effective surgical method for congenital tracheal stenosis associated with congenital heart disease. With the continuous improvement of surgical technique, the mortality has been reduced and the incidence of granulation tissue and mucosa varus also has been reduced. The period of 10 to 24 months of age is the optimal cure time.

Isolated Bridging Bronchus: Findings from Bronchoscopy and Airway Three-Dimensional Reconstruction.

A bridging bronchus (BB) is an aberrant bronchus that is commonly associated with congenital cardiac and great vessel anomalies. We describe a rare case of a BB in a pediatric patient without complicated congenital cardiac and great vessel anomalies. Bronchoscopy and 3-dimensional reconstruction computed tomography may be useful in recognizing this rare airway malformation. Antibiotics, mucolytic, and mechanical vibration sputum expectoration treatments were recommended during episodes of respiratory infection. Slide tracheoplasty is an appropriate technique if the respiratory status deteriorates.

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.

The role of intraoperative nerve monitoring in tracheal surgery: 20-year experience with 110 cases.

To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury. 110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities. In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p>0.05). Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery.

Neonatal airway: challenging endotracheal intubation in infants with tracheal malformations at birth

Intubating newborn infants can be exacting. We describe two cases of endotracheal intubations in infants born with tracheal malformations. A male infant aged 30 weeks required intubation at birth for...

Side-to-Side Tracheobronchoplasty to Reconstruct Complex Congenital Tracheobronchial Stenosis

Long segment tracheobronchial stenosis is a rare congenital anomaly that can also occur in combination with abnormal bronchial arborization. Long segment tracheal reconstruction in the setting of a supernumerarybridging bronchus has been reported; however, these repairs can be particularly complex. We present our experience using the bridging bronchus to augment long segment tracheal stenosis with a side-to-side tracheobronchoplasty. Four patients with complex long segment tracheobronchial stenosis involving a bronchus suis (right upper lobe bronchus) and a bridging bronchus presented with refractory respiratory distress requiring urgent tracheal reconstruction. Patient 1 was initially managed with modified slide tracheoplasty and tracheostomy. Patients 2, 3, and 4 were managed with single-stage procedures. All patients underwent definitive long segment tracheobronchoplasty consisting of a side-to-side anastomosis between the bridging bronchus and the right upper lobe bronchus. Age at surgery was 569, 69, 24, and 142 days, respectively. Weight at surgery was 9.3, 4.3, 2.7, and 5.9kg. All patients were weaned from mechanical ventilation at 84, 13, 47, and 8 days after side-to-side tracheobronchoplasty. All patients were alive and free fromtracheostomy at follow-up of 6.7, 3.8, 2.7, and 0.5 years. Side-to-side tracheal reconstruction is feasible in severe cases of long segment tracheal stenosis with a right upper lobe bronchus and a bridging bronchus. This technique can be successfully applied in high-risk patients and in the neonatal period and can provide excellent midterm results.

Airway Problems in Neonates-A Review of the Current Investigation and Management Strategies.

Airway problems in the neonatal population are often life threatening and raise challenging issues in diagnosis and management. The airway problems can result from congenital or acquired lesions and can be broadly classified into those causing obstruction or those due to an abnormal “communication” in the airway. Many different investigations are now available to identify the diagnosis and quantify the severity of the problem, and these tests can be simple or invasive. Bronchography and bronchoscopy are essential to determine the extent and severity of the airway problem and to plan treatment strategy. Further imaging techniques help to delineate other commonly associated abnormalities. Echocardiography is also important to confirm any associated cardiac abnormality. In this review, the merits and disadvantages of the various investigations now available to the clinician will be discussed. The current therapeutic strategies are discussed, and the review will focus on the most challenging conditions that cause the biggest management conundrums, specifically laryngotracheal cleft, congenital tracheal stenosis, and tracheobronchomalacia. Management of acquired stenosis secondary to airway injury from endotracheal intubation will also be discussed as this is a common problem. Slide tracheoplasty is the preferred surgical option for long-segment tracheal stenosis, and results have improved significantly. Stents are occasionally required for residual or recurrent stenosis following surgical repair. There is sufficient evidence that a multidisciplinary team approach for managing complex airway issues provides the best results for the patient. There is ongoing progress in the field with newer diagnostic tools as well as development of innovative management techniques, such as biodegradable stents and stem cell-based tracheal transplants, leading to a much better prognosis for these children in the future.

The role of adjunctive procedures in reducing postoperative tracheobronchial obstruction in single lung patients with congenital tracheal stenosis undergoing slide tracheoplasty

PurposeCongenital tracheal stenosis (CTS) and a single right lung treated with slide tracheoplasty (ST) has relatively high rates of mortality and morbidity. We report a single institution's experience with adjunctive procedures at the time of ST to reduce postoperative tracheal obstruction in patients with a single right lung and CTS. MethodsWith IRB approval, 8 patients with a single right lung and CTS who underwent ST in our institution between 2008 and 2016 were reviewed. ResultsSeven of 8 patients (88%) survived, with a median follow-up period of 35 (3–89) months. The only mortality was because of complications unrelated to the airway. Six of 8 patients underwent ST anterior to the aortic arch (tracheal translocation, TT). This was combined with tracheopexy concomitantly in 3 patients and subsequently in one patient. Two patients had insufficient tracheal length for TT. Both underwent aortopexy. Of three patients undergoing TT with tracheopexy concomitantly, two have been successfully extubated, and a third has required tracheostomy for subglottic stenosis. All patients undergoing TT without tracheopexy have experienced severe tracheobronchomalacia. ConclusionWe conclude that adjunctive TT with tracheopexy might be associated with lower rates of tracheobronchial obstruction in patients with a single right lung undergoing ST for CTS. Level of evidenceLevel IV.

先天性気管狭窄症に対するslide tracheoplasty : 周術期管理の諸問題

先天性気管狭窄症に対するslide tracheoplasty : 周術期管理の諸問題

Радикальная коррекция двойного отхождения сосудов от правого желудочка с пластикой трахеи при ринслинг комплексе в условиях искусственного кровообращения и экстракорпоральной мембранной оксигенации у 3-месячного ребенка

В описании клинического случая представлена коррекция редкой патологии – ринг-слинг комплекса в сочетании с двойным отхождением сосудов от правого желудочка у ребенка 3-месячного возраста. Составляющая ринг-слинг комплекса – это неразделенные хрящевые кольца вместе с аномальным отхождением левой ветви легочной артерии от правой ветви с ретротрахеальным ходом и формированием сосудистой петли или так называемого слинга. В мировой литературе данное сочетание, включающее скользящую пластику трахеи и радикальную коррекцию двойного отхождения сосудов от правого желудочка, не описано. Особенностью представленного наблюдения является также ранний возраст пациента. Для клинициста интерес представляют также внезапные изменения клинического состояния больного в результате течения заболевания, что потребовало не только реимплантации аберрантной левой легочной артерии, но и выполнения жизнеспасающей трахеопластики с необходимостью продленного сеанса экстракорпоральной мембранной оксигенации. Следует также отметить, что активная кардиохирургическая помощь больным с сопутствующей патологией трахеи в условиях искусственного кровообращения в нашей стране осуществляется только в последние несколько лет. В связи с этим каждое подобное наблюдение является ценным для накопления опыта, пока еще ограниченного единичными случаями.

Tracheoesophageal fistula: open versus endoscopic repair.

The management of primary or recurrent tracheoesophageal fistula (TEF) remains an important challenge for airway surgeons. The accuracy of prenatal detection can be significantly improved in specialized centers. Routine preoperative and postoperative airway endoscopy is recommended to detect a proximal fistula and evaluate vocal cord motility. Minimally invasive thoracoscopic approaches have equal success and improved cosmesis and visualization as compared with thoracostomy. Novel open approaches for complex TEF include a transcervical, transtracheal approach, and slide tracheoplasty.Endoscopic closure of TEF carries less morbidity. Options include de-epithelialization of the tract, interposed material, and combinations. The mean operative time is 30 min; however multiple treatments are required (average 2.1). Use of continuous positive airway pressure in the immediate postoperative period was not associated with increased leak or recurrence. Children post-TEF repair continue to have frequent gastrointestinal and respiratory symptoms. Prenatal diagnosis is beneficial both for prenatal counseling and for planning care. The ideal endoscopic approach is undecided but remains an interesting alternative to open surgery provided failures are anticipated and prompt repeated treatments initiated to preclude ongoing respiratory complications. Transtracheal approaches and slide tracheoplasty are well tolerated and effective in complex/recurrent cases. Long-term follow-up of patients with TEF is important.

Biodegradable polydioxanone stent as a new treatment strategy for tracheal stenosis in a rabbit model

PurposeCongenital tracheal stenosis (CTS) is a rare condition and difficult to treat. Slide tracheoplasty has unsatisfactory outcomes for severe neonatal symptomatic CTS. This study evaluated the use of biodegradable polydioxanone stents (BD stent) in a rabbit model of CTS. MethodsTracheal stenosis was induced in female Japanese white rabbits, 9–10weeks old, by direct scraping of the tracheal mucosa with a nylon brush following transverse incision of the trachea (control group, n=4). Seven days later, we incised the trachea again and inserted a BD stent (15×5mm) into the trachea (stent group, n=4). Arterial blood gas analysis was performed twice weekly for 1month after the procedure. ResultsIn the control group, respiratory acidosis arising from ventilatory failure was observed on postoperative days 7–10. Rabbits were sacrificed at 11.5days after scraping. Severe tracheal stenosis resulting from inflammatory granulation was detected in the scraped region in all rabbits. In the stent group, arterial blood gas analysis was normal at 28days after stent insertion. The BD stent maintained patency of the tracheal lumen and prolonged survival for 1month. ConclusionsThe use of BD stent represents a promising new treatment method for tracheal stenosis.

Surgical intervention strategies for congenital tracheal stenosis associated with a tracheal bronchus based on the location of stenosis.

The aim of this study was to determine the appropriate surgical intervention strategies for congenital tracheal stenosis (CTS) associated with a tracheal bronchus based on the location of stenosis. The medical records of 13 pediatric patients with CTS associated with a tracheal bronchus at a single institution between January 2006 and December 2015 were retrospectively reviewed. Type 1: tracheal stenosis above the right upper lobe bronchus (RULB) (n=1). One patient underwent slide tracheoplasty and was successfully extubated. Type 2: tracheal stenosis below the RULB (n=7). Tracheal end-to-end anastomosis was performed before 2014, and one patient failed to extubate. Posterior-anterior slide tracheoplasty was performed since 2014, and all three patients were successfully extubated. Type 3: tracheal stenosis above the RULB to the carina (n=5). One patient underwent posterior-anterior slide tracheoplasty and was successfully extubated. Two patients with left-right slide tracheoplasty and another two patients with tracheal end-to-end anastomosis for the stenosis below the RULB could not be extubated. Tracheal end-to-end anastomosis or slide tracheoplasty can be selected for tracheal stenosis above the RULB according to the length of stenosis. Posterior-anterior slide tracheoplasty appears feasible for tracheal stenosis below the RULB or above the RULB to the carina.

Congenital tracheobronchial stenosis

Congenital tracheobronchial stenosis is a rare disease characterized by complete tracheal rings that can affect variable lengths of the tracheobronchial tree. It causes high levels of morbidity and mortality both due to the stenosis itself and to the high incidence of other associated congenital malformations. Successful management of this complex condition requires a highly individualized approach delivered by an experienced multidisciplinary team, which is best delivered within centralized units with the necessary diverse expertise. In such settings, surgical correction by slide tracheoplasty has become increasingly successful over the past 2 decades such that long-term survival now exceeds 88%, with normalization of quality of life scores for patients with non-syndrome-associated congenital tracheal stenosis. Careful assessment and planning of treatment strategies is of paramount importance for both successful management and the provision of patients and carers with accurate and realistic treatment counseling.

Secondary Reverse Slide Tracheoplasty for Airway Rescue

Slide tracheoplasty is used in cases of tracheal stenosis or injury. With expanding indications for its use at tertiary centers, salvage techniques for dehiscence or restenosis after slide tracheoplasty are increasingly relevant. We present a case in which slide tracheoplasty was augmented with an anterior costochondral graft that stenosed again and ultimately failed. We salvaged this airway emergency by performing a secondary reverse slide tracheoplasty. Using this technique, we were able to establish a safe and durable airway using only native airway tissue.

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.

Congenital diaphragmatic hernia and complete tracheal rings: Repair on ECMO

A term newborn female presented with prenatally diagnosed congenital diaphragmatic hernia and postnatally diagnosed complete tracheal rings and tracheal stenosis. Initially, the spells associated with tracheal stenosis were misdiagnosed as pulmonary hypertension. Bronchoscopy showed a critically narrowed airway, and veno-arterial ECMO stabilized the baby for further workup. The endotracheal tube was removed while on ECMO to avoid further injury to the airway. Staged CDH repair followed by slide tracheoplasty were performed on ECMO. The multidisciplinary approach included neonatology, general surgery, otolaryngology, cardiac surgery and anesthesiology.

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.