Reconstruction Of Trachea Research Articles

Video-assisted thoracoscopic surgery resection and reconstruction of thoracic trachea in the management of a tracheal neoplasm.

Intratracheal tumor is a rare tumor, accounting for only 2% of upper respiratory tract neoplasms. Its symptoms are similar to those of head and neck cancers, including coughing up blood, sore throat, and airway obstruction. The diagnosis of this disease is often based on the findings of fibrobronchoscopy or computed tomography (CT). Surgery remains the treatment of choice for tracheal tumor. In patients with benign neoplasms or if the tumors have limited involvement, fibrobronchoscopic resection of the tumor can be performed. For malignant tumors, however, radical resection is required. In the past, open incision is used during the surgery for tumors located in thoracic trachea. Along with advances in video-assisted thoracoscopic surgery (VATS) minimally invasive techniques and devices, VATS resection and reconstruction of the trachea can achieve the radical resection of the tumor and meanwhile dramatically reduce the injury to the patients. In this article we describe the application of VATS resection and reconstruction of trachea in the management of a tracheal neoplasm.

Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of trachea under non-intubated anesthesia with spontaneous breathing.

Radical surgery for tracheal tumors is typically completed under basal anesthesia. Thus, endotracheal intubation and mechanical ventilation are required. However, these procedures may influence the surgical operation and meanwhile prolong the surgical duration and postoperative recovery. In this article we describe the application of video-assisted transthoracic surgery (VATS) resection of a tracheal mass and reconstruction of trachea a non-intubated patient with spontaneous breathing.

Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea.

Tumors of the upper trachea are typically treated by tracheal resection and reconstruction via neck incision under general anesthesia. In recent years, non-intubated thoracic surgery has been widely applied for the treatment of lung diseases due to its advantages including quick postoperative recovery. In this article, we describe the application of non-intubated tracheal resection and reconstruction in one patient for the treatment of a mass in upper trachea.

Adenocystic carcinoma of the trachea

It is presented 40-years experience of tracheal adenocystic carcinoma diagnosis and management in 144 patients. Peculiarities of clinical course and choice of diagnostic and therapeutic measures are discussed in relation to stenosis and hypoxia degree and severity of accompanying inflammatory complications of trachea, bronchi and lungs. Technical tools and original methods of resection and reconstruction of trachea and it's bifurcation after extended lung resection are described. Surgical management is carried out in 96 patients: all patients underwent circular resection of trachea (77) or it's bifurcation (19). Morbidity rate was 22.9% and mortality - 3.1%. Additional radiotherapy was carried out in 50 patients. 41 patients underwent radiotherapy alone. Radiotherapy improves remote results of management. 5-and 10-year survival rate was 78.3±6.1 and 45.9±7.9% after surgery alone, 92.0±3.9 and 77.1±6.5% after combined treatment and 76.4±6.5 and 55.0±10.7% after radiotherapy alone respectively.

Fibro-bronchoscopic cryosurgery for unresectable endobronchial tumors

背景与目的气管、支气管肿瘤性的狭窄或闭塞，大多发生于病程的晚期，患者会出现十分痛苦的症状，如呼吸困难、咯血、阻塞性肺炎和顽固性高热。全身情况较差，心肺功能受限，原发灶和转移灶均不能耐受根治性手术切除。呼吸道梗阻严重影响了生存质量，甚至引起呼吸衰竭导致死亡。因此，一种能够有效解除梗阻的治疗方法就显得尤为重要。我们选择在纤维支气管镜下运用二氧化碳（carbon dioxide, CO2）冷冻技术对气管、支气管腔内肿瘤进行切除，探讨其治疗效果。方法对126例气管、支气管肿瘤进行冷冻治疗（2004年8月-2014年2月），观察近期及远期治疗效果。术前需要进行计算机断层扫描（computed tomography, CT）加气管、支气管的三维重建，纤维气管镜检查后评估冷冻的部位和深度；术中采用全麻或表面麻醉加静脉强化，置入纤维支气管镜至肿物上端约0.5 cm，后将软式冷冻探头经支气管镜活检孔插入。冷冻探头的金属末端置于肿瘤中心，冷冻约30 s-120 s，冷冻温度-50 ℃--70 ℃。在冷冻后未完全溶解前“撕脱”切除肿瘤（冻切法）或者冻时间4 min-6 min后通过负压吸引清除冷冻后坏死的肿瘤组织（冻融法），两种方法相结合可以较为彻底地清除气道内肿瘤，直至管腔通畅。2周后复查气管镜，决定是否需要再次冷冻治疗。结果患者咳嗽、呼吸困难、咯血均有不同程度缓解，显效率为65.1%，总有效率77.0%。围手术期死亡1例，术后气道内出血2例，支气管瘢痕狭窄4例，气管烧灼伤2例，气管软化2例，心房纤颤3例。中位生存期为14个月，1年、2年、3年的生存率分别为58.6%、24.2%、12.2%。结论纤维支气管镜CO2冷冻技术是一种十分简便而有效的微创治疗方法。治疗管腔内生长的中央型气道肿瘤，可以去除肿瘤阻塞气道的部分，重新疏通管腔，迅速控制和缓解气道梗阻所导致的症状，显著提高生存质量。部分患者可以解决麻醉气管插管问题，为下一步治疗创造条件，从而达到根治性切除原发肿瘤的目的。

Tracheal reconstruction using chondrocytes seeded on a poly(l-lactic-co-glycolic acid)-fibrin/hyaluronan

Reconstruction of trachea is still a clinical dilemma. Tissue engineering is a recent and promising concept to resolve this problem. This study evaluated the feasibility of allogeneic chondrocytes cultured with fibrin/hyaluronic acid (HA) hydrogel and degradable porous poly(L-lactic-co-glycolic acid) (PLGA) scaffold for partial tracheal reconstruction. Chondrocytes from rabbit articular cartilage were expanded and cultured with fibrin/HA hydrogel and injected into a 5 × 10 mm-sized, curved patch-shape PLGA scaffold. After 4 weeks in vitro culture, the scaffold was implanted on a tracheal defect in eight rabbits. Six and 10 weeks postoperatively, the implanted sites were evaluated by bronchoscope and radiologic and histologic analyses. Ciliary beat frequency (CBF) of regenerated epithelium was also evaluated. None of the eight rabbits showed any sign of respiratory distress. Bronchoscopic examination did not reveal stenosis of the reconstructed trachea and the defects were completely recovered with respiratory epithelium. Computed tomography scan showed good luminal contour of trachea. Histologic data showed that the implanted chondrocytes successfully formed neocartilage with minimal granulation tissue. CBF of regenerated epithelium was similar to that of normal epithelium. Partial tracheal defect was successfully reconstructed anatomically and functionally using allogeneic chondrocytes cultured with PLGA-fibrin/HA composite scaffold.

Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea.

Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in the intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume, low-pressure cuffs. In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable, due to local or general reasons: long strictures, inflammation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered the treatment of choice in the presence of inflammation and/or when removal is desirable. We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenosis: a 39-year old woman with failed initial operation, and continuous relapses with proliferation after multiple bronchscopic interventions, and a 20-year old man in a poor neurological status, with a long tracheal stricture involving the subglottic larynx (lower posterior part), and inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus). The airway was immediately re-establish, without complications. At 15- and 10-month follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2(nd) patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting appeared safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis, involving the lower posterior subglottic larynx in the presence on inflammation and poor neurological status.

Reconstruction of the (Crico)trachea for malignancy in the virgin and irradiated neck

Reconstruction of the trachea following resection for malignancy is challenging. We present our experience over a 5-year period, and a reconstruction algorithm with particular emphasis on minimising complications associated with radiotherapy. A maximum of six tracheal rings can be resected and anastomosed primarily with acceptable tension. A more conservative approach is required in an irradiated trachea. For a limited defect localised anteriorly or laterally, a tracheal flap can be fashioned. As for more eccentric defects, an option is to convert the defect into an asymmetrical segmental defect, and to primarily anastomose the trachea with rotation of the distal stump. Our workhorse loco-regional flaps for patch reconstruction or suture line reinforcement include the sternocleidomastoid, internal mammary artery perforator and pectoralis major myocutaneous flaps. For extensive defects, a radial forearm free flap (RFFF) with rib cartilage struts for rigidity provides a good solution. Fifteen patients (M:F=4:11, median age 69 years) were identified. Six cases were locally aggressive papillary thyroid cancer. Mean follow-up was 17 months. Five and two patients had had radiotherapy prior to and following tracheal resection, respectively. Nine patients were extubated at the end of surgery, two were successfully decannulated from their T tube subsequently, and one from his tracheostomy. The two surgical complications included a partial RFFF dehiscence causing minor air leak, and major haemorrhage that warranted urgent operation and pectoralis major flap reconstruction. Reconstruction of the trachea requires individualised techniques suited to the patient's body habitus, co-morbidity, previous treatment and the configuration of the defect.

Experimental use of pulmonary flap with alloy stent for the reconstruction of trachea and esophagus

To study the feasibility of applying autogenous pulmonary tissue flap with alloy stent to correct the defects of trachea and esophagus. Twenty-four dogs were divided into tracheal and esophageal groups. Bronchus was ligated to prepare a pulmonary flap. And a defect of 3 - 4 cm long and 1/2 - 2/3 perimeter was made in tracheal or esophageal wall. Pulmonary arteries and veins were protected. Then the pulmonary gas was emitted to create a pulmonary tissue flap. The defect was repaired with a pulmonary flap with a self-expanded stent inside. The gross appearance, histological appearance, CT and barium X-ray films were observed at Weeks 2, 4, 6 and 8 post-operation. Eighteen experimental dogs survived over 2 weeks. Anastomotic leak was the main cause of death. Two dogs died of perforation of ulcer in esophageal group. Reliable cicatrisation was observed between the pulmonary tissue flap and damage area. A quick growth of new tracheal and esophageal epithelium was observed from periphery area to central area. During the first 2 weeks, a little epithelization was observed at free edge of anastomosis equivalent to 1 - 2 layers of new epithelial cells. At weeks 4 - 6 post-operation, the internal surface of defect was covered with 3 - 5 layers of epithelial cells. At Weeks 8 - 10 post-operation, the luminal surface was covered with 6 - 8 layers of stratified epithelial cells. More ulcers could be observed on the surface of pulmonary tissue flap in esophageal group. In pulmonary flap, massive fibrous tissue proliferated and fibroblasts were active, but no necrosis occurred. CT and barium X-ray showed no obstruction in anastomotic stoma. With an excellent compatibility with epithelial cells of trachea and esophagus, the autogenous pulmonary tissue flap can support the mucosal crawl in the defect of trachea and esophagus. When combined with alloy stent, it may be a choice procedure for reconstructing the defect of trachea and esophagus.

Factors Affecting Tissue Culture and Transplantation Using Omentum

In tissue engineering, a stable tissue layer and blood vessels are required for complete tissue formation, to provide structural strength and thickness and to supply oxygen and various nutrients. However, this has not been achieved using in vitro tissue-engineered culture techniques, thus many tissue engineering studies of trachea, bladder, and intestine reconstruction have used omentum. However, many factors critical to cell culture and transplantation using omentum have not yet been studied. For these reasons, we conducted a study of artificial trachea reconstruction in dogs using a poly(lactic-co-glycolic acid) (PLGA) porous scaffold, polypropylene prosthesis, and PKH26-labeled cells. We analyzed factors affecting tissue-engineered reconstruction using omentum, such as cell distribution and formation of cell layer and stability of transplant shape on omentum. As a result, we classified failure factors for tissue-engineered application of omentum and suggested three considerations for effective use of omentum in tissue engineering. Our observations may aid in the design and execution of future studies of omentum usage in tissue engineering.

Regeneration of Tracheal Epithelium Utilizing a Novel Bipotential Collagen Scaffold

The purpose of the present study was to evaluate the effectiveness of a novel bipotential collagen scaffold as a bioengineered trachea for the regeneration of the tracheal epithelium. The bipotential collagen scaffold was developed by conjugating a collagen vitrigel membrane to a collagen sponge in order to promote both epithelial cell growth and mesenchymal cell infiltration. The bipotential collagen scaffold was transplanted into tracheal defects in rats, and a conventional collagen sponge was implanted as a control model. Histologic examinations were undertaken to evaluate the results. The bioengineered trachea was covered with epithelium in the vitrigel model, but not in the control model, at 7 days after implantation. At 14 days after implantation, the bioengineered trachea was covered with epithelium involving the basal cell layer in the vitrigel model. At 28 days after implantation, a columnar ciliated epithelium was observed only in the vitrigel model. Our technique for trachea reconstruction using a novel bipotential collagen scaffold affords a feasible approach for accelerating epithelial regeneration on the intraluminal surface of the host tracheal defect.

Trachealaplasie – eine besonders seltene und dramatische Fehlbildung

Tracheal agenesis (TA), aplasia or total atresia of the trachea are congenital anomalies which are still incompatible with life. Despite the many attempts of different interventions, there are yet no promising, long-term methods of treatment. Only with sufficient proportion of the proximal or distal trachea available, it is possible to place a tracheostomy, which also opens up new vistas of life for the affected child. In most cases the seldom deformation, trachealagenesis, does not get recognised before the child is born. It may therefore be the immediate diagnosis postnatal that is decisive over the final prognosis of the child. The prepartal suspicion of a duodenal stenosis, an aphonic newborn as well as the frustrane attempts of intubation are possible guidelines of TA. In independence of peripartal and anamnestical factors, individual disciplinary decisions are necessary for further treatments. After the cancellation of intensive care the premature infant of the case report died as consequence of postnatal diagnosed tracheal aplasia. Under circumstances, medical treatments such as the ex utero intrapartum procedure (Exit), the temporary method of extracorporal membrane oxygenation (ECMO) or the use of cartilage tissue for the plastic trachea reconstruction can provide advanced medical opportunities.

Accelerated angiogenesis by continuous medium flow with vascular endothelial growth factor inside tissue-engineered trachea☆

To test the effects of a continuous medium flow inside DegraPol scaffolds on the reepithelialization and revascularization processes of a tissue-engineered trachea prosthesis. In this proof-of-principle study a continuous medium flow was maintained within a tubular DegraPol scaffold by an inserted porous catheter connected to a pump system. The impact of the intra-scaffold medium flow on the survival of a tracheal epithelial sheet wrapped around and on chondrocyte delivery to the DegraPol scaffold was studied. In the chick embryo, chorioallantoic membrane (CAM) model angiogenesis within the biomaterial was investigated. Scanning electronic microscopy (SEM) images showed an intact epithelial layer after a 2-week support by continuous medium flow underneath. On histology, three-dimensional cell growth was detected in the continuous delivery group. The CAM assay showed that angiogenesis was enhanced within the DegraPol scaffolds when vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) was added to the perfusate. Taken together, these results demonstrated that the built-in perfusion system within DegraPol scaffolds was able to maintain an intact tracheal epithelial layer, allowed a continuous delivery of cells, and kept an efficient VEGF/VPF expression level which accelerated angiogenic response in the CAM assay. This design combines the in vitro and in vivo parts of tissue engineering and offers the possibility to be used as an in vivo bioreactor implanted for the tissue-engineered reconstruction of trachea and of other organs.

Prefabricated and Prelaminated Forearm Flaps for Larynx and Trachea Reconstruction

The current surgical treatment for unilateral, advanced, glottic cancer is a total laryngectomy. Tracheal autotransplantation by prefabrication with a custom radial forearm fascia flap allows for reconstruction of extended hemi-laryngectomy defects. The technique involves a two-stage procedure. After the neck and tumor resection, a 4-cm cervical trachea segment is wrapped with a radial forearm fascia flap that is designed with a proximal skin paddle which is used for temporary closure of the extended defect and serves as a monitor island after microvascular anastomoses in the neck. In 2 weeks, this trachea segment is revascularized. In a second stage, after the hemi-laryngectomy, the prefabricated vascularized trachea segment is completely isolated from the airway and transformed into a patch which is sutured to the laryngeal defect.

S3-2 Experimental and clinical study of two-stage reconstruction of trachea with "sandwich" pedicle artificial trachea(Artificial Trachea-Biomaterial and/or Regenerative Surgery)

S3-2 Experimental and clinical study of two-stage reconstruction of trachea with "sandwich" pedicle artificial trachea(Artificial Trachea-Biomaterial and/or Regenerative Surgery)

Engineering a Composite Neotrachea in a Rat Model

Attempts to reconstruct the trachea have been largely unsuccessful because of its rigidity and opening to the outside environment. Materials that impart rigidity are usually alloplastic, so they cannot be exposed to the open environment without an unacceptably high risk of infection and rejection. The authors hypothesized that tissue engineering principles can be employed to construct a well-integrated neotrachea with rigid support and an epithelial lining to mimic the structure and function of the native trachea. A 30-mm-long segment of polytetrafluoroethylene vascular graft with a diameter of 10 mm was lined with a fascial flap based on the superficial inferior epigastric artery with full-thickness skin grafts on its luminal surface. The composite unit was then buried under the abdominal skin of 20 rats and harvested 3 weeks later. Microfil and methylene blue dye were injected into the superficial inferior epigastric arteries and histologic analyses were performed to assess microcirculation and polytetrafluoroethylene-tissue integration. Two composite neotracheas experienced minor damage due to chewing by the rats, but all other neotracheas were viable and without infection. Injection studies demonstrated excellent circulation throughout the fascial flaps and skin grafts and across the polytetrafluoroethylene grafts to the overlying abdominal skin. Histologic analyses revealed abundant muscle-walled blood vessel ingrowth within the polytetrafluoroethylene grafts and all layers of the neotracheas with minimal inflammatory reactions. The authors successfully have engineered a well-integrated neotrachea in rats that possesses rigid support, an epithelial lining, and reliable coverage-the prerequisites for successful trachea reconstruction.

INVITED COMMENTARY

INVITED COMMENTARY

Surgical Treatment of Pulmonary Artery Sling and Tracheal Stenosis

Pulmonary artery sling is a rare vascular ring and is commonly associated with tracheal stenosis. Symptomatic newborns and infants with these complex lesions have a high mortality rate without surgical intervention. The ideal operation remains controversial, with debate focusing on the need for left pulmonary artery for reimplantation and the technique of tracheal reconstruction. From 1983 to 2003, 14 patients with pulmonary artery sling (mean age, 7 months; range, 6 days to 27 months) underwent repair of pulmonary artery sling alone (6 patients), tracheoplasty alone (1 patient), and pulmonary artery sling repair with tracheoplasty (7 patients). Preoperatively, 7 patients were intubated, 2 had VATER (vertebral, anal, tracheal, esophageal, and radial anomalies) syndrome, and 2 patients had agenesis of the right lung. The left pulmonary artery was reimplanted at the ductal insertion site in 13 patients. One patient had left pulmonary artery translocation. Tracheoplasty employing extracorporeal circulation consisted of autologous pericardial patch (6 patients) or slide tracheoplasty (2 patients). Six patients with pulmonary artery sling and mild tracheal stenosis required only left pulmonary artery reimplantation. Concomitant procedures included closure of atrial septal defect (4 patients), ventricular septal defect (4 patients), and shunt for Fallot's tetralogy (2 patients). There were 2 hospital deaths (2 of 14;14%) from abdominal sepsis (1) and renal failure (1). Reoperations included diaphragm plication (2), tracheostomy (1), and bronchoscopy with laser resection of granulation tissue (5 patients: 2 slide, 3 pericardium). Follow-up was complete in all patients (mean, 42 months) with 1 late death from fungal sepsis. At follow-up, all left pulmonary artery anastomoses were patent by echocardiography, and no patient has required reoperation for trachea reconstruction. These data demonstrate that tracheal repair is not always necessary in the presence of pulmonary artery sling; that agenesis of the right lung is not a contraindication to successful complete repair; and that simultaneous correction of intracardiac defects can be safely performed in selected patients. This study suggests that in newborns and infants, pericardial patch and slide tracheoplasty are effective methods for trachea reconstruction.

Circumferential trachea reconstruction with a prefabricated axial bio-synthetic flap: experimental study

The ideal method, in reconstruction of circumferential tracheal defects more than 50% of the total tracheal length, is still a question. Current methods lack either in epithelial lining or in skeletal framework. In this study, we designed an axial biosynthetic prefabricated flap to reconstruct the circumferential tracheal defects in rabbits. Ten rabbits are used. The inner mucosal lining is substituted by hairless epithelium obtained from proximal ear. The tracheal cartilage is substituted by polypropylene mesh and the tracheal adventitia is substituted by lateral thoracic fascia as a vascular supply. The study is designed in three stages. Stage 1: Hairless epithelial graft is obtained by secondary healing of a full thickness skin defect in ear. Stage 2: Epithelial graft, polypropylene mesh and lateral thoracic fascia are tubed around a silicone catheter. This structure is dissected through its pedicle (lateral thoracic vessels and fascia) to the axilla and mobilized. The prefabricated neotrachea is carried on its pedicle to the cervical area through a subcutaneous tunnel formed superficial to the sternum and left there for 2 weeks. Stage 3: The silicone catheter is taken out and prefabricated neotrachea is adapted to the defect formed in native trachea and anastomized. Later the animals are evaluated for 4 weeks. The patency of the lumen, the viability of the epithelial graft and fascia, airtightness of the anastomoses and other features of the reconstruction are evaluated by radiological, macroscopical and histological examinations. Survival at 4 weeks was 70%. All of the prefabricated neotracheas and epithelial grafts were viable. The rigidities, longitudinal elasticities, diameters and wall thickness were similar to native tracheas. Occlusion of lumen is encountered only in one animal. There was no hair growth from the epithelial lining. The study defines a new method of circular tracheal reconstruction with successful substitution of inner lining, skeletal framework and vascular supply.

Long-term outcome of the implanted hydroxyapatite block for the reconstruction of trachea

Long-term outcome of the implanted hydroxyapatite block for the reconstruction of trachea