Tracheobronchial Reconstruction Research Articles

Right tracheal sleeve pneumonectomy with VV-ECMO assistance for non-small cell lung cancer through anterior thoracotomy: a single centre experience.

For a long time, non-small cell lung cancer (NSCLC) arising less than 2 cm distal to the carina has been usually considered unresectable and incurable with a radical or extended resection because of surgical technical difficulty and airway management. Recently, the introduction of more advanced surgical techniques, often including the use of extracorporeal life support (ECLS), has allowed us to extend the limits of conventional surgery, increasing the rate of complete surgical resection. ECLS also overcomes the limitation of conventional ventilation during complex tracheo-bronchial reconstruction, avoiding the presence of disturbing lines or tubes that obstruct the operative field during a challenging surgery. In this article, we share our experience in performing right tracheal sleeve pneumonectomy with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in three cases by anterior right thoracotomy, reporting our tips and tricks.

Tracheobronchial reconstruction by inverted Barclay\u2019s method for tracheobronchial injury in an 8-year-old girl: a case report

BackgroundTracheobronchial injury in children is rare but can be highly fatal in severe cases. Therefore, prompt diagnosis and treatment are required. The appropriate treatment method depends on the extent and severity of the injury.Case presentationAn 8-year-old girl fell from the fifth floor and was transported to a local hospital. She had a tracheobronchial injury, went into cardiopulmonary arrest during transportation to our hospital. She was revived with cardiopulmonary resuscitation, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was commenced. Subsequently, we performed tracheobronchial reconstruction by inverted Barclay’s method for tracheobronchial injury. She was switched from VA-ECMO to venovenous (VV)-ECMO 4 days postoperatively, and VV-ECMO was eventually discontinued 27 days after the surgery. The patient was awake and weaned off the ventilator on postoperative day 58. She was discharged 97 days after the surgery.ConclusionsTracheobronchial reconstruction by inverted Barclay’s method is the preferred surgical technique when other reconstruction techniques are expected to cause excessive tension on the anastomosis of the right main bronchus.

Patient-specific simulation for tracheobronchial reconstruction procedures using 3-dimensional operable models: A proof-of-concept study.

Patient-specific simulation for tracheobronchial reconstruction procedures using 3-dimensional operable models: A proof-of-concept study.

A 3-dimensional airway model for tracheobronchial surgery.

A 3-dimensional airway model for tracheobronchial surgery.

Repairing the injured bronchus in blunt chest trauma – A case series

Introduction Traumatic bronchial injury (TBI) is uncommon, difficult to diagnose and often missed. The incidence of TBI among blunt trauma patients is estimated to be around 0.5–2%. Bronchoplastic surgery is indicated in most cases to repair the tracheobronchial airway and preserve lung capacity. There is limited existing literature addressing the management of this condition in view of its rarity. The comprehensive management and outcomes of these patients are discussed. Methods The case notes of all patients who presented with persistent lung collapse due to trauma since July 2017 were reviewed retrospectively. Those patients requiring surgical intervention were included in the review. The mode of injury, clinical, radiological and bronchoscopy findings, concurrent injuries, type of surgery, length of stay (LOS) and operative outcomes were reviewed. Results Out of 11 patients who presented with persistent lung collapse post-blunt trauma, four (36%) were found to have structural bronchial disruption. All of them underwent successful repair of the injured bronchus, without the need of a pneumonectomy. The other seven patients were successfully treated conservatively. Conclusion The repair of the injured bronchus is essential in improving respiratory function and to prevent a pneumonectomy. Routine bronchoscopic evaluation should be performed for all suspected airway injuries as recommended in our management algorithm. Delayed presentations should not hinder urgent referral to thoracic centers for tracheobronchial reconstruction.

Tracheobronchial Reconstruction with Implantation of the Right Main Bronchus : Surgical Technique in the Treatment of Tracheal Adenoid Cystic Carcinoma (ACC)

Tracheobronchial Reconstruction with Implantation of the Right Main Bronchus : Surgical Technique in the Treatment of Tracheal Adenoid Cystic Carcinoma (ACC)

Extracorporeal membrane oxygenation support for complex tracheo-bronchial procedures†.

The published experience with advanced broncho-plastic procedures performed with extracorporeal membrane oxygenation (ECMO) support is very limited. We examined our results to assess the risks and benefits of this approach. We retrospectively analysed all patients with thoracic malignancies who underwent complex tracheo-bronchial reconstruction under ECMO support in our department between 2001 and 2013. Ten patients (age range 21-81 years, mean 54 ± 11 years) underwent complex tracheo-bronchial reconstructions under veno-arterial ECMO support. In 7 patients, the underlying pathology was non-small-cell lung cancer, in 2 cases carcinoid tumour and in 1 case adenoid cystic carcinoma. ECMO cannulation was central (n = 7) or peripheral (n = 3). Mean time on bypass was 113 ± 17 min (range 70-135 min). A complete resection (R0) was achieved in 8 patients (80%). There was no perioperative mortality. Patients were discharged from the hospital after 7-52 days (median 11 days). Median time on ICU was 1 day (range 1-36 days). There was no complication related to the use of ECMO in this series. Mean follow-up time was 1694 ± 1385 days (range 12-4338). The 1-, 3- and 5-year Kaplan-Meier survival was 100, 74 and 56%, respectively. Based on this experience, we consider veno-arterial ECMO support as a safe and valuable approach for complex airway surgery.

Successful tracheobronchial reconstruction of communicating bronchopulmonary foregut malformation and long segment congenital tracheal stenosis: a case report

Communicating bronchopulmonary foregut malformation (CBPFM) and congenital tracheal stenosis (CTS) are difficult developmental disorders especially when they are presented simultaneously in a patient. The authors report a case of a newborn boy born at 37 weeks of gestation weighing 2356 g with CBPFM (right esophageal lung) and long segment CTS. Staged surgical repair (by-force endotracheal intubation for securing the airway followed by bronchotracheal anastomosis for CBPFM, tracheostomy with handmade, length-adjustable tracheostomy tube, and slide tracheoplasty) was performed. He has been healthy without tracheostomy for 25 months after slide tracheoplasty. This is the first report of a successful tracheobronchial reconstruction for a patient with a long segment CTS and CBPFM preserving the affected lung function.

EComment. Mucoepidermoid carcinoma: common findings and surgical treatment

We read with interest the paper by Papiashvilli and co-authors, reporting on an interesting case of mucoepidermoid carcinoma of the lower trachea in a 9-year old boy [1]. Mucoepidermoid carcinomas are rare neoplasms [2] of the bronchial tree arising from mucous and serous glands of the epithelium. They are rare and represent about 1% to 5% of bronchial adenomas, including also adenoid cystic carcinomas (cylindromas), mucous gland adenomas and carcinoids. The term “bronchial adenomas” is not correct because it refers to a benign process, and experience has demonstrated that these tumours have a broad spectrum of biologic activity and can sometimes have malignant behaviour. The term “bronchial adenomas” has therefore been recently replaced by “bronchial gland tumours”. These slow-growing tumours usually manifest with irritation and obstruction of the tracheobronchial tree and symptoms are related to their site [3]. When these masses are located in the trachea, as with the case presented by Papiashvilli et al, they produce upper respiratory tract occlusion with cough, wheezing and dyspnea. In this young patient, respiratory distress was interpreted as asthma until a CT scan showed the tracheal obstruction. Tracheal obstruction must always be suspected in intractable asthma, also in young patients. In cases of localization in the proximal or segmental bronchi, symptoms are usually related to progressive occlusion of a bronchus and therefore are characterized by relapsing pneumonia. Complete surgical resection is the treatment of choice for mucoepidermoid carcinoma. Endoscopic resection has been attempted, but the incidence of local relapse is high. It has a role only as a temporary option in order to plan and facilitate surgery. The principles of surgery are a clear margin at frozen section, complete locoregional lymph nodes removal and maximum sparing of lung parenchyma with tracheobronchial resection and reconstruction techniques. In the case reported by Papiashvilli and co-workers they performed an excellent and successful operation through a sternotomy, which is an unusual access to the lower trachea. As reported by the authors, the choice was based on “difficulty ventilating the child” and “the existence of immediate cardiopulmonary by-pass facilities”. Being general thoracic surgeons, we would have made the same operation through a right thoracotomy, and would have been ready to use a partial by-pass with peripheral cannulation, if required. We appreciate the report of such an unusual case successfully treated in a young boy. Conflict of Interest: None declared

Tracheobronchial reconstructions with bronchoplastic closure: An alternative method in treatment of bronchogenic carcinoma involving the carina or tracheobronchial angle

Our objective was to summarize our experience with tracheobronchial reconstructions using bronchoplastic closure for airway defects after noncircumferential resections of bronchogenic carcinoma involving the carina or tracheobronchial angle. From January 1990 to December 2005, all patients who underwent tracheobronchial reconstructions with bronchoplastic closure for bronchogenic carcinoma involving the carina or tracheobronchial angle were included. The clinical data for patients were collected retrospectively, including demographic characteristics, occurrences of postoperative complications, and survival. A total of 40 patients were eligible, including 23 who had right pneumonectomies, 6 who had right upper lobectomies, and 11 who had left pneumonectomies, associated with lower lateral wall of the trachea resections or with partial carinal resections for centrally localized tumors. The airway defects ranged from 0.5×2 cm to 2×4 cm and involved up to 50% of the airway circumference. Microscopic residual disease was found postoperatively at the bronchial margin in 20% (8/40). Of 40 patients, 2 (5.0%) had pulmonary atelectasis develop, 2 (5.0%) arrhythmia, 2 (5.0%) bronchopleural fistula, and 1 (2.5%) airway stenosis after operation. Thirty-day mortality was 2.5% (1/40). Median survival for 40 patients was 18.5 months with a cumulative survival of 72.2%, 26.6%, and 21.3% at 1, 3, and 5 years, respectively. Tracheobronchial reconstruction using bronchoplastic closure might be a reasonable option for closing massive central airway defects for advanced bronchogenic carcinoma involving the tracheobronchial angle or carina, avoiding tracheal sleeve pneumonectomy with limited excision of the lateral wall of the trachea or carina.

Invited Commentary

Invited Commentary

A Novel Tracheobronchial Reconstruction for Right Upper Lung Carcinoma Involving the Lower Trachea: Preliminary Results

We developed a novel technique for tracheobronchial reconstruction after resection of carcinoma of the right upper lung involving the right main bronchus and lower trachea. Preliminary results of the technique are reported. Between December 2007 and October 2011, 9 patients underwent treatment with our new technique. The right upper lobe was resected together with the involved right main bronchus and right lateral wall of the lower trachea. Closure of the trachea was started at the level of the carina and continued upward, leaving an oval opening at the upper end of the tracheal defect, to which the bronchus intermedius was reimplanted. The sutured lower trachea became the extension of the left main bronchus. The procedure was completed successfully in all 9 patients. Two patients underwent partial carinal resection, 2 underwent replacement of the superior vena cava by interposition graft, 2 underwent partial resection of the superior vena cava, and 1 underwent partial resection of the esophageal wall. There were no perioperative deaths. No major complications, including dehiscence, stenosis, and adult respiratory distress syndrome, were observed. Arrhythmia occurred in 2 patients, and vocal cord paresis and pneumonia occurred in 1 patient. One patient died 31 months after operation, and 1 patient was lost to follow-up 28 months after operation, without tumor recurrence. The other 7 are alive to date. Despite this being a small series and short follow-up, this tracheobronchial reconstruction shows encouraging preliminary results with low mortality and morbidity, and could be an alternative to other methods for the treatment of carefully selected patients with advanced carcinoma of the right upper lobe.

Extracorporeal Membrane Oxygenation Support for Resection of Locally Advanced Thoracic Tumors

The international experience with resection of advanced thoracic malignancies performed with extracorporeal membrane oxygenation (ECMO) support is limited. We examined our results to assess the risks and benefits of this approach. We retrospectively analyzed all patients with thoracic malignancies who underwent tumor resection with ECMO support in our department between 2001 and 2010. Nine patients (aged 21 to 71 years; mean, 54.8±7.5 years) underwent complex tracheobronchial resections (n=6) or resections of greater thoracic vessels (n=3) under venoarterial (VA) ECMO support. In 7 patients the underlying pathologic condition was non-small cell lung cancer, in 1 patient it was carcinoid tumor, and in 1 patient it was synovial sarcoma. The indication for extracorporeal support was complex tracheobronchial reconstruction (n=5), resection of the descending aorta (n=2), and resection of the inferior vena cava (n=1). ECMO cannulation was central (n=4), peripheral (n=4), or combined (n=1). Mean time on bypass was 110±19 minutes (range 40 to 135 minutes). A complete resection (R0) was achieved in 8 patients (89%). One patient died perioperatively as a result of hepatic necrosis. Eight patients were discharged from the hospital after 7 to 42 days (median, 10 days). Median time in the intensive care unit was 1 day (range, 0 to 36 days). The only complication related to the use of ECMO was a lymphatic fistula in the groin. Mean follow-up time was 38±42 months (range, 9 to 111 months). The actuarial 3-month survival was 88.9%, and the 1-year, 3-year, and 5-year survival was 76.7%. Based on this experience, we consider VA ECMO support to be a safe alternative to cardiopulmonary bypass (CPB) for advanced general thoracic operations.

Tratamento endovascular de pseudoaneurisma de aorta torácica com fístula aorto-brônquica em pós-operatório tardio de cirurgia de correção de coarctação de aorta

Fístula aorto-brônquica é uma conexão entre a aorta e o brônquio, e mesmo quando imediatamente reconhecida e tratada possui alto risco de letalidade. Pode se desenvolver após cirurgias de aorta, e é geralmente uma consequência de pseudoaneurisma. A hemoptise, massiva ou intermitente, é o principal sintoma apresentado. O tratamento convencional da fístula aorto-brônquica é a cirurgia aberta de aorta torácica, com reconstrução traqueobrônquica. Recentemente, o reparo endovascular tem sido proposto como uma alternativa. Os autores apresentam um relato de tratamento endovascular, realizado com êxito, de pseudoaneurisma de aorta torácica com fístula aorto-brônquica 22 anos após cirurgia para correção de coarctação aórtica.

Biodegradable polymer coating promotes the epithelization of tissue-engineered airway prostheses

We have developed a prosthesis that includes a collagen layer for tracheobronchial reconstruction and applied it in a canine model. In previous studies luminal epithelization remained partial or rather slow because of the early disintegration of the collagen layer. We have improved this type of prosthesis by coating the luminal surface with a biodegradable polymer, which serves to protect the collagen layer. The effect of the polymer coating on the epithelization of the luminal surface of the prosthesis was examined. The main frame consisted of a polypropylene mesh tube, measuring 15 mm in inner diameter and 30 mm in length, with reinforcing rings. Collagen extracted from porcine skin was conjugated to this frame. The luminal surface was coated with a polymer, poly (L-lactic-acid-co-epsilon-caprolactone). In 5 beagle dogs the left main bronchus was replaced with this prosthesis, periodic bronchoscopic observations were conducted, and microscopic evaluations were performed. All dogs survived until they were killed, except for 1 animal in which pneumonia developed, and this animal died at 13 months after replacement. None of the dogs showed adverse complications caused by the prosthesis. Bronchoscopic observations revealed that the polymer remained on the luminal surface for 2 weeks. The luminal surface in 4 dogs was completely covered with ciliated columnar epithelium or nonciliated squamous epithelium, and 90% epithelization was achieved in 1 dog. The biodegradable polymer coating protected the collagen layer and promoted better epithelization. This improved epithelization on the luminal surface could therefore potentially increase the success rates in airway replacement with artificial prostheses.

Inhalation with Tobramycin® to improve healing of tracheobronchial reconstruction☆

Sleeve resections were introduced to preserve lung function in patients with limited pulmonary reserve. Ischaemia and infection of the distal part of the anastomosis is the leading cause of bronchial anastomotic leakage. We have learned from our experience in lung transplantation that inhalation with Tobramycin helps prevent anastomotic insufficiency. We would like to present our experience in patients with tracheobronchial sleeve and prophylactic Tobramycin inhalation. Retrospective analysis of 114 patient records, between 01.01.2005 and 31.12.2006, where a bronchial anastomosis (patients with tracheal resection were excluded) was performed. All patients received Tobramycin inhalation (2 x 80 mg) for 7 days. Data analysed were; length of chest tube drainage in days, complications, morbidity and hospital mortality. In 694 patients, an anatomic resection was performed. Of these, 114 (16%) were sleeve resections and 63 (9%) pneumonectomies. In 21 women and 93 men, between 25 and 84 years old, sleeve lobectomy was performed 104 times and carinal resection 10 times. A preoperative neoadjuvant therapy had been given in 26%. Radical (R0) resection was possible in 94%. The duration of the operation was between 83 and 225 min (median: 127 min). Chest tubes were removed on average after 6 days. Patients were discharged after 11 days. The rate of bronchial anastomotic leakage was 4.4%. There were two patients with postoperative respiratory insufficiency and mechanical ventilation, two patients with technical failure required early correction of the suture and one patient with a necrosis of the anastomosis. Thirty-day hospital mortality was 2.6% (3/114). Increasing experience with sleeve resection has reduced the rate of pneumonectomy below 10%, although a number of the patients had received neoadjuvant therapy and the carinal resection rate of necrosis and infection of the anastomosis was low. We therefore recommend use of local antibiotic inhalation after sleeve resection.

Perioperative extracorporeal membrane oxygenation support for critical pediatric airway surgery

Extracorporeal membrane oxygenation (ECMO) has been used for cardiopulmonary support in neonates, infants, and adults. We report the application of ECMO for critical airway surgery when mechanical ventilation cannot provide adequate gas exchange. Three pediatric patients underwent emergency ECMO establishment because of hypercapnia that could not be managed by conventional mechanical ventilation. The pathology included: (1) left pulmonary artery sling with long-segment tracheal stenosis; (2) absence of the right intermediate bronchus and abnormal origin of the right lower bronchus arising from the left main bronchus; (3) right-lung agenesis with long-segment tracheobronchial stenosis. Venoarterial ECMO was established. Before ECMO, the arterial pH values were 7.28, 7.0, and 7.08, and the PaCO2 values were 111.8, 112.0, and 208.7 mmHg for each patient, respectively. After ECMO support, respiratory acidosis was reversed. The patients then underwent surgical intervention. The surgical procedures included: (1) slide tracheoplasty and reimplantation of the left pulmonary artery; (2) resection of the stenotic tracheal segment and reconstruction of the bronchial tree; (3) tracheal dilatation and stent implantation. The ECMO durations were 11, 5, and 16 h, respectively. All patients were successfully weaned off ECMO without complications. In conclusion, ECMO provided adequate ventilation support for patients undergoing critical tracheobronchial reconstruction when conventional mechanical ventilation could not maintain adequate gas exchange.

Latrogenic tracheobronchial lesions--a report on 13 cases.

Tracheobronchial ruptures are occurrences which mainly result from blunt or penetrating neck or thoracic trauma, but also from long-term complications of intubation or tracheostomy. Acute iatrogenic tracheobronchial lesions are very uncommon. From February 1995 to July 1998, we treated 13 patients (12 female, 1 male, mean age 68 years, range 45-86) in our institution for iatrogenic tracheobronchial injuries after single lumen intubation (n = 8), double lumen intubation (n = 4), and tracheostomy (n = 1). We retrospectively analyzed the medical records of these patients concerning age, sex, symptoms, endoscopic and intraoperative findings, treatment and outcome. All patients underwent surgical treatment via right-sided thoracotomy. In the cases of 11 patients, repeated postoperative bronchoscopy revealed sufficient reconstruction of the lesions. Nevertheless, only 5 patients survived. The remainder died of the sequelae of trauma-related hypoxia, underlying (malignant) diseases, or of septic multiorgan failure after a median of 15 days (1 hour to 27 days). While technical problems of tracheobronchial reconstruction in our series were controllable, the long-term results were not satisfying. Our data suggest that the key for better outcome of these kind of lesions lies in an early diagnosis and immediate treatment, thus keeping the trauma-treatment interval with the concomitant hypoxic damage as short as possible.

Histopathologic changes after tracheobronchial reconstruction with costal cartilage graft for congenital tracheal stenosis

Background/Purpose: Congenital tracheal stenosis is an uncommon, life-threatening condition. Recently, tracheoplasty using costal cartilage grafts to enlarge the lumen was used successfully in such cases. In this study, we evaluated postoperative changes of costal cartilage grafts after tracheoplasty. Methods: Costal cartilage patch tracheoplasty was used for surgical correction of long-segment congenital tracheal stenosis in 18 infants. Six patients whose tracheal specimens were obtained at autopsy are included in this study. The mean age at the time of repair was 4.8 months, and the mean period after operation was 7.5 months. Cartilage graft survival and epithelialization of inner layer was evaluated in each case. Results: The mean width and length of grafts was 6.3 × 35 mm at operation and 4.0 × 22 mm at autopsy. The graft size was diminished gradually after operation and was replaced completely by mature scar tissue 2 years after operation. However, diameter of the reconstructed site was not reduced. Reepithelialization of the graft site with ciliated columnar epithelium was found in every case. Chondrocyte numbers were reduced and remaining cartilage was rather eosinophilic, suggesting that the degenerative process was ongoing in the graft. Conclusions: The costal cartilage grafts established a functional tracheal lumen, and reepithelialization with ciliated columnar epithelium was found at the graft site. The costal cartilage grafts continues to be an important option as graft material for tracheal reconstruction in infants with long segment congenital tracheal stenosis. J Pediatr Surg 36:329-333. Copyright © 2001 by W.B. Saunders Company.

A Case of Recovery of Respiratory Function after Long Term Atelectasis by Resection of a Tuberculous Main Bronchus and Tracheo-bronchial Reconstruction

A Case of Recovery of Respiratory Function after Long Term Atelectasis by Resection of a Tuberculous Main Bronchus and Tracheo-bronchial Reconstruction