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Ann Thorac Surg 1996;61:1827
© 1996 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Northwestern University Medical School Division of Cardiovascular-Thoracic Surgery Children's Memorial Hospital 2300 Children's Plaza, Box 22 Chicago, IL 60614

See also page 1824.

Doctor Jacobs and colleagues have reported a novel management strategy for an infant with long-segment congenital tracheal stenosis, pulmonary artery sling, and ventricular septal defect. The infant initially underwent complete resection of the trachea with primary end-to-end repair posterior to the left pulmonary artery along with ventricular septal defect closure. The anastomosis appears to have elongated and stenosed, and the baby required prolonged endoluminal stenting for airway maintenance. At age 18 months intubation was necessary and the child underwent repeat sternotomy and had tracheal repair with an anterior tracheal homograft over elongated posterior scar tissue with a silicone intraluminal stent. Thirteen months after this procedure, the child has a completely epithelialized trachea with a normal caliber airway.

Doctor Jacobs and colleagues are to be congratulated for their heroic efforts and an excellent eventual result. However, the road to this success was certainly quite long and arduous and the complete tracheal resection, although dramatic, was really unsuccessful. Pediatric surgeons have speculated on the percentage of trachea that can be ``successfully'' resected in an infant. This report would indicate the answer is somewhat less than 100% given the postoperative morbidity of this particular child. By way of contrast, the use of tracheal homograft as an anterior tracheoplasty was successful, is very innovative, and perhaps should be a part of the armamentarium of surgeons dealing with complex tracheal anomalies. Clearly, tracheal homograft transplantation was not part of the original plan for this particular child, but rather succeeded in extracting the patient from a very precarious situation.

It would appear from the pathology described that this baby might have been a candidate for pericardial, cartilage, or slide tracheoplasty rather than complete tracheal resection as the initial procedure. At Children's Memorial Hospital we have performed more than 30 pericardial patch tracheoplasties in similar infants with long-segment tracheal stenosis from complete tracheal rings-occasionally associated with a ``cartilage plate'' anteriorly. When divided anteriorly and stented open, the ``cartilage plate'' will mold just like complete tracheal rings. In 4 patients with residual tracheal or bronchial narrowing, we have later augmented the pericardial tracheoplasty with a cartilage graft. Another alternative, the slide tracheoplasty, seems especially feasible after reviewing this case report as it is like resecting ``only'' half of the trachea, leaving the child with a tracheal lumen four times the original cross-section. Finally, the other surgical alternative would be to implant the tracheal homograft at the original procedure. This would place the homograft trachea over complete tracheal rings (with normal mucosa) rather than over posterior scar tissue.

Doctor Jacobs and colleagues are to be congratulated for their innovative use of a tracheal homograft. The 100% resection of the trachea opens the surgeon's mind to the surgical possibilities with an infant's trachea, but is not recommended as the procedure of choice for long-segment tracheal stenosis. These infants should undergo primary tracheoplasty at the time of diagnosis using pericardium, cartilage, or the slide tracheoplasty technique.

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carl L. Backer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Backer, C. L. Search for Related Content PubMed PubMed Citation Articles by Backer, C. L. Related Collections Related Article