Ann Thorac Surg 2005;79:687-689
© 2005 The Society of Thoracic Surgeons
Case report
Endoscopic Carbon Dioxide Laser Division of Congenital Complete Tracheal Rings: A New Operative Technique
W. Andrew Clement, FRCSa,*,
Neil K. Geddes, FRCSa,
Crispin Best, FRCAb
a Department of Otolaryngology, Glasgow, United Kingdom
b Department of Anesthesia, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, United Kingdom
Accepted for publication September 5, 2003.
* Address reprint requests to Dr Clement, Department of Otolaryngology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow G3 8SJ, UK
wacxh{at}hotmail.com
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Abstract
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A carbon dioxide laser was used through a bronchoscope to split the posterior aspect of complete tracheal rings in the distal trachea of a 16-month-old boy previously palliated for cyanotic congenital heart disease. After laser division of the complete tracheal rings, the patient was successfully extubated. Subsequently, the boy had granulation tissue develop, which required bronchoscopic resection, and then severe posterior tracheal impingement developed from the esophageal herniation, which required placement of a distal tracheal stent. Although unsuccessful in this case, carbon dioxide laser division of complete tracheal rings may be a safe and effective method of treating congenital tracheal stenosis in selected cases.
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Introduction
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Many procedures have been advocated for the treatment of congenital stenosis due to complete tracheal rings [1]. Open procedures carry the associated risks of sternotomy or thoracotomy, and in many cases, extracorporeal membranous oxygenation or cardiopulmonary bypass. Balloon techniques may be associated with a higher risk of tracheal rupture and pneumothoraxes [2]. Carbon dioxide lasers have been used successfully in both pediatric [3] and adult acquired tracheal stenosis [4]; this has not previously been described in the treatment of congenital tracheal stenosis.
A 16-month-old boy who had a complex atrioventricular septal defect, pulmonary atresia, and complete tracheal rings (born at 35 weeks gestation) was cyanotic with labored breathing, requiring ventilation. Previous history included an echocardiogram at 6 days of age that had revealed situs solitus, atrioventricular septal defect, single cardiac outlet, concordant atrioventricular connections, bilateral superior vena cavae, and pulmonary atresia. Bronchoscopy and air bronchogram, which identified the stenosis, were performed at 8 days of age because of difficulties with ventilation. At the age of 4 weeks he had undergone a modified Blalock-Taussig shunt. He was stridulous from birth and remained the same until this admission at 16 months of age. He had required several admissions for worsening stridor associated with upper respiratory tract infections.
Bronchoscopy at 16 months of age revealed a segmental tracheal stenosis consisting of complete tracheal rings in the distal half of his trachea (Fig 1). The fusiform stenosis measured approximately 2.0 cm in length and ended 1.8 cm above the carina. Its maximum diameter was 3 mm, and it tapered to a minimum diameter of 2.2 mm. The stenosis took up 33% of the length of the trachea and incorporated six tracheal rings. The right upper lobe bronchus arose from the distal trachea. The equipment used were a 3.5 mm Storz rigid ventilating laser bronchoscope and a Sharplan 1030 carbon dioxide laser. The laser was set at 5 watts continuous pulse. The laser was used on the posterior tracheal wall to create a split in the complete cartilaginous rings. A 3.5 mm bronchoscope was then passed easily to the carina. The trachea was splinted using a 3.5 mm Portex endotracheal tube. He was transferred to the intensive care unit postoperatively where he remained sedated and intubated and he was started on a reducing dose of dexamethasone. He was extubated on postoperative day 7 after repeat bronchoscopy. Twelve days later his breathing became more stridulous. Therefore he underwent bronchoscopy during which granulation tissue was identified and debulked. Nebulized budesonide was given for 10 days. Postoperatively, his breathing intermittently deteriorated again. At further bronchoscopy (Fig 2), on cessation of continuous positive airway pressure, the esophageal wall was found to have ballooned into the tracheal lumen, just above the carina; this almost completely obstructed the trachea. Therefore, endoscopic tracheal stenting under radiologic guidance was performed. A Palmaz (8 mm x 29 mm) tracheal stent was inserted and dilated to 6 mm (Fig 3).
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Fig 3. Air bronchogram after Palmaz stent placement. Note the right upper lobe bronchus arising from the distal trachea.
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The patient has since undergone a bi-directional Glenn procedure and is progressing well. He has required three stent dilations during the last 15 months, which have all been uneventful with no granulation tissue. The stent diameter is now approximately 8 mm.
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Comment
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This procedure was performed after discussion with our cardiothoracic team. They felt that combining pericardial tracheoplasty with a bi-directional Glenn procedure could be associated with increased morbidity because of the underlying congenital cardiopulmonary abnormalities and also because of the technical difficulties of repairing the tracheal stenosis due to the site of the right upper lobe bronchus attachment. Throughout the laser procedure, a cardiothoracic surgeon and the extracorporeal membrane oxygenation team were available.
Endoscopic carbon dioxide lasers have been described before in acquired tracheal stenosis, but never before in children for congenital stenosis. Using an endoscopic laser allows a controlled split to be made in the tracheal cartilages in a normal anatomical site under direct vision. This has advantages in two situations: (1) In patients in which no cardiac or great vessel anomalies exist, it may negate the requirement for extracorporeal membrane oxygenation or cardiopulmonary bypass and open procedures such as thoracotomy and sternotomy; and (2) in patients requiring major cardiac surgery the main advantage is that the airway can be stabilized before this surgery.
A single successful case detailing an endoscopic laser with potassium titanyl phosphate for balloon dilation for congenital tracheal stenosis has been reported [5]. The theoretical advantages of carbon dioxide versus an endoscopic laser with potassium titanyl phosphate are that the depth of the burn is less and can be visualized more effectively, therefore causing less chondritis with decreased granulation tissue formation and decreased risk of pneumothoraxes and tracheoesophageal fistula formation. We performed our procedure without balloon dilation. This is important because the use of balloon dilation may be associated with an increased risk of iatrogenic pneumothoraxes [2].
The possibility of stent placement after using a laser was preoperatively discussed. Although there is limited experience in our department regarding stent removal, we believe it was best to stabilize this child's airway before major cardiac surgery. We intend to remove the stent at a later date by endoscopy, or if that is unsuccessful, by an open procedure. If required, a slide tracheoplasty will be performed at that stage.
There are several factors that we believe contributed to failure of this technique, including the severity of the stenosis, the length of the stenosis, and the patient's other underlying bronchial abnormalities. Although this child required tracheal stenting after the laser procedure, this procedure remains a treatment option for those children in whom it is believed that open procedures will increased their chances of morbidity. Carbon dioxide laser division of complete tracheal rings may be a safe and effective method of treating congenital tracheal stenosis in selected cases. Further research into this area is required to confirm this.
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References
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- Myer CM III, Hartley BE. Pediatric laryngotracheal surgery. Laryngoscope. 2000;110(11):1875–1883[Medline]
- Bagwell CE, Talbert JL, Tepas JJ III. Balloon dilatation of long-segment stenoses. J Pediatr Surg. 1991;26(2):153–159[Medline]
- Laing MR, Albert DM, Quinney RE, Bailey CM. Tracheal stenosis in infants and young children. J Laryngol Otol. 1990;104:229–235[Medline]
- Ossoff RH, Tucker GF, Duncavage JA, Toohill RJ. Efficacy of bronchoscopic carbon dioxide laser surgery for benign strictures of the trachea. Laryngoscope. 1985;95:1220–1223[Medline]
- Otherson HB Jr, Hebra A, Tagge EP. A new method of treatment for complete tracheal rings in an infant: endoscopic laser division and balloon dilatation. J Pediatr Surg. 2000;35(2):262–264[Medline]
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Abstract
Introduction
