Ann Thorac Surg 2005;80:266-267
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Eddie Hoover, MD
(112) Department of Surgery, Buffalo VAMC, 3495 Bailey Ave, Buffalo, NY 14215
(Email: eddie.hoover{at}med.va.gov).
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Introduction
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In this article the established group of investigators and clinicians describe a rare condition called "malacia of the intrathoracic trachea," which results in expiratory collapse of the membranous portion of this part of the airway secondary to severe central airway obstruction. Then they report their experience at the Massachusetts General Hospital with a series of 14 consecutive patients treated over a 10-year period utilizing a new technique they developed. This technique utilizes Marlex mesh to restore the proper anatomic configuration of the membranous portion of the intrathoracic trachea, thus preventing expiratory collapse and the resulting sequelae of expiratory stridor, persistent cough, difficulty in clearing secretions, and dyspnea. The authors review the history of other investigators’ results in this field using various stents and tracheoplastic procedures, and review their own experience with autologous fascia lata and pericardium, only to condemn their continued use because of tissue attenuation over time. They finally tried polypropylene mesh as it met all the theoretical requirements for success including ease of handling, pliability, and permanency due to tissue in-growth and incorporation of the mesh into the membranous tracheal wall. Their long-term results are what one would expect from a disease that continues to cause deterioration of tissue and function over time, even if the patient stops smoking as they point out in the Discussion section. They provide detailed data on the preoperative evaluation and how they incorporate the results into arriving at a decision to offer surgery to potential candidates. These tests are easily reproducible in most medical centers.
The authors provide a detailed set of directions as to how they actually secure the mesh while pointing out some of the pitfalls they have learned during the years to simplify the procedure and insure success. The instructions sound fairly straightforward until one tries to reconcile them with Figure 5A. Perhaps they should have used two or more figures to illustrate proper placement and suturing of the mesh. By using only one figure, this leaves a lot to the imagination of the reader, because it is not intuitively clear to me how they move from step to step by looking at this figure. That brings me to the crux of this commentary, that is, who should be doing these cases? My associate, Dr Hsu and I have done our fair share of tracheal resections over the past 25 years, but we have also sent 2 or 3 patients to this group with excellent outcomes in extremely complex cases. I have never seen the condition described herein. If this distinguished group has only seen 14 such cases over the past decade, then my guess would be that not too many other thoracic surgeons have seen this disorder. Although it is our nature to presume that we can "read, think, and do," I would suggest that these patients would be better served if they were referred to some group with a longstanding interest and proven record in dealing with these complex procedures. After all, the patient only gets one chance at a successful outcome.
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The Society of Thoracic Surgeons: Forty-Second Annual Meeting
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Please mark your calendars for the Forty-Second Annual Meeting of The Society of Thoracic Surgeons, to be held in New Orleans, Louisiana, from January 30–February 1, 2006. The program will provide in-depth coverage of thoracic surgical topics selected to enhance and broaden the knowledge of cardiothoracic surgeons. Attendees will benefit from traditional Abstract Presentations, as well as Surgical Forums, Breakfast Sessions, Surgical Motion Pictures, and Town Hall Meetings on specific topics.
Advance registration forms, hotel reservation forms, and details regarding transportation arrangements, as well as the complete meeting program, will be mailed to Society members this fall. Also, complete meeting information will be available on the Society’s Web site at www.sts.org. Nonmembers who wish to receive information on the Annual Meeting may contact the Society’s secretary, Douglas E. Wood.
Abstracts for the meeting must be submitted electronically. The electronic submission form may be accessed at www.sts.org. There is no charge for submitting abstracts. The submission deadline is August 8, 2005 at 5:00 PM CDT. Please direct any questions regarding your submission to the Society’s headquarters.
Douglas E. Wood, MD Secretary The Society of Thoracic Surgeons 633 N. Saint Clair St, Suite 2320 Chicago, IL 60611-3658 Telephone: (312) 202-5800 Fax: (312) 202-5801 e-mail: mailto:sts{at}sts.org website: www.sts.org
Related Article
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Tracheoplasty for Expiratory Collapse of Central Airways
- Cameron D. Wright, Hermes C. Grillo, Zane T. Hammoud, John C. Wain, Henning A. Gaissert, Victor Zaydfudim, and Douglas J. Mathisen
Ann. Thorac. Surg. 2005 80: 259-266.
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