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Ann Thorac Surg 2006;82:1540-1542
© 2006 The Society of Thoracic Surgeons

How To Do It

Variations in the Technique of Slide Tracheoplasty to Repair Complex Forms of Long-Segment Congenital Tracheal Stenoses

Wolfram Beierlein, MD*, Martin J. Elliott, FRCS*

Cardiothoracic Unit, Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom

Accepted for publication November 1, 2005.

* Address correspondence to Dr Elliott, The Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London, WC1N 3JH United Kingdom (Email: elliom1{at}gosh.nhs.uk).


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 Footnotes
 Acknowledgments
 References
 
Slide tracheoplasty has become the preferred technique for repair of long-segment congenital tracheal stenosis with complete tracheal rings. Complex morphological subtypes require technical modifications, which we present as follows.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 Footnotes
 Acknowledgments
 References
 
Twenty-six patients with a median age of 7.7 months have been operated on so far. Eleven had purely supracarinal long-segment congenital tracheal stenosis with complete tracheal rings (LSCTS). Nine had abnormal tracheal arborization including tracheal bronchus, bronchus intermedius, and right pulmonary agenesis. In 5 patients, the LSCTS involved the right main bronchus. One patient had bilateral main bronchus stenoses. Concomitant difficult tracheobronchial conditions included tracheobronchial malacia, external tracheal compression despite absence of vascular anomaly, and tracheostomy. Despite these multiple problems it was possible to perform slide tracheoplasty in all patients by modifying the site and orientation of the longitudinal tracheobronchial incisions. Appropriately modified slide tracheoplasty is applicable to all types of long-segment congenital tracheal stenoses.

Slide tracheoplasty (STP) was conceived to repair supracarinal LSCTS. The technique includes transecting the trachea in mid-stenosis and performing an oblique side-to-side anastomosis. This reduces tracheal length but doubles the circumference, quadruples the cross-sectional area, and decreases the resistance to airflow [1–4]. The technical modifications described as follows also allows the application of STP to complex LSCTS.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 Footnotes
 Acknowledgments
 References
 
Between December 1995 and June 2005 we performed 26 STPs in children aged 13 days to 14.8 years (median, 7.7 months). Eleven had supracarinal LSCTS, 9 had abnormal tracheal arborization (4 tracheal bronchi, 4 bronchi intermedia, 1 right pulmonary agenesis). In 5 patients, the LSCTS included the right main bronchus. One patient had bilateral main bronchus stenoses. Concomitant difficult tracheobronchial conditions included malacia in 6 patients, tracheostomy in 2, and external tracheal compression without vascular anomaly in 1.

Concomitant congenital cardiovascular anomalies were frequent in 21 patients, with left pulmonary artery sling being the most common in 12. Seven patients had undergone cardiovascular surgery elsewhere, and 13 required simultaneous repair.

Four patients died, 2 from airway-related causes and 2 more from airway-unrelated causes. Thirteen patients required subsequent tracheal redo procedures (6 patients underwent redo-surgery and 12 patients had bronchoscopic reinterventions).

Through median sternotomies, simple right atrio-aortic cardiopulmonary bypass was used in all cases, unless concurrent cardiovascular repair required bicaval cannulation, hypothermia, and cardioplegia. We used cardiopulmonary bypass in all patients to optimize conditions for the extensive dissection and secure oxygenation during the tracheal reconstruction. The trachea was mobilized circumferentially by separating its adventitia and the pre-tracheal fascia, using pinpoint diathermia and preserving the recurrent laryngeal nerves. Normal tracheal and bronchial tissue must be exposed cranially and caudally. Adequate mobilization may require division of the thyroid isthmus, dissection out to the first bronchial divisions, and mobilization of all pericardial reflections and carinal lymph nodes. Hyoid release of the larynx can be considered to increase mobilization of the trachea. Extensive tracheobronchial mobilization has been shown not to compromise vascular supply in this age group [5].

The stenosis was transected at midpoint with the cranial and caudal stump incised on opposite sides into normal tracheobronchial tissue. A suction catheter was positioned through the endotracheal tube, which kept the area dry and minimized bacterial contamination. Both tracheal ends were slid together and anastomosed using 5-0 polydioxanone interrupted horizontal mattress sutures, ensuring that a pure mucosal anastomosis was created internally.

The endotracheal tube was advanced to the midpoint of the reconstruction under fibreoptic bronchoscopic control before ventilation was started. A fibrin sealant was used to secure an airtight seal. The chest was closed in layers over drains with iodine irrigation for 48 hours to prevent mediastinitis after the open trachea had been exposed to the mediastinum.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
Footnotes
 Acknowledgments
 References
 
Abnormal Arborization
A tracheal bronchus is not uncommon in these patients and can be located very distally, which created a carinal trifurcation in 2 patients. In this setting the anterior incision in the distal tracheal half was cut slightly and spirally onto the left main bronchus to stay away from the right bronchi. Otherwise STP was performed as in patients without aberrant bronchus.

If the tracheal bronchus to the right lung is more cranial and large, unlike the technique suggested by Grillo and colleagues [1], we do not resect, but we involve the bronchus intermedius in the slide procedure (see Fig 1) to benefit from the large oblique anastomosis.


Figure 1
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  		Fig 1. Slide tracheoplasty in abnormal arborization (bronchus intermedius). The dotted lines represent the incision.

 
In the combination of absent lung with LSCTS, STP can be performed as any supracarinal type. However, because of the rotation of the mediastinum toward the side of the absent lung, the head vessels compressed the reconstructed trachea in our only case, and we had to divide the carotid artery after magnetic resonance angiography confirmation that the circle of Willis was intact.

Unilateral Main Bronchus Stenosis
The right main bronchus was uniformly affected and the first bronchial cartilages were complete rings. The distal anterior tracheobronchial incision was continued into the right main bronchus, and the anastomosis took a spiral shape toward the right to achieve a wide airway (see Fig 2).


Figure 2
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  		Fig 2. Slide tracheoplasty in the presence of right main bronchial stenosis. The dotted lines represent the incision.

 
Bilateral Main Bronchus Stenoses
STP can deal with one side exclusively. In our only patient (who was third in this series), this condition only became obvious postoperatively. Since then we insist on preoperative bronchography, which alone can provide the diagnosis. This infant underwent pericardial patch enlargement of its left main bronchus origin with an external Hagl support [6] secondarily, but died 73 days later from persisting airway problems. Now we try to avoid patch repairs unless they are necessary as a technique of last resort. [7]

Tracheobronchial malacia affects postoperative weaning from ventilation. When identified preoperatively at the origin of a main bronchus, the anterior incision was cut into the affected bronchus, so that the STP provided an anterior nonmalacic wall segment. Despite this, 3 patients required subsequent endobronchial stenting.

When external tracheobronchial compression was present without vascular anomaly (ie, in 1 patient), the STP was supplemented by aortopexy.

Two patients had a pre-existing tracheostomy. An STP was performed successfully by incorporating the tracheal defect into the incision in the cranial stump, which was cut anteriorly, unlike all the other patients. It was also necessary to split the cricoid cartilage. However, recurrent granulations at the former tracheostomy site required repeated balloonings before finally resolving.

Our experience suggests that slide tracheoplasty is made much easier if previous trauma to the trachea, including laser and tracheostomy, can be avoided.

In conclusion, appropriately modified slide tracheoplasty can be applied successfully to all types of long-segment congenital tracheal stenoses.


   Acknowledgments
Top
 Abstract
 Introduction
 Technique
 Comment
 Footnotes
 Acknowledgments
References
 
This work was generously supported by a grant of the Richard Hall Fund. Research at the Institute of Child Health and Great Ormond Street Hospital for Children National Health Service Trust benefits from research and development funding received from the National Health Service executive. The authors are very grateful to Gemma Price for her excellent drawings.

Between submission of this paper and its publication, Dr Wolfram Beierlein was tragically killed in a road traffic accident in France. Wolfram Beierlein's death will be a huge loss to cardiothoracic surgery. He was an extremely good surgeon with a brilliant mind and was also a charming colleague. We would like to dedicate this paper to his memory and use it as a means of expressing our condolences to his family and many many friends.


   Footnotes
Top
 Abstract
 Introduction
 Technique
 Comment
 Footnotes
Acknowledgments
 References
 
* Dr Beierlein is deceased. Back


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 Footnotes
 Acknowledgments
 References
 

  1. Grillo HC, Wright CD, Vlahakes GJ, MacGillivray TE. Management of congenital tracheal stenosis by means of slide tracheoplasty or resection and reconstruction, with long-term follow-up of growth after slide tracheoplasty J Thorac Cardiovasc Surg 2002;123:145-152.[Abstract/Free Full Text]
  2. Tsang V, Murday A, Gillbe C, Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis Ann Thorac Surg 1989;48:632-635.[Abstract]
  3. Rutter MJ, Cotton RT, Azizkhan RG, Manning PB. Slide tracheoplasty for the management of complete tracheal rings J Pediatr Surg 2003;38:928-934.[Medline]
  4. Koopman JP, Bogers AJ, Witsenburg M, Lequin MH, Tibboel D, Hoeve LJ. Slide tracheoplasty for congenital tracheal stenosis J Pediatr Surg 2004;39:19-23.[Medline]
  5. Macchiarini P, Dulmet E, de Montpreville V, Mazmanian GM, Chapelier A, Dartevelle P. Tracheal growth after slide tracheoplasty J Thorac Cardiovasc Surg 1997;113:558-566.[Abstract/Free Full Text]
  6. Hagl S, Jakob H, Sebening C, et al. External stabilization of long-segment tracheobronchomalacia guided by intraoperative bronchoscopy Ann Thorac Surg 1997;64:1412-1421.[Abstract/Free Full Text]
  7. Kocyildirim E, Kanani M, Roebuck D, et al. Long-segment tracheal stenosis: slide tracheoplasty and a multi-disciplinary approach impove outcomes and reduce costs J Thorac Cardiovasc Surg 2004;128:876-882.[Abstract/Free Full Text]



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