Ann Thorac Surg 2006;82:2305-2307
© 2006 The Society of Thoracic Surgeons
How To Do It
Alternative Approach to the Surgical Management of Congenital Tracheal Stenosis
Nahidh Hasaniya, MD,
Chawki F. elZein, MD*,
Sylvio Mara, MD,
Mary Jane Barth, MD,
Michel Ilbawi, MD
Heart Institute for Children, Hope Children’s Hospital, Oak Lawn, Illinois
Accepted for publication February 3, 2006.
* Address correspondence to Dr elZein, Heart Institute for Children, 4440 W 95th St, Oak Lawn, IL 60453 (Email: chawki{at}thic.com).
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Abstract
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Congenital tracheal stenosis is a serious disease associated with high operative mortality and morbidity, especially in the newborn period. Its surgical management involves either sliding tracheoplasty, which is associated with extensive dissection and recurrent stenosis, or with pericardial patch tracheoplasty that fails to address recoiling of the stenotic complete ring and collapse of the patch into the tracheal lumen. We report a modification of the latter technique, in which a half ring external stenting device is used to keep the rings from recoiling.
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Introduction
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Congenital tracheal stenosis due to complete tracheal rings is a serious disease associated with high operative mortality and morbidity especially in the newborn period. When the stenotic segment is long, resection and end-to-end anastomosis is not a good option. Sliding tracheoplasty, although a better alternative, involves extensive dissection and reconstruction [1, 2]. Pericardial patch tracheoplasty, originally described by Idriss and colleagues [3], has a relatively high rate of recurrent stenosis due to recoil of the opened complete rings and collapse of the pericardial patch into the tracheal lumen during spontaneous inspiration. Use of costal cartilage or periosteal graft has not rectified the problem [4, 5]. We describe a technical modification of patch tracheoplasty that incorporates the use of an external rigid half ring to support the pericardial patch and to prevent the cartilaginous rings from recoiling.
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Technique
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Patient 1
Patient 1 is a 2-year-old girl with a history of nonresolving intermittent stridor since birth and severe recent respiratory distress after an upper respiratory syncitial viral infection. Bronchoscopy revealed a 60% tracheal stenotic segment (4 cm long) caused by complete rings, extending from 2 cm below the vocal cords to the carina in a funnel-shaped pattern. The severity and extent of the narrowing were defined by a computed tomographic chest scan.
Patient 2
Patient 2 is a 3-month-old male infant who was admitted for repair of Tetralogy of Fallot and who had a difficult intubation at surgery. Bronchoscopy revealed tracheal stenosis due to complete rings, involving most of the trachea and extending into the right and left main stem bronchi.
Surgery was done through a median sternotomy incision. The trachea was approached by opening the posterior pericardium between the superior vena cava and the ascending aorta. The anterior tracheal surface was dissected, preserving the lateral vascular pedicles. Cardiopulmonary bypass was instituted with mild hypothermia (32°C). The endotracheal tube was pulled out and a bronchoscopy was performed to delineate the limits of the stenotic segment. The trachea was anteriorly opened along the entire length of the stenotic segment, and the incision was extended an extra 0.5 cm proximal and distal to the narrowed segment to ensure complete relief of the obstruction. When the stenosis involved the main stem bronchus, the incision was extended into it. A piece of autologous pericardium was harvested and sutured to the edges of the tracheotomy using continuous 4-0 polydioxanone sutures and was taken through the outer wall of the trachea without including the mucosa. A piece of stainless steel wire (K wire, 0.9 mm diameter) was fashioned into a half circle with a diameter equal to the fully expanded open tracheal ring. Its ends were sutured to the edges of the incised trachea, and the pericardial patch was fixed to the wire externally at three points to keep it from infolding (Fig 1). Two or three external stents were used depending on the length of the stenosis. Bronchoscopy was performed to check the repair. An endotracheal tube was introduced and positioned under direct vision to stent the trachea, and patient was weaned from cardiopulmonary bypass. The patient was kept paralyzed on mechanical ventilation for 2 to 5 days after surgery. Prophylactic antibiotics were given for 1 week.
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Fig 1. Diagram showing the patch in place with the half circle device holding the trachea and patch in the open position. Inset shows incision line and ring.
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The first patient had an uneventful recovery. She was kept intubated and paralyzed for 1 week after surgery, after which she was successfully extubated. She stayed in the intensive care unit for 10 days and was discharged home 2 weeks after her operation. A follow-up bronchoscopy before discharge showed a wide open trachea with no granulation tissue formation (Fig 2). A follow-up chest roentgenogram shows the device in place (Fig 3). Her follow-up period was 3 years, during which she was asymptomatic and had four bronchoscopies. No granulation tissue formed and no intervention was needed.
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Fig 2. Bronchoscopy showed wide patent trachea 2 years after surgery with minimal granulation tissue. The tracheal rings are seen posteriorly and the pericardial membrane anteriorly.
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The second patient underwent patch tracheoplasty of the main trachea and two main stem bronchi, with application of the K-wire to the main trachea. He kept having wheezing develop after the operation and a repeat bronchoscopy after 10 days showed narrowing of the left main stem bronchus and left bronchomalacia. He underwent repair of the Tetralogy of Fallot and implantation of the external stent to the left main stem bronchus. The anterior wall of the bronchus was anchored to the stenting device. He was extubated successfully approximately 10 days after the operation, and he was free from any respiratory symptoms. His total hospital stay was approximately 2 months. He had three follow-up bronchoscopies before discharge; all showed no evidence of granulation tissue. He had major gastroesophageal reflux disease that prolonged his hospital stay. A follow-up bronchoscopy at 1 year after discharge showed a wide open trachea and main stem bronchi (Figs 4,
Figs 5). He had no granulation tissue formation and no intervention was needed.
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Comment
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Repair of congenital tracheal stenosis is indicated in symptomatic patients or in those with life-threatening obstruction. Endoscopic dilation with or without stent placement is usually ineffective, because of the nature of the underlying pathology. Resection with end-to-end anastomosis, slide tracheoplasty, or patch tracheoplasty is the surgical procedure used to treat complete tracheal rings [3, 6, 7]. When the stenosis involves more than half the length of the trachea, as is the case in most patients, resection with end-to-end anastomosis or slide tracheoplasty requires extensive dissection and laryngeal release. This may put several vital structures at risk of injury, namely the recurrent laryngeal nerve, esophagus, pulmonary vessels, or the tracheal vascular pedicle. Patch tracheoplasty requires minimal dissection to expose the anterior surface of the trachea and has little chance of damage to these or other structures. Materials used to patch the tracheal stenosis include autologous or bovine pericardium and costal cartilage. Rigidity of the cartilaginous stent helps to keep the trachea open without recoiling; however it is difficult to tailor and obtain an airtight suture line. It does not solve the problem of having complete circumferential cartilaginous rings as the child grows. Moreover, resecting costal cartilage increases postoperative incisional pain. The autologous pericardium is readily available, easy to access and harvest, and easy to tailor and manipulate. It can be used to patch areas of stenosis involving the main stem bronchi without residual air leak [8]. The pericardium usually becomes pseudo-epithelialized with time and adheres to the surrounding mediastinal tissues. It also restores a membranous-like portion to the tracheal wall and hence disrupts the circumferential stenotic complete tracheal rings and allows growth [9]. However, the soft unsupported pericardium does not prevent recoiling of the longitudinally split tracheal rings, which would collapse into the lumen of the trachea due to negative inspiratory pressure, resulting in compromise of the tracheal lumen. This involves longer postoperative intubation and higher incidence of recurrence. The technical modification used prevents recoiling of the longitudinally split tracheal rings and keeps the pericardial patch from collapsing into the tracheal lumen until the patch becomes adherent to the surrounding tissues. Its use may be extended to patients with severe tracheomalacia where external stenting may minimize respiratory symptoms and avoid prolonged intubation or tracheostomy. After 3 years of follow-up we did not see any complications related to the presence of a rigid foreign body within the mediastinum. The possibility of the wire device eroding into the surrounding structures is rather remote, especially if its ends are blunted and its center is secured to the trachea and the pericardial patch with sutures.
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References
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Abstract
Introduction
