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Ann Thorac Surg 2007;84:1031-1033
© 2007 The Society of Thoracic Surgeons

Case Reports

Successful Reconstruction of Traumatic Carinal Tissue Loss Using the Esophagus in an Infant

Erik S. Stubberuda, Jeffrey Phillip Jacobs, MD, FACSa,*, Richard P. Harmel, Jr, MDb, Thomas Andrews, MD, FACSc, Paul J. Chai, MDa, Harald L. Lindberg, MD, PhDa, James Anthony Quintessenza, MD, FACSa

a Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, St. Petersburg and Tampa, Florida
b Division of Pediatric Surgery, All Children’s Hospital, St. Petersburg, Florida
c Division of Otolaryngology, All Children’s Hospital, St. Petersburg, Florida

Accepted for publication January 23, 2007.

* Address correspondence to Dr Jacobs, The Congenital Heart Institute of Florida, Cardiac Surgical Associates, 603 7th St S, Suite 450, St. Petersburg, FL 33701 (Email: jeffjacobs{at}msn.com).


Dr Jacobs discloses a financial relationship with CardioAccess.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition.

Tracheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss.

We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition.

A 9-month-old girl presented to the emergency department in severe respiratory distress 4 days after the successful removal of a button battery from her esophagus. The patient required emergent intubation and was taken to the operating room for micro-laryngoscopy and bronchoscopy, which revealed posterior tracheal wall perforation and anterior esophageal wall perforation. Due to difficulty in oxygenating the patient during the procedure, she was emergently placed on extracorporeal membrane oxygenation support.

The tracheal injury constituted a 3-cm defect in the posterior distal tracheal wall involving the carina and proximal right and left main stem bronchi (Fig 1) and was initially repaired using a pedicled intercostal muscle flap taken from the right fourth and fifth intercostals muscles. This procedure was performed through a right posterolateral thoracotomy while on cardiopulmonary bypass with removal of the fourth and fifth ribs. The esophagus was ligated proximal and distal to the 4 to 6 cm esophageal defect using multiple cerclage sutures, and a gastrostomy tube was then placed. The patient was weaned from cardiopulmonary bypass and transferred to the intensive care unit.


Figure 1
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  		Fig 1. Initial bronchoscopy documented tissue loss involving the distal trachea, carina, and bilateral main stem bronchi. The arrows denote posterior tracheal tears extending into the proximal right and left mainstem bronchi.

 
The patient’s postoperative course was complicated by adequate ventilation but poor oxygenation, and therefore she was placed on an oscillator ventilator. During the next 10 days she underwent several bronchoscopies to optimize pulmonary toilet. On postoperative day 10, the patient had increasing problems develop with pneumothorax and oxygenation. Emergent bronchoscopy revealed partial dehiscence of the tracheal reconstruction. The patient was taken emergently to the operating room and underwent a redo tracheal reconstruction through a median sternotomy on cardiopulmonary bypass with resection of the dehisced region of trachea with end-to-end anastomosis of the anterior tracheal wall after using an interposition flap of esophageal mucosa for the posterior tracheal and carinal wall to avoid undue tension. Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi (Fig 2). The esophagus was transected and oversewn proximal and distal to the region used for the interposition flap. The patient was successfully weaned from cardiopulmonary bypass and postoperative bronchoscopy demonstrated patent bronchi with an intact tracheal reconstruction.


Figure 2
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  		Fig 2. (Top) After opening the trachea anteriorly, the esophagus (arrow) was visualized immediately posterior to the disrupted posterior trachea and carina. (Bottom) Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi. The arrows point to the orifices of the bronchi.

 
After the second tracheoplasty the patient was successfully extubated and was ventilating spontaneously. However, bronchoscopy initially demonstrated severe tracheomalacia and bronchomalacia at the posterior aspect of the carina consistent with prolapse of the interposed esophageal mucosa. Subsequent bronchoscopies completed 2 months and 16 months after the esophageal patch tracheoplasty demonstrated moderate nonobstructive granulation tissue at the area of the carina and mild bronchomalacia but with a nonobstructed airway.

Proximal esophageal secretions were initially managed with sump suction, and eventually the family agreed to proceed with creation of a cervical esophagostomy. Seventy-seven days after the second tracheoplasty the patient underwent a cervical end esophagostomy. The blind proximal esophageal pouch was mobilized up into a left cervical incision and exteriorized as an end cervical esophagostomy. No esophageal tissue was left behind from the upper portion of the esophagus proximal to the point of previous esophageal transaction; in fact, the distal 1.5 cm of the blind proximal esophageal pouch was resected. The remaining proximal esophagus was brought up between the sternal and clavicular heads of the sternocleidomastoid muscle and secured to the lateral skin incision. The patient required two subsequent dilations of the cervical esophagostomy to allow sufficient drainage.

Eighteen months after the initial injury, the patient underwent esophageal reconstruction with a colonic interposition through a combined laparotomy, left thoracotomy, and cervical incision, using the right mid-ascending and transverse colon passed through a retro-hilar tract in the left chest. An esophagram on postoperative day 7 revealed no leak, and the patient was started on a clear liquid diet that was subsequently advanced. The child is now ten months status post colonic interposition and tolerating oral feeds at home with a stable nonproblematic airway. Potentially troublesome esophageal mucosal mucous secretions into the reconstructed airway have not been problematic. The patient is currently doing quite well.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Tracheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss. This case demonstrates several principles relevant to the management of severe airway injuries in children.

Patients with a battery lodged in the esophagus are at higher risk for complication than other esophageal foreign bodies and must be carefully evaluated for tracheoesophageal fistulas [1, 2]. Extracorporeal membrane oxygenation can successfully bridge these patients to definitive reconstruction. Goldman and colleagues [3] reported a series of four children 13 months of age or younger with severe tracheal disease in whom extracorporeal membrane oxygenation was used to achieve stability prior to repair.

Viable tissue can be used to reconstruct the defect. Esophageal tissue has previously been used for tracheal reconstruction in both children [4] and adults [5]. Vascularized muscle flaps can also facilitate healing of life-threatening mediastinal wounds [4, 5]. Backer and colleagues [4] reported a series of eight children with life threatening mediastinal wounds managed with vascularized muscle flaps including pectoralis major, rectus abdominis, and cervical strap muscle. One of these eight patients had tracheal dehiscence after repair of an acquired tracheoesophageal fistula from battery erosion. In Backer and colleagues’ case [4], the trachea was initially repaired with viable esophagus, subsequently dehiscenced, and then successfully reconstructed with a pericardial patch sealed with a left pectoralis major muscle flap.

Creation of a cervical esophagostomy and initiation of sham feedings protects the mediastinum and provides an opportunity to retain oral feeding skills while receiving enteral nutrition through a gastrostomy [4, 5]. Surgery to re-establish gastrointestinal continuity is best delayed until after the patient is fully recovered from the acute injury [1, 4, 5]. Delaying the non-emergent esophageal replacement permits resolution of residual infection, inflammation, and edema [1, 4, 5]. The colon provides an excellent esophageal substitute in children [4, 6]. Successful management of complex pediatric tracheal problems requires a multidisciplinary collaborative approach involving cardiothoracic, general, and otolaryngology surgeons as well as pulmonologists and specialized nurses and respiratory therapists [7, 8].


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Imamoglu M, Cay A, Kosucu P, Ahmetoglu A, Sarihan H. Acquired tracheo-esophageal fistulas caused by button-battery lodged in the esophagus Pediatr Surg Int 2004;20:292-294.[Medline]
  2. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction J Pediatr Surg 1999;34:1527-1531.[Medline]
  3. Goldman AP, Macrae DJ, Tasker RC, et al. Extracorporeal membrane oxygenation (ECMO) as a bridge to definitive tracheal surgery in children J Ped 1996;128:386-388.[Medline]
  4. Backer CL, Pensler JM, Tobin GR, Mavroudis C. Vascularized muscle flaps for life-threatening mediastinal wounds in children Ann Thorac Surg 1994;57:797-801discussion 801–2.[Abstract]
  5. Pfitzmann R, Kaiser D, Weidemann H, Neuhaus P. Plastic reconstruction of an extended corrosive injury of the posterior tracheal wall with an autologous esophageal patch Eur J Cardiothorac Surg 2003;24:463-465.[Abstract/Free Full Text]
  6. Khan AR, Mohammed AR, Alwafi A, Ress BI, Lari J. Esophageal replacement with colon in children Pediatr Surg Int 1998;13:79-83.[Medline]
  7. Jacobs JP, Quintessenza JA, Andrews T, et al. Tracheal allograft reconstruction: the total North American experience and worldwide pediatric experiences Ann Thorac Surg 1999;68:1043-1051discussion 1052.[Abstract/Free Full Text]
  8. Jacobs JP, Quintessenza JA, Botero LM, et al. The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease Eur J Cardiothorac Surg 2000;18:505-512.[Abstract/Free Full Text]



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