Ann Thorac Surg 2008;85:1096-1097. doi:10.1016/j.athoracsur.2007.09.035
© 2008 The Society of Thoracic Surgeons
Case Reports
Slide Plasty of Trachea and Right Main Bronchus in a Newborn
Jan Brazdil, MDa,*,
Tomas Tlaskal, MD, PhDa,
Pavel Vojtovic, MDa,
Petr Pohunek, MDb,
Martin Cihar, MDc
a Pediatric Cardiocentrum, Motol University Hospital, Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
b Pediatric Department, Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
c Division of Neonatology, Department of Gynecology and Obstetrics, Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
Accepted for publication September 17, 2007.
* Address correspondence to Dr Brazdil, Motol University Hospital, Pediatric Cardiocentrum FN Motol, V Uvalu 84, Prague 5, 150 06, Czech Republic (Email: jan.brazdil{at}seznam.cz).
 |
Abstract
|
|---|
Congenital stenosis of airways is a rare and possibly life-threatening congenital defect with difficult treatment and uncertain prognosis. In our report, we describe a rare case of a 1-month-old newborn with concomitant stenosis of trachea and main bronchus and its successful treatment using slide plasty.
|
Introduction
|
|---|
Congenital airway stenosis is a rare abnormality and constitutes a small percentage of all causes for stenotic airways in children. Concomitant stenosis of the trachea and main bronchus is extremely rare. The management of lower respiratory tract stenosis depends on the severity and site of the lesion. Initial conservative management is preferred, but an operative treatment would be the solution in life-threatening cases.
A 1-month-old male newborn was referred to our department from another institution because of critical clinical status. The patient was a term neonate born by cesarean section in the 39th week of gestation, weighing 3,070 g and measuring 49 cm. Apgar score was normal. The immediate postnatal period was uneventful. After 1 hour, dyspnea at rest with no associated tachypnea developed in the patient. The baby became clinically stable over the next 12 hours with dyspnea appearing only during agitation. Then a chest roentgenogram and echocardiography were done, but no vascular anomaly was detected. There were no laboratory signs of infection at that time. The dyspnea gradually worsened. The bronchoscopy on day 10 of life showed a stenosis of the distal trachea and a significant stenosis of the right main bronchus. Clinical status required endotracheal intubation with ventilatory support of the patient. Repeated attempts at extubation failed because of severe dyspnea. A tracheostomy was performed on day 27 to facilitate the care of airways, supposing the surgical treatment would not be feasible. However, the dyspnea progressed, an infection of the lower respiratory tract ensued, and a severe emphysema of the right lung developed. After referral to our hospital, repeat bronchoscopy showed almost complete occlusion of the right main bronchus. Then magnetic resonance imaging, angiography, and bronchography were done to rule out the possible compression by an anomalous vessel, but all the results were negative. A decision to operate on the patient due to the failure of the conservative treatment was taken.
The tracheostomy was replaced by nasal intubation in the operation theater. The operation (surgeon professor Tlaskal) was performed through the median sternotomy with use of cardiopulmonary bypass. After a subtotal resection of the thymus, the pericardium was opened and the aorta was preparated. Then the distal trachea and right main bronchus were reached and mobilized. Heparin was given, the ascending aorta and the right atrium were cannulated and the cardiopulmonary bypass was set up. The operation was performed at 35°C. Intraoperatively, severe emphysema of both lungs was found. The trachea showed tubular narrowing at the level of 8 mm above the carina. The tracheal diameter decreased externally from 8 mm to 4.5 mm and intraluminally from 5 mm to 3.5 mm. The left main bronchus was of normal size, the right main bronchus was critically narrowed just under the carina with a slit-shaped lumen of 1 mm, and the length of the bronchial narrowing was 3 mm. Mucosa of the distal trachea and of the stenotic part of the bronchus showed severe inflammatory changes. The airway wall was of normal constitution with no malacia. We did not find any vascular malformation or other structural cause of the obstruction.
We divided the trachea 3 mm above the carina and made a 7-mm incision on the left side of the proximal stump. Then we made an incision of the same length through the distal stump to the lateral wall of the right main bronchus. The proximal and distal portions were then joined together (Fig 1) using a continuous 7-0 polydioxanone suture. The tightness of the anastomosis was checked and no leak was observed. The patient was rewarmed, the cardiopulmonary bypass was withdrawn, and heparin was reversed by protamine administration. Intraoperative bronchoscopy showed an effective enlargement of the trachea and the right main bronchus.
The immediate postoperative course was uncomplicated. Bronchoscopy on postoperative day 3 showed granulation tissue formation above the carina narrowing the tracheal lumen by one third; the main bronchi were free of obstruction. During the next few days there was progressive obstruction of the trachea due to the growth of the granulation tissue. Conservative treatment led to its regression with improvement of respiratory function. The patient was extubated on postoperative day 14 and was discharged from the hospital on the postoperative day 68 in good condition. A bronchoscopy before discharge showed a normal stable trachea with only partial prolapse of mucosa in the carina and remnants of granulation tissue in the right main bronchus. There was no significant airway narrowing.
In the following period the patient had normal development and there were no significant respiratory symptoms, except for one mild episode of upper respiratory tract infection. The patient was thriving, had normal neurologic development, and no episodes of wheezing or desaturation were noted. A follow-up bronchoscopy was performed 9 months after the operation. There was a mild deformity of the right wall of the distal trachea. The trachea was slightly flattened at the level of the carina. Residual flat granulation tissue was seen in the orifice of the right main bronchus with no narrowing of the lumen. The wall of the trachea and the main bronchi were stable.
|
Comment
|
|---|
The question of solving stenosis of the lower respiratory tract in infants and children is very difficult and demands a multidisciplinary approach [1]. Tracheal stenosis may be acquired or congenital. Acquired tracheal stenoses are usually postintubation stenosis [2], with traumatic and neoplastic being less common. Primary congenital stenoses are very rare, but the combination of congenital stenosis of the trachea and main bronchus is even rarer. Symptoms relate to the degree of airway obstruction and possible ongoing infection leading to respiratory distress, emphysema, and pneumonia. These may result in a life-threatening status necessitating urgent surgical treatment.
The first report of a successful operation of congenital tracheal stenosis was published in 1964 [3]. Since then a great number of operative techniques have been proposed, including a simple resection with end-to-end anastomosis, several kinds of plasty, and allograft tracheal replacement [4]. Anatomic findings are a decisive factor in the choice of treatment technique. Slide tracheoplasty was first described by Tsang and colleagues [5] in 1989, and were then developed by Grillo [6]. Recently, Le Bret and colleagues [7] have published an article on slide tracheobronchoplasty in an infant with tracheal hypoplasia extending to both main bronchi.
The postoperative complications are a result of either the preoperative clinical status of the patient or of the surgery itself. The risk of sutural dehiscence in infants is greater than in adults. The advantage of the slide method is the use of native tracheal tissue without the need of any other material for augmentation. The number of postoperative complications is also smaller compared with other methods. Usually there is a minimum tendency to develop granulation tissue along the suture line after slide plasty; however, in this case the abundant growth of the granulation tissue was not inconsiderable in the first postoperative days. Experimentally, the continuing growth of the trachea has been documented after slide tracheoplasty [8]. Slide plasty of concomitant congenital stenosis of the distal trachea and the main bronchus seems to be a suitable therapeutic method for treating an otherwise life-threatening condition.
|
References
|
|---|
- Elliott M, Roebuck D, Noctor C, et al. The management of congenital tracheal stenosis Int J Pediatr Otorhinolaryngol 2003;67(Suppl 1):S183-S192.[Medline]
- Wright CD, Graham BB, Grillo HC, Wain JC, Mathisen DJ. Pediatric tracheal surgery Ann Thorac Surg 2002;74:308-314.[Abstract/Free Full Text]
- Cantrell JR, Guild HG. Congenital stenosis of the trachea Am J Surg 1964;108:297-305.[Medline]
- Backer CL, Mavroudis C, Gerber ME, Holinger LD. Tracheal surgery in children: an 18-year review of four techniques Eur J Cardiothorac Surg 2001;19:777-784.[Abstract/Free Full Text]
- Tsang V, Murday A, Gillbe C, Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis Ann Thorac Surg 1989;48:632-635.[Abstract]
- Grillo HC. Slide tracheoplasty for long-segment congenital stenosis Ann Thorac Surg 1994;58:613-619.[Abstract]
- Le Bret E, Garabédian EN, Teissier N, et al. Slide tracheobronchoplasty in an infant J Thorac Cardiovasc Surg 2006;132:181-183.[Free Full Text]
- 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]
Top
Abstract
Introduction
