Ann Thorac Surg 2008;85:1118-1120. doi:10.1016/j.athoracsur.2007.08.003
© 2008 The Society of Thoracic Surgeons
How To Do It
Modified Sliding Tracheal Plasty Using the Bridging Bronchus for Repair of Long-Segment Tracheal Stenosis
Siegfried Hagl, MDa,
Christian Sebening, MDa,
Wolfgang Springer, MDb,
Tsvetomir Loukanov, MDa,*
a Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
b Department of Paediatric Cardiology, University of Heidelberg, Heidelberg, Germany
Accepted for publication August 2, 2007.
* Address correspondence to Dr Loukanov, Department of Cardiac Surgery, INF 110, University of Heidelberg, Heidelberg, 69120, Germany (Email: tsvetomir_loukanov{at}med.uni-heidelberg.de).
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Abstract
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A child with severe respiratory distress, previously operated on at age 4 months for pulmonary sling and atrial septal defect, underwent reoperation at age 4 years because of long-segment congenital tracheal stenosis complicated by an abnormal branching of the trachea-bridging bronchus. We review the anatomy of that rare pathomorphology and describe a slide tracheoplasty that uses the bridging bronchus for treatment of this complex anomaly.
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Introduction
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Slide tracheoplasty with reimplantation of the left pulmonary artery has become one of the preferred techniques for repair of long-segment congenital tracheal stenosis [1] in association with a pulmonary artery sling [2]. Bridging bronchus was first described by Gonzalez-Crussi and colleagues [3]. We present a modification of this surgical technique for reconstruction of the trachea in a patient with stenosis of a long segment of the trachea associated with pulmonary sling syndrome and bridging bronchus.
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Technique
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A diaphragm hernia on the right site was diagnosed in the fetus at week 21 of the pregnancy and was corrected elsewhere with postoperative use of extracorporeal membrane oxygenation (ECMO) for respiratory failure. At the age of 4 months, a pulmonary sling was repaired and an atrial septal defect was closed using extracorporeal circulation. After this surgical treatment, the child had repeated recurrent upper respiratory tract infections and episodes of severe respiratory distress. During one such episode at the age of 10 months, the patient was intubated and ventilated.
Because of these symptoms, 3-dimensional computed tomography (CT) was performed at the age of 4 years and revealed the congenital tracheal lesion (Fig 1). A long-segment tracheal stenosis was seen between a bridging bronchus and the carina, with an estimated length of 3.5 cm. The lumen of the trachea was 2.2 mm at the most stenotic part. Bronchoscopy confirmed this finding. Distal to the origin of the bridging bronchus, a 3-cm-long segment with complete tracheal rings was present.
Surgical reintervention was undertaken at our institution when the child was 4 years old. The operation was performed through a midline resternotomy with the use of extracorporeal circulation. The aortic arch and pulmonary arteries were extensively dissected and mobilized. The pulmonary ligaments were transected. The right lung was hypoplastic. The left pulmonary artery (LPA) had been reimplanted at the site of transection into the right pulmonary artery (RPA). The significantly dilatated RPA and the dilated proximal segment of the LPA compressed the distal part of the trachea and the carina now anteriorly.
To reach adequate mobilization of the entire intrathoracic part of the trachea, dissection and resection of the scar tissue as well as excision of postinflammatory enlarged lymph nodes was performed. The upper part of the trachea was normal, with an external diameter of about 11 mm. The right upper lobe bronchus was found to arise at an angle of 45° as a bridging bronchus. The external diameter of the proximal segment of the bridging bronchus was 6 to 7 mm. The stenotic distal part of the trachea was 4.5 cm long and extended to the carina. The carina and the 2 main bronchi were hypoplastic but showed normal structure and morphology of the wall.
Cardiopulmonary bypass was initiated, and the child was cooled to 30°C. The LPA was dissected at its origin site and connected orthotopically in the left anterolateral position with the main trunk of the PA with an end-to-side anastomosis. This maneuver achieved complete relief of anterior tracheal compression.
The mediastinal pleura was resected and the pericardium was incised circumferentially around the pulmonary hilus bilaterally. Thus, maximal mobilization of the hili, the main bronchi, carina, and the distal part of the trachea up to 2 to 2.5 cm in all directions was reached.
Despite extensive mobilization of the trachea, it was not possible to perform end-to-end anastomosis by any current technique described to reconstruct the 4.5-cm-long stenotic tracheal segment. We decided to use the mobilized and normally structured bridging bronchus for augmentation of the distal part of the trachea. The bridging bronchus and upper pulmonary lobe were dissected free from dense adhesions and also extensively mobilized. In this way, it was possible to attach the bridging bronchus side-to-side to the entire segment of the dysplastic distal trachea, including the carina and the proximal part of the right bronchus. The distal hypoplastic and dysplastic part of the trachea (4 cm length) was then incised anterolaterally on the right side in a longitudinal fashion, including the carina and the proximal segment of the right bronchus. The lumen of the distal stenotic part of the trachea was inspected and was reduced to 2 mm. The inspection of the lumen revealed extensive fibrotic changes and complete cartilaginous rings. No mucous layer was detectable macroscopically.
The bridging bronchus was then opened with a corresponding longitudinal 4.5-cm-long incision starting proximally. The incision of the distal trachea was correspondingly extended to the carina and right main bronchus. Both structures were anastomosed side-to-side, using interrupted 5-0 polydioxanone suture. The anastomosis was free of tension. This technique was used to widen the internal diameter of the distal trachea to 7 mm. By slight anterolateral rotation and with the help of the intact cartilage rings of the bridging bronchus, the dysplastic "funnel segment" was not only enlarged but also stabilized (Fig 2).
Intraoperative bronchoscopic monitoring showed a well-reconstructed, mechanically stable trachea with 3 patent bronchial ostia forming a trifurcation of both main bronchi and bridging bronchus. To avoid external compression of the carina from the dilatated right PA, the RPA was anteriorly fixed to the right atrium using pledged sutures in the sense of an "atriopexy."
Cardiopulmonary bypass was discontinued, with stable hemodynamics, sinus rhythm, and normothermia. Arterial pressure was 85/45 mm Hg; PO
2 was 452 mm Hg at a fraction of inspired oxygen of 1.0. The overall extracorporeal circulation time was 207 min.
The patient was extubated on postoperative day 14 but had to be reintubated because of carbon dioxide retention. Another three reintubation episodes followed for the same reason. The definitive extubation under endoscopic monitoring was possible 25 days after the operation.
A localized pneumonic infiltration developed that was successfully treated with antibiotics. The child was treated with continuous positive airway pressure, oxygen therapy, and later, intensive physiotherapy. The patient was finally discharged home on postoperative day 90 in a good clinical condition, fully mobilized, without the need of oxygen, and without signs of respiratory distress. At the 1-year follow-up, the patient was in good health, without supportive therapy, and free of symptoms.
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Comment
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The presented case, in which the patient had been previously operated on for pulmonary sling, is interesting in several aspects. The patient presented with a rare and complex tracheobronchial malformation with bridging bronchus, and a long tracheal stenosis ("funnel" type) associated with PA sling. This complex condition was associated with previously surgically treated diaphragm hernia and Meckel diverticulum. In addition, the right lung of the patient was hypoplastic. Despite the unfavorable anatomy, the necessity of performing a procedure with the aim of improving the patient’s seriously compromised respiratory function was agreed to by the family.
Slide tracheoplasty as a widely used corrective surgical technique for repair of long-segment tracheal stenosis was not feasible in this patient because of the very long segment of funnel trachea combined with bridging bronchus.
We reported previously a similar case in which we successfully reconstructed the trachea by end-to-end anastomosis after long-segmental resection [4]. In this patient, the length of the stenotic segment was clearly above 30% of the intrathoracic trachea, which according to Grillo and colleagues [5] is considered as an upper limit for an end-to-end reconstruction of congenital tracheal stenosis independently of the technique used.
The technique we used in the present case permitted use of the bridging bronchus as "augmentation plasty material" for enlarging of the stenotic tracheal segment. Tsang and colleagues [6] described the slide tracheoplasty technique in 1989, involving transsection and spatulation of the proximal and distal ends through the stenosed area, with anastomosis of the two spliced extremities. We modified their technique with a long, parallel-configured anastomosis of bridging bronchus and the stenotic tracheal segment. This required extensive mobilization of the trachea and the bronchial system. To avoid tension, extensive bilateral hilar release was necessary.
The great value of cardiopulmonary bypass in such repair of complex tracheal malformations, especially when associated cardiac defects and vascular malformations are present, should be emphasized and considered [7]. Extracorporeal circulation facilitated the surgical procedure, guaranteed adequate oxygen supply, and ensured hemodynamic stability during this complex repair. This technique used in patients with bridging bronchus may be an alternative to the one described by Grillo and colleagues [5] and Beierlein and Elliott [1].
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Acknowledgments
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Thanks are due to Professor Dr. med. Klaus G. Schmidt, Childrens Clinic, University of Duesseldorf for the preoperative computed tomography scan of the trachea.
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References
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- Beierlein W, Elliott M. Variations in the technique of slide tracheoplasty to repair complex forms of long-segment congenital tracheal stenosis Ann Thorac Surg 2006;82:1540-1542.[Abstract/Free Full Text]
- Jonas RA. Invited commentary Ann Thorac Surg 1999;68:994.[Free Full Text]
- Gonzalez-Crussi F, Padilla L-M, Miller JK, et al. "Bridging bronchus." A previously undescribed airway anomaly Am J Dis Child 1976;130:1015-1018.[Abstract/Free Full Text]
- Loukanov T, Sebening C, Springer W, Hagl S. A case of pulmonary artery sling associated with long-segment funnel trachea and bridging bronchus Ann Thorac Surg 2004;78:1839-1842.[Abstract/Free Full Text]
- 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]
- Tsang V, Murday A, Gillbe C, Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis Ann Thorac Surg 1989;48:632-635.[Abstract]
- Loukanov TS, Sebening C, Springer W, Ulmer H, Hagl S. Simultaneous management of congenital tracheal stenosis and cardiac anomalies in infants J Thorac Cardiovasc Surg 2005;130:1537-1541.[Abstract/Free Full Text]
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Abstract
Introduction
