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Department of Cardiothoracic Surgery, University of Witwatersrand, Johannesburg, South Africa
Accepted for publication January 16, 2009.
* Address correspondence to Dr Davidson, PO Box 7648, Petit, Johannesburg, 1512, South Africa (Email: mdavidson{at}vodamail.co.za).
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A 33-year-old man presented with a suspected tracheoesophageal fistula on July 20, 2007. He had been involved in a motor vehicle accident and sustained a head injury with skull fractures and an intracranial hemorrhage along with rib fractures and a lung contusion. He had been treated by the trauma unit with a tracheostomy and a prolonged course of ventilation.
On July 23, 2007, a rigid bronchoscopy and esophagoscopy were performed, which confirmed a long segment tracheoesophageal fistula approximately 3.5-cm long, ending 2 cm proximal to the carina. Repair by using a transverse cervical collar incision with a mediastinal split was performed. The esophageal tear was repaired in two layers with 3.0 polydioxanone monofilament suture. A flap of sternocleidomastoid muscle was brought down to cover the esophagus, and 4.5 cm of necrotic trachea was resected. A primary anastomosis was performed with interrupted 3.0 polydioxanone monofilament sutures. The patient was extubated on the table without complication.
Three days subsequently, the patient had a coughing bout and sudden respiratory distress developed with progressive surgical emphysema. He was rushed to the operating room where it was found that the tracheal anastomosis had dehisced. The posterior tracheal wall was especially friable. He was intubated directly through the trachea and ventilated. At this point in time, his saturations were low, and he was suffering from aspiration and adult respiratory distress syndrome. It was believed that it would be better to allow him to overcome this acute incident before proceeding. Incidentally, it was discovered that he was HIV positive.
Two days later, his endotracheal tube slipped out and he was taken back to the operating room where (due to the short residual stump of distal trachea) he was selectively intubated through each main bronchus and ventilated. It was noted that mediastinitis had developed, and there was a small leak from the esophageal repair. Given his poor clinical state, the leak was treated conservatively with well-positioned Penrose drains, parenteral nutrition, and appropriate antibiotics.
After much debate and consultation as to the best path forward, and after consulting the University of the Witwatersrand Ethics Committee, it was decided that if we were unable to anastomose the trachea primarily, we would replace the trachea with banked aortic homograft.
On August 2, 2008, after having made a significant recovery from his prior respiratory insult, he was taken to the operating room. An initial attempt was made with the aid of our ear, nose, and throat surgeons to perform a suprahyoid release to gain more length for a primary anastomosis. Despite this, it was believed that a primary anastomosis would still be under too much tension. Cardiopulmonary bypass was instituted to provide adequate oxygenation. The esophagus appeared to be intact, and it was elected to continue to treat the esophagus conservatively with well-positioned drains and parenteral nutrition, with a view to performing a feeding jejunostomy in due course.
The necrotic edges of the trachea were debrided, and the defect in the trachea reconstructed using a size 23-mm banked aortic homograft of 6 cm in length. Fearing collapse of the homograft during expiration, we elected to stent the homograft with a Montgomery tube placed through an incision in the native trachea proximal to the proximal anastomosis. The patient was then ventilated through an endotracheal tube placed into the Montgomery tube. Initially, he came off bypass on a fair amount of adrenaline and a substantial amount of time was spent obtaining hemostasis.
He progressed well and was weaned off inotropes over the subsequent days. Four days later, a feeding jejunostomy was created. His ventilation continued to improve, and 2 days later, on August 8, 2007, he was extubated. He was mobilized, and despite good respiratory function, he suddenly arrested 4 days later on August 12, 2007. Subsequent autopsy showed dehiscence of the proximal anastomosis with generalized mediastinitis.
De Delva and colleagues [2] have reported successful tracheal transplantation with autologous thoracic aorta in nine sheep. Of the six sheep that survived to necropsy it was noted that longitudinal scarring initially reduced the tracheal defect by 56%. Furthermore, the initima was replaced by squamous epithelium in four sheep and mucociliary epithelium in two in a time-dependant manner. In two sheep, there were even noted islands of immature chondrogenesis. The authors concluded that reconstruction of the trachea with allogeneic aorta might be a feasible strategy.
In France, after three trials with 51 sheep, whereby the trachea was replaced with allogeneic and autologous aorta, they proceeded to successfully replace 7 cm of trachea with autologous infrarenal aorta in a human patient suffering from squamous carcinoma [3–5]. The patient did well initially with the stent being removed at 3 months. At 6 months, the patient passed away due to a respiratory infection; but there was no evidence of anastomotic disruption [5]. Of the sheep, all were stented with either a permanent or removable endoluminal tracheal stent and there was no anastomotic leakage. Furthermore, necropsy showed lining of the aorta with epithelium and formation of immature cartilage rings [3, 4].
Thus, although the literature is confined to mostly animal experiments and two case presentations, the literature portrays aortic allografts as a potential for large segment tracheal replacement.
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Furthermore, one can debate the use of cardiopulmonary bypass, as it caused a considerable hindrance in the form of postoperative hemorrhage. What is more, we wonder whether it would not have been better to divert the esophagus at the time of breakdown of the first repair, preventing one possible source of the mediastinitis. Bearing all of this in mind and in keeping with recent literature, we believe that the use of an aortic homograft for long-segment tracheal reconstruction is a credible option that requires further investigation.
In light of recent developments, whereby a patient's trachea was successfully replaced with a tissue-engineered human cadaver tracheal allograft, we (the authors) believe that tracheal replacement with aortic allograft is still a viable option. Although tissue engineering might be the best conduit in patients with planned reconstruction of the trachea and time available, the use of an aortic allograft is probably the most readily available conduit in the emergency setting. Furthermore, we surmise that the present cost of tissue engineering would be cost-prohibitive, especially for developing countries.
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  D. McGiffin, K. Wille, K. Young, and K. Leon Salvaging the dehisced lung transplant bronchial anastomosis with homograft aorta Interact CardioVasc Thorac Surg, December 1, 2011; 13(6): 666 - 668. [Abstract] [Full Text] [PDF]
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