| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1996;62:989
© 1996 The Society of Thoracic Surgeons
DR HERMES C. GRILLO (Boston, MA): I thank Dr Bando and associates for the opportunity to read this very careful and excellent report in manuscript form.It was demonstrated many years ago that the juvenile trachea does indeed grow after anastomosis, but it very quickly became clear that resection and reconstruction were impossible for these long congenital stenoses. In 1982, Kimura and colleagues offered a solution, namely longitudinal tracheoplasty with a cartilaginous patch. Since then, Idriss, Backer, Mavroudis, and their colleagues in Chicago and the group from Indianapolis have used patches of pericardium with success. Huddleston's report from St. Louis last year offered added good results with cartilage patch tracheoplasty. Patch tracheoplasty has matured as a relatively safe and effective technique for these critically ill patients. Recently, in an effort to simplify this approach, Goldstraw, in England, proposed a procedure known as a slide tracheoplasty, using the patient's own tissues for repair. We have had success with a small series of these cases, although our patients were less critical than the tiny patients described by Bando and associates.
The relative merits of cartilage versus pericardium for patch tracheoplasty have been argued, and I think the controversy will continue. There are arguments in favor of and against both. I think the techniques offer similar results. Also, the information from this study on reepithelialization in the 1 unfortunate case is interesting and helpful.
The relative merits of patch tracheoplasty, whether done by cartilage or pericardium, versus slide tracheoplasty deserve careful study. This will have to be done by surgeons in children's hospitals. From my calculations from combined reports from children's hospitals in Indianapolis, Chicago, and St. Louis, it seems that each group can expect, at best, to treat 1 or 2 of these patients per year. Therefore, it may take a long time to reach consensus. It may well be that both approaches—slide and patch tracheoplasty—will find a place in the management of these very difficult cases, which vary so much in extent and in form.
One additional observation is that in patients with this disease who did not require urgent repair, whom we followed for as long as 18 years, the stenotic segment has grown in proportion to the normal trachea. I believe we can expect, as was shown in this study, that reconstructed tracheal tissue will continue to grow, whether in patch or in slide mode. I applaud Dr Bando and associates for their very thoughtful report and their excellent results.
DR HAROLD C. URSCHEL, Jr (Dallas, TX): I congratulate Dr Bando, and would like to mention a technique that Dr Fritz Barton has developed in Dallas to aid in tracheal reconstruction. His technique transfers a free parietalis fascia graft as an envelope over cartilage strips to replace several anterior tracheal rings. This free graft is sutured by an anastomosis to the superior thyroid artery and middle thyroid vein with a microscope. This has been an extremely helpful and valuable tool in tracheal reconstruction.
DR CHARLES B. HUDDLESTON (St. Louis, MO): I too applaud Dr Bando and associates on their excellent results. These are extremely sick patients in general, given that virtually all of them in this series were intubated and many of them had associated severe congenital heart disease, which adds to the complexity of managing these patients.
I do have two questions for Dr Bando. I notice from the manuscript that some of the patients clearly had segments of the trachea involved that were less than 50% of the total length. In our series, we confined our anterior tracheoplasties to those with very long segments, and did segmental resections of the shorter segments of trachea that were involved. Doctor Bando, can you comment about this?
One major difference between the series from Indianapolis and the series from Chicago is that the latter had a tremendous amount of difficulty with granulation tissue requiring multiple bronchoscopic treatments, I think on average about ten bronchoscopies per patient after their repairs. I cannot tell exactly what the difference in the technique is from one series to another, but this is an obvious contrast between the series. Doctor Bando, can you explain what might be the difference?
DR BANDO: I thank all the discussants for their comments.
First of all, I thank Dr Grillo for his comments. It is quite an honor for us to have him discuss our paper, and all of us are indebted to him for his tremendous work on understanding tracheal operations.
I also appreciate Dr Urschel's comments and complement him on his new techniques.
Regarding the questions raised by Dr Huddleston, the first question was related to the short segmental stenosis. The advantage of either anterior pericardial tracheoplasty or rib cartilage repair is that there is no limitation on the length or location of the stenosis that needs to be repaired. Either of these techniques is applicable for short or long segmental stenosis. Even if the stenosis area is extended to the left or right main bronchus, one need only extend the patch to that region to reconstruct very nicely with these techniques.
Regarding the question on how to avoid the granulation problem, I think there are two important issues. The first is suturing technique. As indicated in the illustration, special care was taken not to place the sutures in the tracheal mucosa so as to avoid any suture material in the lumen of the airway, which would stimulate granulation tissue formation. The second issue is the duration of intubation. The longer the intubation time, the more likely that there will be a granulation problem. As we gained experience, we were able to extubate 6 and 8 days after operation in the last 2 patients. We did not see any granulation problems at the tracheoplasty site in these patients.
Related Article
Ann. Thorac. Surg. 1996 62: 981-989.
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
