Slide Tracheoplasty as a Rescue Technique After Unsuccessful Patch Tracheoplasty Martin J. Elliott, MD, FRCS, Simone Speggiorin, MD, Vladimiro L. Vida, MD, Massimo A. Padalino, MD, PhD, Paola E. Cogo, MD, PhD, Cesare Cutrone, MD, Loris Mirri, MD, and Giovanni Stellin, MD Cardiothoracic Unit, Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom; Pediatric Cardiac Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, Airway Endoscopic Surgery Unit, and Pediatrics Department, University of Padua, Padua, Italy
Long-segment tracheal stenosis with complete tracheal rings is a severe and life-threatening problem in small children. Slide tracheoplasty has largely become the treatment of choice for these patients [1– 4]. Its use after the failure of other techniques has not been previously reported. We describe a 3-year-old child who underwent
a rescue slide tracheoplasty for re-stenosis after initial patch tracheoplasty for long-segment tracheal stenosis and pulmonary artery sling.
C
cised cartilages. The left pulmonary artery was then re-implanted, anterior to the trachea, into the main pulmonary artery. A control FOB showed an impaired patency of the trachea and persistent narrowing proximal to the patch tracheoplasty. The postoperative period was characterized by air trapping whenever sedation was stopped. Fiberoptic bronchoscopy showed residual complete tracheal rings stenosing the upper segment of the trachea. A computed tomographic scan showed there was a stenotic segment 1 cm cranially from the carina (3.5 ⫻ 3 mm in diameter) (Figs 1 and 2). The patient was paralyzed, sedated, and mechanically ventilated. There was little improvement and eventually the child’s condition began to deteriorate. Forty-eight days later, and after CT and bronchoscopic data had been reviewed by the tracheal team at Great Ormond Street, London, the patient underwent a second surgical procedure lead by the first author (MJE). We initially believed that in view of the scarring of the pervious operation, slide tracheoplasty (the preferred choice at Great Ormond Street) would probably not succeed because of the inability to mobilize the trachea. A patch tracheoplasty was anticipated. Surgery was performed through a redo median sternotomy and on normothermic cardiopulmonary bypass. The trachea was extensively mobilized by division of the thyroid isthmus, incision of the pericardial reflections, and removal of the subcarinal nodes and hilar dissection out to the first bronchial division, allowing the bronchi to be pulled closer into the mediastinum. The trachea was then divided transversally at the midpoint of the identified stenosis, cephalad to the pericardial patch, which was removed. The presence of several unresected complete tracheal rings was confirmed. The upper tracheal segment was incised longitudinally along its posterior surface until normal trachea was observed posteriorly, and a reciprocal, anterior, incision was made on the lower
Technique A 3-year-old boy who was suffering from frequent episodes of respiratory distress (treated with antibiotics and corticosteroids) was referred to the Padua unit. A diagnosis of long-segment tracheal stenosis, complete tracheal rings, and left pulmonary artery sling was made by computed tomographic angiography and fiberoptic bronchoscopy (FOB) (Fig 1). A decision was made to repair the anomalies in one operation. Through a median sternotomy, and on normothermic cardiopulmonary bypass, the trachea and the left pulmonary artery were exposed. The left pulmonary artery was transected at its origin from the main pulmonary trunk, and the trachea was circumferentially mobilized. Three complete tracheal rings were removed. The tracheal ends were directly anastomosed posteriorly, and a glutaraldehyde-treated autologous pericardial patch was inserted anteriorly to enlarge the stenotic segment that extended cephalad from the exAccepted for publication Jan 9, 2009. Address correspondence to Dr Elliott, The Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London, WC1N 3H, United Kingdom; e-mail:
[email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.01.024
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ongenital long-segment tracheal stenosis is a severe and life-threatening problem in small children. During the last two decades many techniques have been proposed to correct this pathology, but slide tracheoplasty (STP) has largely become the treatment of choice for these patients, due to its better surgical outcome. The use of STP in reoperations as a salvage procedure adds an important technique to the armamentarium of surgeons tackling these difficult problems. In this article, we describe the use of STP as rescue technique after a failing patch tracheoplasty for long-segment tracheal stenosis and pulmonary artery sling.
(Ann Thorac Surg 2009;88:1029 –31) © 2009 by The Society of Thoracic Surgeons
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Fig 1. (A) Computed tomographic scan showing a coronal section of the trachea and the main bronchi. The long segment tracheal stenosis can be seen on the lower third (arrow). (B) Computed tomographic scan showing the sling of the left pulmonary artery compressing the trachea (arrow).
FEATURE ARTICLES
segment extending into the right main bronchus. The tips of the distal and proximal segments were trimmed, and the flaps were slid together and sutured with 5-0 polydioxanone interrupted sutures. The 5.5-mm endotracheal tube was advanced to the midpoint of the reconstruction, and the lateral aspects of the flaps were closed with continuous polydioxanone. The patient was then ventilated, no leak was identified, and then he was easily weaned from the cardiopulmonary bypass. Chest closure was well tolerated. A mediastinal irrigation system with iodine solution was left in situ for 48 hours to prevent mediastinitis [1], and the patient was transferred in stable condition to the intensive care unit. The patient was subsequently extubated on postoperative day 12, when FOB revealed a widely patent tracheal anastomosis with minimal malacia. The child was discharged shortly afterwards, and at 6 months postoperatively the patient re-
Fig 2. Computed tomographic scan showing three-dimensional reconstruction of the airways. The residual stenotic segment (arrow) can be seen on the lower part of the trachea.
mained asymptomatic with the FOB demonstrating a good surgical result and good airway patency.
Comment Long-segment tracheal stenosis is defined when the stenosis includes more than two thirds of the trachea. The malformation is rare in children, but life-threatening and difficult to treat [2]. There are different techniques to correct tracheal stenosis. These include pericardial tracheoplasty (PTP), tracheal autograft, and STP. In the past, the PTP and the tracheal autograft were largely used to treat this malformation, but the surgical results were unsatisfactory and characterized by high recurrence of re-stenosis [3, 4]. Subsequently, STP became a popular alternative to PTP and tracheal autograft, providing lower mortality and morbidity [1, 2–5]. In this case, the patient underwent surgical correction by PTP procedure, but there was incomplete ring resection. In the postoperative period, re-stenosis occurred, preventing weaning from the ventilator. The re-stenosed trachea was well studied with FOB and computed tomographic scan. The stenosis incorporated further cartilaginous circumferential rings in the cranial segment of the trachea, and thickening of the pericardial patch in the distal segment. As reported by Backer and colleagues [3], although patients who underwent PTP survived at the operation, they often had prolonged hospital stay secondary to patch malacia, recurrent stenosis, and exuberant granulation tissue. These patients required multiple endoscopic debridements, and in almost one fourth of them, reoperation was necessary [2, 4, 6, 7]. Despite our preoperative impression that a redo patch tracheoplasty would be indicated, careful, but extensive tracheal and bronchial mobilization allowed STP to be performed, correcting the re-stenosis by opening the circumferential cartilaginous rings by removing the patch and enlarging the tracheal lumen. Given the apparent superiority of long-term results for slide tracheoplasty, this case provides encouragement to surgeons faced with recurrent stenosis of the trachea in which it may still be
possible to perform a slide type of repair if adequate dissection is carried out.
References 1. Elliott M, Hartley BE, Wallis C, Roebuck D. Slide tracheoplasty. Curr Opin Otolaryngol Head Neck Surg 2008;16:75– 82. 2. Kocyildirim E, Kanani M, Roebuck D, et al. Long-segment tracheal stenosis: slide tracheoplasty and a multidisciplinary approach improve outcomes and reduces costs. J Thorac Cardiovasc Surg 2004;128:876 – 82. 3. 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– 84.
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4. Backer CL, Mavroudis C, Dunham CE, Holinger LD. Reoperation after pericardial patch tracheoplasty. J Pediatr Surg 1997;32:1108 –12. 5. Louktanov T, 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– 41. 6. 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;123:145–52. 7. Beierlein W, Elliott MJ. Variation in the technique of slide tracheoplasty to repair complex forms of long-segment congenital tracheal stenosis. Ann Thorac Surg 2006;82:1540 –2.
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Ann Thorac Surg 2009;88:1029 –31
