Surgical Treatment of Long-Segment Tracheal Anomalies in Infants and Children

Abstract

Background: Tracheal stenosis in combination with vascular and/or cardiac anomalies is a life-threatening condition in infants and children presenting with severe symptoms of airway obstruction. The optimal surgical treatment of these cases remains controversial. Objectives: We present here a group of infants and children with combined tracheal malformations and vascular and/or cardiac anomalies. More than 30 % of the stenotic trachea was resected in a subgroup of the patients. A reconstruction with end-to-end anastomosis was achieved on the basis of extensive mobilization of the whole tracheobronchial tree and use of CPB. Methods: The clinical outcome in 37 children with a median age of 8 (1 - 72) months was analyzed retrospectively. The patients presented with severe airway obstruction in combination with congenital heart defects and/or vascular anomalies. Cardiac catheterization, bronchoscopy and thoracic computer tomography were performed prior to operation. The operations were performed under CPB and consisted of tracheal resection with end-to-end anastomosis or external stabilization. Associated intracardiac and vascular anomalies were repaired simultaneously. Results: All but 1 patient survived and had a straightforward recovery. The patients were extubated under bronchoscopic control with a median intubation time after airway repair of 12.2 days. The average follow-up was 8.4 years (1 - 14 years) and the surviving patients did not show signs of restenosis clinically. A segment longer than 30 % of the tracheal length was resected and reconstructed with end-to-end anastomosis in 57 % of the patients (12 of 21 patients). Conclusions: Our experience demonstrates that resection of tracheal stenosis and end-to-end anastomosis can be achieved successfully even in cases with stenosis of more than 30 % of the total tracheal length. The use of CBP allowed extensive mobilization of the tracheobronchial tree and resection with end-to-end tension-free anastomotic reconstruction.

Key words

cardiovascular surgery - thoracic surgery - tracheal stenosis

References

• 1 Backer C L, Mavroudis C. Congenital heart surgery nomenclature and database project: vascular rings, tracheal stenosis, pectus excavatum. Repair of congenital tracheal stenosis with a free tracheal autograft.  Ann Thorac Surg. 2000;  69 308-318
• 2 Yamaguchi M, Oshima Y, Hosokawa Y, Ohashi H, Tsugawa C, Nishijima E, Tsubota N. Concomitant repair of congenital tracheal stenosis and complex cardiac anomaly in small children.  J Thorac Cardiovasc Surg. 1990;  100 181-187
• 3 Dunham M E, Holinger L D, Backer C L, Mavroudis C. Management of severe congenital tracheal stenosis.  Ann Otol Rhinol Laryngol. 1994;  103 351-356
• 4 Loukanov T, Sebening C, Springer W, Hagl S. A case of pulmonary artery sling associated with long-segment funnel trachea and bronchus suis.  Ann Thorac Surg. 2004;  78 1839-1842
• 5 Loukanov 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 1537-1541
• 6 Pillai J B, Smith J, Hasan A, Spencer D. Review of pediatric airway malacia and its management, with emphasis on stenting.  Eur J Cardiothorac Surg. 2005;  27 35-44
• 7 Backer C L, Mavroudis C, Dunham M E, Holinger L D. Pulmonary artery sling: results with median sternotomy, cardiopulmonary bypass, and reimplantation.  Ann Thorac Surg. 1999;  67 1738-1745
• 8 Hagl S, Jakob H, Sebening C, van Bodegom P, Schmidt K, Zilow E, Fleischer F, Ulmer H. External stabilization of long-segment tracheobronchomalacia guided by intraoperative bronchoscopy.  Ann Thorac Surg. 1997;  64 1412-1420
• 9 Jaquiss R D, Lusk R P, Spray T L, Huddleston C B. Repair of long segment tracheal stenosis in infancy.  J Thorac Cardiovasc Surg. 1995;  110 1504-1511
• 10 Freidman E, Perez-Atayde A R, Silvera M, Jonas R A. Growth of tracheal anastomoses in lambs: comparison of PDS and Vicryl suture and interrupted and continuous techniques.  J Thorac Cardiovasc Surg. 1990;  100 188-193
• 11 Tsang V, Murday A, Gillbe C, Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis.  Ann Thorac Surg. 1989;  48 632-635
• 12 Jonas R A. Invited commentary.  Ann Thorac Surg. 1999;  68 994
• 13 Grillo H C, Wright C D, Vlahakes G J, MacGillivray T E. 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
• 14 Hammer G B. Pediatric thoracic anesthesia.  Anesth Analg. 2001;  92 1449-1464
• 15 Kim H K, Kim Y T, Sung S W, Park J D, Kang C H, Kim J H, Kim Y J. Management of congenital tracheal stenosis.  Eur J Cardiothorac Surg. 2004;  25 1065-1071
• 16 DeWitt R C, Hallman C H. Use of cardiopulmonary bypass for tracheal resection.  Tex Heart Inst J. 2004;  31 188-190
• 17 Peterffy A, Konstantinov I E. Resection of distal tracheal and carinal tumors with the aid of cardiopulmonary bypass.  Scand Cardiovasc J. 1998;  32 109-112
• 18 Nakayama D K, Harrison M, de Lorimier A A, Brasch R C, Fishman N H. Reconstructive surgery for obstructive lesions of the intrathoracic trachea in infants and small children.  J Pediatr Surg. 1982;  17 854-868