- Email: [email protected]
Successful Reconstruction of Traumatic Carinal Tissue Loss Using the Esophagus in an Infant
Ann Thorac Surg 2007;84:1031–3
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
References
Before Operation
6 Months After Operation
18 Months After Operation
4.3 109 3.37 81 7.61 0.62 7.19 (106)
3.43 87 2.91 88 7.75 0.7 6.58 (97)
3.49 89 3.04 86 8.27 0.63 6.22 (97)
FEV1 ⫽ forced expiratory volume in 1 second; PEFR ⫽ peak expiratory flow rate; TV ⫽ tidal volume; TLC ⫽ total lung capacity; VC ⫽ vital capacity.
second at 1.0%, and peak flow rate were slightly increased (Table 1). Furthermore, total lung capacity had reached 97% of the predicted value, showing that the lung was sufficiently inflated.
Comment The results of the present case suggest that ventilatory movement of the rib cage can compensate for loss of bilateral diaphragmatic function in a healthy adult patient with normal pulmonary function. When a patient showed restrictive or obstructive lung function before surgery, the compensatory mechanism might be ineffective. Weak peri-thoracic muscles or diaphragmatic breathing (as in small children) would also result in insufficient ventilation. Except for a nerve resection, hypothermic injury, stretching, or blunt trauma of the phrenic nerve causes transient paralysis, which recovers in most patients within 1 year [4]. In a previous study of cases of bilateral diaphragmatic paralysis induced by neuralgic amyotrophy, most adult patients improved symptomatically, but not functionally, during follow-up periods of 2 to 4 years [5]. In addition, Stolk and Versteeg [3] reported that the mean vital capacity value of neuralgic amyotrophy patients was improved by 17% after bilateral diaphragmatic plication, and the effect was sustained for at least 12 months. Because recovery of phrenic paralysis could not be expected in the present case, the aim of the bilateral plication was to fix both diaphragms for increasing efficiency of chest wall ventilation. Although the patient was dependent on chest wall motion exclusively for breathing, he showed no symptomatic or functional insufficiency for 18 months. However, when the plicated diaphragms become stretched with time and are gradually elevated, the ventilatory function likely decreases back to its original impaired level. Thus, phrenic nerve reconstruction with a nerve graft might be an effective intervention to maintain the recovery of phrenic function for a long period of time [6]. Based on the present results, we believe that bilateral diaphragmatic plication is an effective means of providing sufficient ventilatory function in selected patients with bilateral phrenic nerve paralysis. © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Graham DR, Kaplan D, Evans CC, Hind CRK, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990;49:248 –52. 2. Takeda S, Nakahara K, Fujii Y, Matsumura A, Minami M, Matsuda H. Effect of diaphragmatic plication on respiratory mechanics in dogs with uni- and bilateral phrenic nerve paralysis. Chest 1995;107:798 – 804. 3. Stolk J, Versteeg MIM. Long-term effect of bilateral plication of the diaphragm. Chest 2000;117:786 –9. 4. Watanabe T, Trusler GA, Williams WG, Edmond JF, Coles JG, Hosokawa Y. Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 1987;94:383– 8. 5. Mulvey DA, Aquilina RJ, Elliot MW, Moxham J, Green M. Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic examination of 16 patients presenting with dyspnea. Am Rev Respir Dis 1993;147:66 –71. 6. Schoeller T, Ohlbauer M, Wechselberger G, Piza-Katzer H, Margreiter R. Successful immediate phrenic nerve reconstruction during mediastinal tumor resection. J Thorac Cardiovasc Surg 2001;122:1235–7.
Successful Reconstruction of Traumatic Carinal Tissue Loss Using the Esophagus in an Infant Erik S. Stubberud, Jeffrey Phillip Jacobs, MD, FACS, Richard P. Harmel, Jr, MD, Thomas Andrews, MD, FACS, Paul J. Chai, MD, Harald L. Lindberg, MD, PhD, and James Anthony Quintessenza, MD, FACS Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, St. Petersburg and Tampa, and Divisions of Pediatric Surgery and Otolaryngology, All Children’s Hospital, St. Petersburg, Florida
We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition. (Ann Thorac Surg 2007;84:1031–3) © 2007 by The Society of Thoracic Surgeons
T
racheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss. We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and Dr Jacobs discloses a financial relationship with CardioAccess. Accepted for publication Jan 23, 2007. Address correspondence to Dr Jacobs, The Congenital Heart Institute of Florida, Cardiac Surgical Associates, 603 7th St S, Suite 450, St. Petersburg, FL 33701; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.01.047
FEATURE ARTICLES
Table 1. Pulmonary Function
VC (L) % of VC FEV1 (L) FEV1 (%) PEFR (L/s) TV (L) TLC (%)
1031
1032
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
Ann Thorac Surg 2007;84:1031–3
patient had increasing problems develop with pneumothorax and oxygenation. Emergent bronchoscopy revealed partial dehiscence of the tracheal reconstruction. The patient was taken emergently to the operating room and underwent a redo tracheal reconstruction through a median sternotomy on cardiopulmonary bypass with resection of the dehisced region of trachea with end-toend anastomosis of the anterior tracheal wall after using an interposition flap of esophageal mucosa for the posterior tracheal and carinal wall to avoid undue tension. Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi (Fig 2). The esophagus was transected and oversewn proximal and distal to the region used for the interposition flap. The patient was successfully weaned from cardiopulmonary bypass and postoperative bronchoscopy demonstrated patent bronchi with an intact tracheal reconstruction.
FEATURE ARTICLES
Fig 1. Initial bronchoscopy documented tissue loss involving the distal trachea, carina, and bilateral main stem bronchi. The arrows denote posterior tracheal tears extending into the proximal right and left mainstem bronchi.
carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition. A 9-month-old girl presented to the emergency department in severe respiratory distress 4 days after the successful removal of a button battery from her esophagus. The patient required emergent intubation and was taken to the operating room for micro-laryngoscopy and bronchoscopy, which revealed posterior tracheal wall perforation and anterior esophageal wall perforation. Due to difficulty in oxygenating the patient during the procedure, she was emergently placed on extracorporeal membrane oxygenation support. The tracheal injury constituted a 3-cm defect in the posterior distal tracheal wall involving the carina and proximal right and left main stem bronchi (Fig 1) and was initially repaired using a pedicled intercostal muscle flap taken from the right fourth and fifth intercostals muscles. This procedure was performed through a right posterolateral thoracotomy while on cardiopulmonary bypass with removal of the fourth and fifth ribs. The esophagus was ligated proximal and distal to the 4 to 6 cm esophageal defect using multiple cerclage sutures, and a gastrostomy tube was then placed. The patient was weaned from cardiopulmonary bypass and transferred to the intensive care unit. The patient’s postoperative course was complicated by adequate ventilation but poor oxygenation, and therefore she was placed on an oscillator ventilator. During the next 10 days she underwent several bronchoscopies to optimize pulmonary toilet. On postoperative day 10, the
Fig 2. (Top) After opening the trachea anteriorly, the esophagus (arrow) was visualized immediately posterior to the disrupted posterior trachea and carina. (Bottom) Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi. The arrows point to the orifices of the bronchi.
After the second tracheoplasty the patient was successfully extubated and was ventilating spontaneously. However, bronchoscopy initially demonstrated severe tracheomalacia and bronchomalacia at the posterior aspect of the carina consistent with prolapse of the interposed esophageal mucosa. Subsequent bronchoscopies completed 2 months and 16 months after the esophageal patch tracheoplasty demonstrated moderate nonobstructive granulation tissue at the area of the carina and mild bronchomalacia but with a nonobstructed airway. Proximal esophageal secretions were initially managed with sump suction, and eventually the family agreed to proceed with creation of a cervical esophagostomy. Seventy-seven days after the second tracheoplasty the patient underwent a cervical end esophagostomy. The blind proximal esophageal pouch was mobilized up into a left cervical incision and exteriorized as an end cervical esophagostomy. No esophageal tissue was left behind from the upper portion of the esophagus proximal to the point of previous esophageal transaction; in fact, the distal 1.5 cm of the blind proximal esophageal pouch was resected. The remaining proximal esophagus was brought up between the sternal and clavicular heads of the sternocleidomastoid muscle and secured to the lateral skin incision. The patient required two subsequent dilations of the cervical esophagostomy to allow sufficient drainage. Eighteen months after the initial injury, the patient underwent esophageal reconstruction with a colonic interposition through a combined laparotomy, left thoracotomy, and cervical incision, using the right midascending and transverse colon passed through a retrohilar tract in the left chest. An esophagram on postoperative day 7 revealed no leak, and the patient was started on a clear liquid diet that was subsequently advanced. The child is now ten months status post colonic interposition and tolerating oral feeds at home with a stable nonproblematic airway. Potentially troublesome esophageal mucosal mucous secretions into the reconstructed airway have not been problematic. The patient is currently doing quite well.
Comment Tracheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss. This case demonstrates several principles relevant to the management of severe airway injuries in children. Patients with a battery lodged in the esophagus are at higher risk for complication than other esophageal foreign bodies and must be carefully evaluated for tracheoesophageal fistulas [1, 2]. Extracorporeal membrane oxygenation can successfully bridge these patients to definitive reconstruction. Goldman and colleagues [3] reported a series of four children 13 months of age or younger with severe tracheal disease in whom extracor-
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
1033
poreal membrane oxygenation was used to achieve stability prior to repair. Viable tissue can be used to reconstruct the defect. Esophageal tissue has previously been used for tracheal reconstruction in both children [4] and adults [5]. Vascularized muscle flaps can also facilitate healing of lifethreatening mediastinal wounds [4, 5]. Backer and colleagues [4] reported a series of eight children with life threatening mediastinal wounds managed with vascularized muscle flaps including pectoralis major, rectus abdominis, and cervical strap muscle. One of these eight patients had tracheal dehiscence after repair of an acquired tracheoesophageal fistula from battery erosion. In Backer and colleagues’ case [4], the trachea was initially repaired with viable esophagus, subsequently dehiscenced, and then successfully reconstructed with a pericardial patch sealed with a left pectoralis major muscle flap. Creation of a cervical esophagostomy and initiation of sham feedings protects the mediastinum and provides an opportunity to retain oral feeding skills while receiving enteral nutrition through a gastrostomy [4, 5]. Surgery to re-establish gastrointestinal continuity is best delayed until after the patient is fully recovered from the acute injury [1, 4, 5]. Delaying the non-emergent esophageal replacement permits resolution of residual infection, inflammation, and edema [1, 4, 5]. The colon provides an excellent esophageal substitute in children [4, 6]. Successful management of complex pediatric tracheal problems requires a multidisciplinary collaborative approach involving cardiothoracic, general, and otolaryngology surgeons as well as pulmonologists and specialized nurses and respiratory therapists [7, 8].
References 1. Imamoglu M, Cay A, Kosucu P, Ahmetoglu A, Sarihan H. Acquired tracheo-esophageal fistulas caused by buttonbattery lodged in the esophagus. Pediatr Surg Int 2004;20: 292– 4. 2. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction. J Pediatr Surg 1999;34:1527–31. 3. Goldman AP, Macrae DJ, Tasker RC, et al. Extracorporeal membrane oxygenation (ECMO) as a bridge to definitive tracheal surgery in children. J Ped 1996;128:386 – 8. 4. Backer CL, Pensler JM, Tobin GR, Mavroudis C. Vascularized muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg 1994;57:797– 801; discussion 801–2. 5. Pfitzmann R, Kaiser D, Weidemann H, Neuhaus P. Plastic reconstruction of an extended corrosive injury of the posterior tracheal wall with an autologous esophageal patch. Eur J Cardiothorac Surg 2003;24:463–5. 6. Khan AR, Mohammed AR, Alwafi A, Ress BI, Lari J. Esophageal replacement with colon in children. Pediatr Surg Int 1998;13:79 – 83. 7. Jacobs JP, Quintessenza JA, Andrews T, et al. Tracheal allograft reconstruction: the total North American experience and worldwide pediatric experiences. Ann Thorac Surg 1999;68: 1043–51, discussion 1052. 8. Jacobs JP, Quintessenza JA, Botero LM, et al. The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease. Eur J Cardiothorac Surg 2000;18: 505–12.
FEATURE ARTICLES
Ann Thorac Surg 2007;84:1031–3
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
References
Before Operation
6 Months After Operation
18 Months After Operation
4.3 109 3.37 81 7.61 0.62 7.19 (106)
3.43 87 2.91 88 7.75 0.7 6.58 (97)
3.49 89 3.04 86 8.27 0.63 6.22 (97)
FEV1 ⫽ forced expiratory volume in 1 second; PEFR ⫽ peak expiratory flow rate; TV ⫽ tidal volume; TLC ⫽ total lung capacity; VC ⫽ vital capacity.
second at 1.0%, and peak flow rate were slightly increased (Table 1). Furthermore, total lung capacity had reached 97% of the predicted value, showing that the lung was sufficiently inflated.
Comment The results of the present case suggest that ventilatory movement of the rib cage can compensate for loss of bilateral diaphragmatic function in a healthy adult patient with normal pulmonary function. When a patient showed restrictive or obstructive lung function before surgery, the compensatory mechanism might be ineffective. Weak peri-thoracic muscles or diaphragmatic breathing (as in small children) would also result in insufficient ventilation. Except for a nerve resection, hypothermic injury, stretching, or blunt trauma of the phrenic nerve causes transient paralysis, which recovers in most patients within 1 year [4]. In a previous study of cases of bilateral diaphragmatic paralysis induced by neuralgic amyotrophy, most adult patients improved symptomatically, but not functionally, during follow-up periods of 2 to 4 years [5]. In addition, Stolk and Versteeg [3] reported that the mean vital capacity value of neuralgic amyotrophy patients was improved by 17% after bilateral diaphragmatic plication, and the effect was sustained for at least 12 months. Because recovery of phrenic paralysis could not be expected in the present case, the aim of the bilateral plication was to fix both diaphragms for increasing efficiency of chest wall ventilation. Although the patient was dependent on chest wall motion exclusively for breathing, he showed no symptomatic or functional insufficiency for 18 months. However, when the plicated diaphragms become stretched with time and are gradually elevated, the ventilatory function likely decreases back to its original impaired level. Thus, phrenic nerve reconstruction with a nerve graft might be an effective intervention to maintain the recovery of phrenic function for a long period of time [6]. Based on the present results, we believe that bilateral diaphragmatic plication is an effective means of providing sufficient ventilatory function in selected patients with bilateral phrenic nerve paralysis. © 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Graham DR, Kaplan D, Evans CC, Hind CRK, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990;49:248 –52. 2. Takeda S, Nakahara K, Fujii Y, Matsumura A, Minami M, Matsuda H. Effect of diaphragmatic plication on respiratory mechanics in dogs with uni- and bilateral phrenic nerve paralysis. Chest 1995;107:798 – 804. 3. Stolk J, Versteeg MIM. Long-term effect of bilateral plication of the diaphragm. Chest 2000;117:786 –9. 4. Watanabe T, Trusler GA, Williams WG, Edmond JF, Coles JG, Hosokawa Y. Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 1987;94:383– 8. 5. Mulvey DA, Aquilina RJ, Elliot MW, Moxham J, Green M. Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic examination of 16 patients presenting with dyspnea. Am Rev Respir Dis 1993;147:66 –71. 6. Schoeller T, Ohlbauer M, Wechselberger G, Piza-Katzer H, Margreiter R. Successful immediate phrenic nerve reconstruction during mediastinal tumor resection. J Thorac Cardiovasc Surg 2001;122:1235–7.
Successful Reconstruction of Traumatic Carinal Tissue Loss Using the Esophagus in an Infant Erik S. Stubberud, Jeffrey Phillip Jacobs, MD, FACS, Richard P. Harmel, Jr, MD, Thomas Andrews, MD, FACS, Paul J. Chai, MD, Harald L. Lindberg, MD, PhD, and James Anthony Quintessenza, MD, FACS Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, St. Petersburg and Tampa, and Divisions of Pediatric Surgery and Otolaryngology, All Children’s Hospital, St. Petersburg, Florida
We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition. (Ann Thorac Surg 2007;84:1031–3) © 2007 by The Society of Thoracic Surgeons
T
racheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss. We present a case report of an infant who underwent successful reconstruction of a traumatic tracheal and Dr Jacobs discloses a financial relationship with CardioAccess. Accepted for publication Jan 23, 2007. Address correspondence to Dr Jacobs, The Congenital Heart Institute of Florida, Cardiac Surgical Associates, 603 7th St S, Suite 450, St. Petersburg, FL 33701; e-mail: [email protected].
0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.01.047
FEATURE ARTICLES
Table 1. Pulmonary Function
VC (L) % of VC FEV1 (L) FEV1 (%) PEFR (L/s) TV (L) TLC (%)
1031
1032
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
Ann Thorac Surg 2007;84:1031–3
patient had increasing problems develop with pneumothorax and oxygenation. Emergent bronchoscopy revealed partial dehiscence of the tracheal reconstruction. The patient was taken emergently to the operating room and underwent a redo tracheal reconstruction through a median sternotomy on cardiopulmonary bypass with resection of the dehisced region of trachea with end-toend anastomosis of the anterior tracheal wall after using an interposition flap of esophageal mucosa for the posterior tracheal and carinal wall to avoid undue tension. Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi (Fig 2). The esophagus was transected and oversewn proximal and distal to the region used for the interposition flap. The patient was successfully weaned from cardiopulmonary bypass and postoperative bronchoscopy demonstrated patent bronchi with an intact tracheal reconstruction.
FEATURE ARTICLES
Fig 1. Initial bronchoscopy documented tissue loss involving the distal trachea, carina, and bilateral main stem bronchi. The arrows denote posterior tracheal tears extending into the proximal right and left mainstem bronchi.
carinal chemically induced corrosive injury using an esophageal flap to reconstruct the trachea and subsequently re-establishing gastrointestinal continuity with a colon interposition. A 9-month-old girl presented to the emergency department in severe respiratory distress 4 days after the successful removal of a button battery from her esophagus. The patient required emergent intubation and was taken to the operating room for micro-laryngoscopy and bronchoscopy, which revealed posterior tracheal wall perforation and anterior esophageal wall perforation. Due to difficulty in oxygenating the patient during the procedure, she was emergently placed on extracorporeal membrane oxygenation support. The tracheal injury constituted a 3-cm defect in the posterior distal tracheal wall involving the carina and proximal right and left main stem bronchi (Fig 1) and was initially repaired using a pedicled intercostal muscle flap taken from the right fourth and fifth intercostals muscles. This procedure was performed through a right posterolateral thoracotomy while on cardiopulmonary bypass with removal of the fourth and fifth ribs. The esophagus was ligated proximal and distal to the 4 to 6 cm esophageal defect using multiple cerclage sutures, and a gastrostomy tube was then placed. The patient was weaned from cardiopulmonary bypass and transferred to the intensive care unit. The patient’s postoperative course was complicated by adequate ventilation but poor oxygenation, and therefore she was placed on an oscillator ventilator. During the next 10 days she underwent several bronchoscopies to optimize pulmonary toilet. On postoperative day 10, the
Fig 2. (Top) After opening the trachea anteriorly, the esophagus (arrow) was visualized immediately posterior to the disrupted posterior trachea and carina. (Bottom) Esophageal tissue was used to reconstruct the posterior 40% of the distal third of the trachea, the carina, and the bilateral proximal main stem bronchi. The arrows point to the orifices of the bronchi.
After the second tracheoplasty the patient was successfully extubated and was ventilating spontaneously. However, bronchoscopy initially demonstrated severe tracheomalacia and bronchomalacia at the posterior aspect of the carina consistent with prolapse of the interposed esophageal mucosa. Subsequent bronchoscopies completed 2 months and 16 months after the esophageal patch tracheoplasty demonstrated moderate nonobstructive granulation tissue at the area of the carina and mild bronchomalacia but with a nonobstructed airway. Proximal esophageal secretions were initially managed with sump suction, and eventually the family agreed to proceed with creation of a cervical esophagostomy. Seventy-seven days after the second tracheoplasty the patient underwent a cervical end esophagostomy. The blind proximal esophageal pouch was mobilized up into a left cervical incision and exteriorized as an end cervical esophagostomy. No esophageal tissue was left behind from the upper portion of the esophagus proximal to the point of previous esophageal transaction; in fact, the distal 1.5 cm of the blind proximal esophageal pouch was resected. The remaining proximal esophagus was brought up between the sternal and clavicular heads of the sternocleidomastoid muscle and secured to the lateral skin incision. The patient required two subsequent dilations of the cervical esophagostomy to allow sufficient drainage. Eighteen months after the initial injury, the patient underwent esophageal reconstruction with a colonic interposition through a combined laparotomy, left thoracotomy, and cervical incision, using the right midascending and transverse colon passed through a retrohilar tract in the left chest. An esophagram on postoperative day 7 revealed no leak, and the patient was started on a clear liquid diet that was subsequently advanced. The child is now ten months status post colonic interposition and tolerating oral feeds at home with a stable nonproblematic airway. Potentially troublesome esophageal mucosal mucous secretions into the reconstructed airway have not been problematic. The patient is currently doing quite well.
Comment Tracheal injuries can be especially difficult to manage in infants and small children. Traumatic tracheoesophageal fistulas are among the most problematic airway injuries, and those caused by chemical corrosion injuries are especially treacherous secondary to tissue loss. This case demonstrates several principles relevant to the management of severe airway injuries in children. Patients with a battery lodged in the esophagus are at higher risk for complication than other esophageal foreign bodies and must be carefully evaluated for tracheoesophageal fistulas [1, 2]. Extracorporeal membrane oxygenation can successfully bridge these patients to definitive reconstruction. Goldman and colleagues [3] reported a series of four children 13 months of age or younger with severe tracheal disease in whom extracor-
CASE REPORT STUBBERUD ET AL TRACHEAL RECONSTRUCTION WITH ESOPHAGUS
1033
poreal membrane oxygenation was used to achieve stability prior to repair. Viable tissue can be used to reconstruct the defect. Esophageal tissue has previously been used for tracheal reconstruction in both children [4] and adults [5]. Vascularized muscle flaps can also facilitate healing of lifethreatening mediastinal wounds [4, 5]. Backer and colleagues [4] reported a series of eight children with life threatening mediastinal wounds managed with vascularized muscle flaps including pectoralis major, rectus abdominis, and cervical strap muscle. One of these eight patients had tracheal dehiscence after repair of an acquired tracheoesophageal fistula from battery erosion. In Backer and colleagues’ case [4], the trachea was initially repaired with viable esophagus, subsequently dehiscenced, and then successfully reconstructed with a pericardial patch sealed with a left pectoralis major muscle flap. Creation of a cervical esophagostomy and initiation of sham feedings protects the mediastinum and provides an opportunity to retain oral feeding skills while receiving enteral nutrition through a gastrostomy [4, 5]. Surgery to re-establish gastrointestinal continuity is best delayed until after the patient is fully recovered from the acute injury [1, 4, 5]. Delaying the non-emergent esophageal replacement permits resolution of residual infection, inflammation, and edema [1, 4, 5]. The colon provides an excellent esophageal substitute in children [4, 6]. Successful management of complex pediatric tracheal problems requires a multidisciplinary collaborative approach involving cardiothoracic, general, and otolaryngology surgeons as well as pulmonologists and specialized nurses and respiratory therapists [7, 8].
References 1. Imamoglu M, Cay A, Kosucu P, Ahmetoglu A, Sarihan H. Acquired tracheo-esophageal fistulas caused by buttonbattery lodged in the esophagus. Pediatr Surg Int 2004;20: 292– 4. 2. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction. J Pediatr Surg 1999;34:1527–31. 3. Goldman AP, Macrae DJ, Tasker RC, et al. Extracorporeal membrane oxygenation (ECMO) as a bridge to definitive tracheal surgery in children. J Ped 1996;128:386 – 8. 4. Backer CL, Pensler JM, Tobin GR, Mavroudis C. Vascularized muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg 1994;57:797– 801; discussion 801–2. 5. Pfitzmann R, Kaiser D, Weidemann H, Neuhaus P. Plastic reconstruction of an extended corrosive injury of the posterior tracheal wall with an autologous esophageal patch. Eur J Cardiothorac Surg 2003;24:463–5. 6. Khan AR, Mohammed AR, Alwafi A, Ress BI, Lari J. Esophageal replacement with colon in children. Pediatr Surg Int 1998;13:79 – 83. 7. Jacobs JP, Quintessenza JA, Andrews T, et al. Tracheal allograft reconstruction: the total North American experience and worldwide pediatric experiences. Ann Thorac Surg 1999;68: 1043–51, discussion 1052. 8. Jacobs JP, Quintessenza JA, Botero LM, et al. The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease. Eur J Cardiothorac Surg 2000;18: 505–12.
FEATURE ARTICLES
Ann Thorac Surg 2007;84:1031–3