A new technique for surgical correction of bronchial stenosis

A New Technique By John

for Surgical H.T. Waldhausen,

Correction Mark Richardson,

Seattle, l Bronchial stenosis in children presents an even more challenging reconstructive procedure than does tracheal stenosis because of the smaller luminal diameter of the bronchus. Multiple techniques have been used, with varying success. Pericardium is readily available and can be used as a bronchial patch; however, it is floppy and tends to collapse, resulting in luminal narrowing and eventual scarring leading to restenosis. We devised a technique that uses glutaraldehyde-soaked pericardium with a rib cartilage stent to reconstruct the bronchus in two children who had main-stem bronchial stenosis. Copyright o 1994 by W.B. Saunders Company

INDEX WORDS:

Bronchial stenosis, pericardial graft.

B

RONCHIAL stenosis is an uncommon problem in children. Management can be difficult because of small luminal diameter and the proximity of the lung parenchyma to the bronchial lesion. Various methods of tracheobronchial reconstruction have been described, with mixed results. Pericardium has been used as a patch with some success but has been associated with early postoperative collapse of the lumen or later scarring and eventual restenosis.1-4 We report two cases in which glutaraldehyde-soaked pericardium was used to increase patch stiffness, and was combined with a bridge of rib cartilage to function as a graft stent. CASE

REPORTS

Case 1 In an II-year-old white boy, a left main-stem bronchial lesion developed secondary to aspiration of a nut at approximately 2years of age. He had a history of chronic cough, atelectasis in the left upper lobe, wheezing, and decreased exercise tolerance. Bronchoscopy showed stenosis 1 to 1.5 cm distal to the carina, 2 to 2.5 cm in length. Via a median sternotomy, a glutaraldehyde-soaked pericardial patch with a cartilage stent was used to bridge the stenotic airway. The patch was also tacked anteriorly to the aorta. Postprocedure bronchoscopy showed an open airway. At the 6-month follow-up examination, a reexpanded left upper lobe was noted, and there was improved exercise tolerance.

Case 2 In a 4-year-old native American boy with a history of bronchopulmonary dysplasia, laryngeal papillomatosis developed secondary to maternal venereal warts. He had undergone multiple laser excisions of the papillomas and received interferon in an effort to control the lesions. Scarring developed, as did severe stenosis of the right main-stem bronchus, with a l-mm opening secondary to phototherapy. A ventilation perfusion (VQ) scan preoperatively showed poor perfusion and no right lung ventilation. Via a right thoracotomy, the patient underwent patching of the right mainstem bronchus, using a glutaraldehyde-soaked pericardial patch and a cartilage stent. Intraoperative bronchoscopy showed a patent

Journal of Pediafric Surgery, Vol29, No 2 (February). 1994: pp 199-200

of Bronchial

Stenosis

and Dale G. Hall

Washington bronchus, and the follow-up VQ scan showed improved right lung ventilation. A chest x-ray 3 months postoperatively also showed improvement, and the patient was doing well at the 6 month follow-up.

Technique The operative approach depends of the site of stenosis, and can be through either a standard median sternotomy or a thoracotomy (Fig 1). An appropriate-size pericardial patch is harvested and soaked for 15 minutes in .6% glutaraldehyde solution, and followed by three 5-minute normal saline rinses. Intraoperative bronchoscopy is used to determine the length of the stenosis. The endotracheal tube is inserted into the contralateral main-stem bronchus, and the stenotic bronchus is opened. The pericardial patch is sutured into place using fine running prolene sutures. To gain adequate purchase, the bronchial sutures are passed through the full thickness of the bronchus. We believe that the decreased structural integrity of the thin bronchial wall posed a greater problem than did the risk of future granulations on the fullthickness sutures. A cartilage rib graft was harvested, leaving the perichondrium intact. This was fashioned into a bridge, leaving perichondrium on the upper surface, and was sutured to both sides of the stenotic bronchus to stent it open. The pericardial patch was tacked to the middle of the cartilage. If available, the stent was also sutured to the aorta to further stent the bronchus open. (Fig 2) The endotracheal tube was pulled back above the carina, and another bronchoscopy was performed to access luminal patency. The chest was filled with saline to check for an air leak. The area was irrigated with bacitracin solution, and the repair was covered with parietal pleura (if possible) to help seal the repair and increase the vascularity. Chest tubes were placed, and the chest was closed. DISCUSSION

Numerous methods of tracheobronchial reconstruction have been tried, with variable success. Pericardium is useful because it supports the growth of ciliated epithelium and causes minimal retained secretions.’ Being soft and pliable, it is easier to work with and shape than cartilage or bone. It also provides airtight closure. However, some surgeons have found that it is too floppy and causes luminal narrowing, and in time contracts and scars, which causes restenosis.“%3 Glutaraldehyde-soaked pericardium has been used in cardiac surgery without the apparent problem of contraction and stenosis. GIutaraldehyde causes increased cross-linking, which appears to stiffen the

From the Children k Hospital and Medical Center, Seattle, WA. Presented at the 24th Annual Meeting of the American Pediattic Surgical Association. Hilton Head, South Carolina, May I5-ir9 1993. Address reprint requests to Dale G. Hall, MD, Children i Hospital and Medical Center, 4800 Sand Point Way, NE. CHIZ. Seattle, WA 98105. Copyright D 1994 by W.B. Saunder.s Cornpan! 0022-346819412902-0012$03.00/O

199

200

WALDHAUSEN,

Fig 1. Left main-stem bronchial stenosis (as in case 1). This was approached via a median sternotomy, retracting the aorta medially and the pulmonary artery superiorly.

material and cause it to shrink. We believe that this might help alleviate some of the problems with floppiness and contraction noted in other studies. Because of the small bronchial luminal diameter, cartilage stents were used to keep the lumen open and prevent the pericardium from collapsing into it. It is anticipated that, by providing an intact bridge across the anterior bronchus, that bronchial growth will not be restricted.’ Dykes et al believed that the tracheal narrowing found in their studies with pericardium was caused by graft compression, and that a

RICHARDSON, AND HALL

Fig 2. Left main-stem bronchial stenosis with the pericardial patch sutured in place. The cartilage stent [inset) was further pexed to the aorta. The superior vena cava was retracted laterally, and the aorta and pulmonary artery medially.

stent was needed to provide support. The combination of periostium and pericardium was not successful because of poor blood supply and scarring. We chose cartilage because it holds sutures well, is readily available, and has been reported to have a lesser tendency to stricture.3 Our follow-up has been short, but it appears that the bronchial reconstruction was successful in both patients, based on improved chest x-ray results and improved exercise tolerance. The long-term success of this new technique will be determined with time.

REFERENCES 1. Idriss FS, DeLeon SY, Ilbawi MN, et al: Tracheoplasty with pericardial patch for extensive tracheal stenosis in infants and children. J Thorac Cardiovasc Surg 88:527-536, 1984 2. Bryant LR, Eiseman B: Replacement of tracheobronchial defects with autogenous pericardium. J Thorac Cardiovasc Surg 48:733-740,1964

3. Dykes EH, Bahoric A, Smith C, et al: Reduced tracheal growth after reconstruction with pericardium. J Pediatr Surg 25:25-29,199O 4. de Lorimier AA, Harrison MR, Hardy K, et al: Tracheobronchial obstructions in infants and children. Ann Surg 212:277-289, 1990