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Slide tracheoplasty for congenital tracheal stenosis: A case report
Slide Tracheoplasty By Gerald
for Congenital S. Lipshutz, Michael
Russell
Background/Purpose: A variety of techniques used to manage pediatric congenital tracheal authors report the technique of slide tracheoplasty with long congenital tracheal stenosis.
W. Jennings,
Ft. Harrison, San
Tracheal
Francisco,
have been stenosis. The for a child
and
John Craig
Stenosis:
B. Lopoo,
Diana
A Case Report Farmer,
T. Albanese
California
maintain cervical flexion, and the tion in the operating room.
Results: He recovered charged
patient
underwent
without complication day 4.
on postoperative
and
extuba-
was
dis-
Methods:
A P-year-old male presented with a history of stridor with feeding. Bronchoscopy findings showed 50% stenosis from complete cartilaginous rings, extending from 2.5 cm below the vocal cords to 2 cm above the carina. Through a neck incision, the trachea was exposed from the cricoid to both bronchi and transected at the midpoint of the stenosis. The upper trachea was split anteriorly to the area of stenosis just below the cricoid. The lower trachea was split posteriorly in the midline. Posterior dissection allowed sliding and anastomosis of both tracheal segments while the lateral vascular supply was left intact. A brace was placed to
L
ONG
TRACHEAL stenosis is a rare life-threatening condition most often caused by complete tracheal rings. In more than half the cases, the stenosis involves greater than 50% of the length of the trachea.’ Resection of the stenosis and end-to-end anastomosis has been the gold standard treatmenP but often is not possible because of the length of the stenotic segment. If resection is not possible, there are a variety of alternatives to expand the cross-sectional luminal area. These include balloon dilation,’ patch tracheoplasty with costal cartilage,s periosteal grafts.” pericardium.’ or anterior esophageal wall, stent placement.x and slide tracheoplasty.“~“’ In the slide tracheoplasty, a technique originally described by Grille” and Tsang et al.” the trachea is divided at the midpoint of the stenotic segment, vertical incisions are made on the posterior surface of the distal segment and on the anterior surface of the proximal segment, and the 2 segments are slid together. Slide tracheoplasty results in a 4-fold increase of the lumenal cross section’ with shortening of the involved trachea by only one half of the original length of the stenosis. In the first reported use,“’ two infants with funnel-shaped tracheal stenosis were treated with a slide tracheoplasty; I died secondary to infectious pulmonary complications. whereas the second, at II months follow-up, showed no anatomic or physiological evidence of airway narrowing. This report describes the use of the slide tracheoplasty in a child with a long congenital tracheal stenosis involving approximately 40% of the trachea. Journal
Conclusion: Slide tracheoplasty offers several advantages for tracheal reconstruction because it is performed with the native tracheal tissues, can be accomplished through a transverse collar incision, and can repair long stenoses without significant tracheal shortening. J Pediatr Surg 35:259-261. Copyright o 2000 by W.B. Saunders Company. INDEX plasty.
WORDS:
Congenital
CONGENITAL
of Pediatric
Surgery,
Vol35,
No 2 (February).
2000: pp 259-261
tracheal
CASE A Z-year-old
hoy presented
stenosis,
tracheo-
REPORT
with a history
feeding. Bronchoscopy tindings cartilaginous rings. It extended
slide
of intermittent
stridor
with
showed a 50% stenosis from complete from 2.5 cm below the vocal cords to Z
cm above the carina. After endotracheal intubation, the neck extended and a transverse collar neck incision made. The trachea
was was
exposed from the cricoid to both proximal mainstem bronchi (Fip I ): a stemotomy was not necessary. After delining the stenosis. the trachea was divided
in the middle
of the stenosis
with
ventilation
performed
across the operative field with the endotracheal tube passed beyond the stenosis. The cephalad portion of the trachea was split on its anterior surface to above the area of stenosis just below the cricoid ring. The caudad
portion
of trachea
was similarly
split
on its posterior
wall and
extended until membranous trachea was encountered caudally. Posterior dissection allowed sliding of both tracheal segments. whereas the lateral vascular supply was left intact. After superior tracheal segment was anastomosed. interrupted 4-O suture. to the inferior above the carina (Fig 3). The operative
flexing the neck. the first posteriorly. with
segment approximately I cm held endotracheal tube was then
exchanged for an oral endotracheal tube by first passing a pediatric feeding tube through the upper portion of the trachea and out the child’s mouth to use as a guide. The endotracheal tube was then passed under direct vision past the posterior reconstruction, after which the anterior anastomosis
From
was
completed.
die Fercd Tretrmrenr
of Ctr/$ornitr. Presented
This
resulted
Cente,:
Strrt Frmcixo. CA. (II the 30/h Anmrol
in the creation
Defxwrr~renr Meeri17g
Uni\~ersir~
of IIIP At~7ericor1
Strr,qictrl Associrrfion, Rmrclro Mircrgr. Ctrlifomin. Address reprim requests IO Cnrig 7: Alhor~ese. Cr17rrr; lhiver.sir~ of Califonricc. Sm Frmcisco. HSW-1601. Sm Frmcisco. CA 94143-0570. Copyi,& o 2000 by W B. Sounders 0022-346N/OO/3502-0020$03.00/O
of Sqe~.
of a long
Pedicrmric
Mrr,v 16 19. 1999. MD, Ferrd Trenfnrenf 513
Prrrnossus
Aw
Cortrpatg
259
260
LlPSHUl7
Fig 1. The child was placed with neck extended and a transverse collar incision made. The trachea, from cricoid to carina, could be viewed and controlled without a sternotomy. After division of the trachea at the midpoint of the stenosis, the upper portion was split in the anterior midline and the lower portion of the trachea in the posterior midline.
oblique
anastomosis.
markedly
expanding
the lumenal
and was discharged
Fig 2. Edges of the tracheal flap were trimmed, and the upper portion of the trachea was carefully dissected free posteriorly, leaving lateral attachments and vascular supply intact. The upper portion was then slid behind the lower portion with the wedge from the upper part placed into the split made on the lower. The long oblique anastomosis was constructed by placing multiple interrupted sutures, first posteriorly then anteriorly. The inset shows side view after completion of the posterior suture line.
cross-sectional
area. A prefabricated neck brace was placed to hold his neck in tlexion. and the patient underwent extubation in the operating room. The patient recovered without complication postoperative day.
ET AL
home on the fourth
DISCUSSION Treatment of a congenital tracheal stenosis is indicated when there are recurrent hospital admissions, a severe life-threatening obstruction, symptoms suggesting small airway obstruction. and a failure to thrive.s Management has included intensive respiratory therapy with endoscopic stent placement or dilation and corticosteroid injections. tracheal resection, and tracheal grafts. Endoscopic methods are successful in most cases of laryngeal stenosis at all level9 but are only infrequently successful for treatment of major stenoses of the trachea. Forceful dilation of the trachea usually leads to the development of acquired stenoses because mucosal ulceration may penetrate to the cartilage causing chrondritis and subepithelial fibrosis. Compared with other restorative operations for tracheal stenosis, the slide tracheoplasty technique offers several advantages.’ First, the procedure is performed with the patient’s native tracheal tissues. No resection is
performed, and no grafting materials. autogenous or foreign. are used. This helps avoid the postoperative anastomotic strictures commonly seen with these materials. Second, the procedure does not result in tracheal ischemic problems. In studies on newborn piglets. despite creating stenoses involving 100% of the trachea, subsequent slide tracheoplasty did not result in impairment or distortion of growth of the trachea.’ Thus, the length of the tracheal stenosis is not a limiting factor for this procedure. Healing is unaltered because the young trachea appears to have up to 2 times the number of capillaries compared with the adult.’ Third, repair of the stenosis requires only shortening of one half the length of the original stenosis, reducing tension on the anastomosis. Fourth. in infants and children the procedure may be performed through a transverse collar incision, avoiding a median stemotomy. Finally, postoperative intubation and mechanical ventilatory support are not necessary.9 The technique of slide tracheoplasty should be added to the available techniques for treating congenital tracheal stenosis because the repair of long stenoses can be performed without significant tracheal shortening.
REFERENCES 1. Macchiarini growth 566,
after
E, de Montpreville
tracheoplasty.
J Thorac
Cardiovasc
V. et al: Tracheal Surg
113:558-
1997
2. Grille Arch
P, Dulmet
slide HC:
Tracheal
3. Grille
HC, Zannini J Pediatr
reconstruction.
I-39, Surg
Indications
and techniques.
1972
P: Management 19:414-416.
of obstructive
tracheal
disease
Forte
A technique
infant.
5. Majeski tracheal
1984
A.
split:
premature
Otolaryngol93:3
in children.
4. Messineo tracheal
JA.
stenosis
J Pediatr Schreiber
V. Joseph for
T. et al: The
managing
Surg 27: 1142-l JT. Cotton
in the pediatric
burned
tracheal
balloon
posterior
stenosis
in the
144, 1991 R. et al: Tracheoplasty patient.
for
J Trauma
20:81-X6.
K. et al: A new model
of tracheal
19x0 6. Cohen
RC. Filler
RM,
Konuma
SLIDE
TRACHEOPLASTY
stenosis
and its repair
Surg 92:296-304. 7. Cosentino
261
with
1986 CM, Backer
free periosteal
grafts.
J Thorac
Cardiovasc
CL.
tracheoplasty for severe tracheal results. J Pediatr Surg 26:879-X85.
Idriss stenosis 1991
FS. et al: Pericardial in children:
patch
Intermediate
X. Lobe TE: Operative technique and considerations for the reconstruction of congenital stenoses of the trachea in infants. in Lobe TE (ed):
Tracheal
reconstruction
9. Grill0 cheal
in infancy.
Philadelphia.
PA. Saunders.
Slide
tracheoplasty
Ann Thorac
IO. Tsang congenital
V, Murday funnel-shaped
for
long-segment
Surg .58:613-621, A, Gillbe tracheal
congenital
tra-
1994
C. et al: Slide stenosis.
tracheoplasty
Ann Thorac
for
Surg 48:632-
635.1989 I I. Maeda resection 65:658-668.
1991. pp 79-101
HC:
stenosis.
M. Grill0
and
anastomosk
HC:
Effect in
of tension
puppies.
on tracheal
.I Thorac
growth
Cardiovasc
after Surg
1973
Discussion J. Long (Fort thrclerhle, FL): Do you have a bronchogram or a computed tomography scan or magnetic resonance image to show us of your preoperative evaluation of the patient’?
You also mentioned intraoperatively changing your endotracheal tube. Were you able to upsize? G.S. Lipshurz (response): I do not have a bronchogram, CT, or MRI to show you. A similar-size endotracheal tube was used in the operating room.
for Congenital S. Lipshutz, Michael
Russell
Background/Purpose: A variety of techniques used to manage pediatric congenital tracheal authors report the technique of slide tracheoplasty with long congenital tracheal stenosis.
W. Jennings,
Ft. Harrison, San
Tracheal
Francisco,
have been stenosis. The for a child
and
John Craig
Stenosis:
B. Lopoo,
Diana
A Case Report Farmer,
T. Albanese
California
maintain cervical flexion, and the tion in the operating room.
Results: He recovered charged
patient
underwent
without complication day 4.
on postoperative
and
extuba-
was
dis-
Methods:
A P-year-old male presented with a history of stridor with feeding. Bronchoscopy findings showed 50% stenosis from complete cartilaginous rings, extending from 2.5 cm below the vocal cords to 2 cm above the carina. Through a neck incision, the trachea was exposed from the cricoid to both bronchi and transected at the midpoint of the stenosis. The upper trachea was split anteriorly to the area of stenosis just below the cricoid. The lower trachea was split posteriorly in the midline. Posterior dissection allowed sliding and anastomosis of both tracheal segments while the lateral vascular supply was left intact. A brace was placed to
L
ONG
TRACHEAL stenosis is a rare life-threatening condition most often caused by complete tracheal rings. In more than half the cases, the stenosis involves greater than 50% of the length of the trachea.’ Resection of the stenosis and end-to-end anastomosis has been the gold standard treatmenP but often is not possible because of the length of the stenotic segment. If resection is not possible, there are a variety of alternatives to expand the cross-sectional luminal area. These include balloon dilation,’ patch tracheoplasty with costal cartilage,s periosteal grafts.” pericardium.’ or anterior esophageal wall, stent placement.x and slide tracheoplasty.“~“’ In the slide tracheoplasty, a technique originally described by Grille” and Tsang et al.” the trachea is divided at the midpoint of the stenotic segment, vertical incisions are made on the posterior surface of the distal segment and on the anterior surface of the proximal segment, and the 2 segments are slid together. Slide tracheoplasty results in a 4-fold increase of the lumenal cross section’ with shortening of the involved trachea by only one half of the original length of the stenosis. In the first reported use,“’ two infants with funnel-shaped tracheal stenosis were treated with a slide tracheoplasty; I died secondary to infectious pulmonary complications. whereas the second, at II months follow-up, showed no anatomic or physiological evidence of airway narrowing. This report describes the use of the slide tracheoplasty in a child with a long congenital tracheal stenosis involving approximately 40% of the trachea. Journal
Conclusion: Slide tracheoplasty offers several advantages for tracheal reconstruction because it is performed with the native tracheal tissues, can be accomplished through a transverse collar incision, and can repair long stenoses without significant tracheal shortening. J Pediatr Surg 35:259-261. Copyright o 2000 by W.B. Saunders Company. INDEX plasty.
WORDS:
Congenital
CONGENITAL
of Pediatric
Surgery,
Vol35,
No 2 (February).
2000: pp 259-261
tracheal
CASE A Z-year-old
hoy presented
stenosis,
tracheo-
REPORT
with a history
feeding. Bronchoscopy tindings cartilaginous rings. It extended
slide
of intermittent
stridor
with
showed a 50% stenosis from complete from 2.5 cm below the vocal cords to Z
cm above the carina. After endotracheal intubation, the neck extended and a transverse collar neck incision made. The trachea
was was
exposed from the cricoid to both proximal mainstem bronchi (Fip I ): a stemotomy was not necessary. After delining the stenosis. the trachea was divided
in the middle
of the stenosis
with
ventilation
performed
across the operative field with the endotracheal tube passed beyond the stenosis. The cephalad portion of the trachea was split on its anterior surface to above the area of stenosis just below the cricoid ring. The caudad
portion
of trachea
was similarly
split
on its posterior
wall and
extended until membranous trachea was encountered caudally. Posterior dissection allowed sliding of both tracheal segments. whereas the lateral vascular supply was left intact. After superior tracheal segment was anastomosed. interrupted 4-O suture. to the inferior above the carina (Fig 3). The operative
flexing the neck. the first posteriorly. with
segment approximately I cm held endotracheal tube was then
exchanged for an oral endotracheal tube by first passing a pediatric feeding tube through the upper portion of the trachea and out the child’s mouth to use as a guide. The endotracheal tube was then passed under direct vision past the posterior reconstruction, after which the anterior anastomosis
From
was
completed.
die Fercd Tretrmrenr
of Ctr/$ornitr. Presented
This
resulted
Cente,:
Strrt Frmcixo. CA. (II the 30/h Anmrol
in the creation
Defxwrr~renr Meeri17g
Uni\~ersir~
of IIIP At~7ericor1
Strr,qictrl Associrrfion, Rmrclro Mircrgr. Ctrlifomin. Address reprim requests IO Cnrig 7: Alhor~ese. Cr17rrr; lhiver.sir~ of Califonricc. Sm Frmcisco. HSW-1601. Sm Frmcisco. CA 94143-0570. Copyi,& o 2000 by W B. Sounders 0022-346N/OO/3502-0020$03.00/O
of Sqe~.
of a long
Pedicrmric
Mrr,v 16 19. 1999. MD, Ferrd Trenfnrenf 513
Prrrnossus
Aw
Cortrpatg
259
260
LlPSHUl7
Fig 1. The child was placed with neck extended and a transverse collar incision made. The trachea, from cricoid to carina, could be viewed and controlled without a sternotomy. After division of the trachea at the midpoint of the stenosis, the upper portion was split in the anterior midline and the lower portion of the trachea in the posterior midline.
oblique
anastomosis.
markedly
expanding
the lumenal
and was discharged
Fig 2. Edges of the tracheal flap were trimmed, and the upper portion of the trachea was carefully dissected free posteriorly, leaving lateral attachments and vascular supply intact. The upper portion was then slid behind the lower portion with the wedge from the upper part placed into the split made on the lower. The long oblique anastomosis was constructed by placing multiple interrupted sutures, first posteriorly then anteriorly. The inset shows side view after completion of the posterior suture line.
cross-sectional
area. A prefabricated neck brace was placed to hold his neck in tlexion. and the patient underwent extubation in the operating room. The patient recovered without complication postoperative day.
ET AL
home on the fourth
DISCUSSION Treatment of a congenital tracheal stenosis is indicated when there are recurrent hospital admissions, a severe life-threatening obstruction, symptoms suggesting small airway obstruction. and a failure to thrive.s Management has included intensive respiratory therapy with endoscopic stent placement or dilation and corticosteroid injections. tracheal resection, and tracheal grafts. Endoscopic methods are successful in most cases of laryngeal stenosis at all level9 but are only infrequently successful for treatment of major stenoses of the trachea. Forceful dilation of the trachea usually leads to the development of acquired stenoses because mucosal ulceration may penetrate to the cartilage causing chrondritis and subepithelial fibrosis. Compared with other restorative operations for tracheal stenosis, the slide tracheoplasty technique offers several advantages.’ First, the procedure is performed with the patient’s native tracheal tissues. No resection is
performed, and no grafting materials. autogenous or foreign. are used. This helps avoid the postoperative anastomotic strictures commonly seen with these materials. Second, the procedure does not result in tracheal ischemic problems. In studies on newborn piglets. despite creating stenoses involving 100% of the trachea, subsequent slide tracheoplasty did not result in impairment or distortion of growth of the trachea.’ Thus, the length of the tracheal stenosis is not a limiting factor for this procedure. Healing is unaltered because the young trachea appears to have up to 2 times the number of capillaries compared with the adult.’ Third, repair of the stenosis requires only shortening of one half the length of the original stenosis, reducing tension on the anastomosis. Fourth. in infants and children the procedure may be performed through a transverse collar incision, avoiding a median stemotomy. Finally, postoperative intubation and mechanical ventilatory support are not necessary.9 The technique of slide tracheoplasty should be added to the available techniques for treating congenital tracheal stenosis because the repair of long stenoses can be performed without significant tracheal shortening.
REFERENCES 1. Macchiarini growth 566,
after
E, de Montpreville
tracheoplasty.
J Thorac
Cardiovasc
V. et al: Tracheal Surg
113:558-
1997
2. Grille Arch
P, Dulmet
slide HC:
Tracheal
3. Grille
HC, Zannini J Pediatr
reconstruction.
I-39, Surg
Indications
and techniques.
1972
P: Management 19:414-416.
of obstructive
tracheal
disease
Forte
A technique
infant.
5. Majeski tracheal
1984
A.
split:
premature
Otolaryngol93:3
in children.
4. Messineo tracheal
JA.
stenosis
J Pediatr Schreiber
V. Joseph for
T. et al: The
managing
Surg 27: 1142-l JT. Cotton
in the pediatric
burned
tracheal
balloon
posterior
stenosis
in the
144, 1991 R. et al: Tracheoplasty patient.
for
J Trauma
20:81-X6.
K. et al: A new model
of tracheal
19x0 6. Cohen
RC. Filler
RM,
Konuma
SLIDE
TRACHEOPLASTY
stenosis
and its repair
Surg 92:296-304. 7. Cosentino
261
with
1986 CM, Backer
free periosteal
grafts.
J Thorac
Cardiovasc
CL.
tracheoplasty for severe tracheal results. J Pediatr Surg 26:879-X85.
Idriss stenosis 1991
FS. et al: Pericardial in children:
patch
Intermediate
X. Lobe TE: Operative technique and considerations for the reconstruction of congenital stenoses of the trachea in infants. in Lobe TE (ed):
Tracheal
reconstruction
9. Grill0 cheal
in infancy.
Philadelphia.
PA. Saunders.
Slide
tracheoplasty
Ann Thorac
IO. Tsang congenital
V, Murday funnel-shaped
for
long-segment
Surg .58:613-621, A, Gillbe tracheal
congenital
tra-
1994
C. et al: Slide stenosis.
tracheoplasty
Ann Thorac
for
Surg 48:632-
635.1989 I I. Maeda resection 65:658-668.
1991. pp 79-101
HC:
stenosis.
M. Grill0
and
anastomosk
HC:
Effect in
of tension
puppies.
on tracheal
.I Thorac
growth
Cardiovasc
after Surg
1973
Discussion J. Long (Fort thrclerhle, FL): Do you have a bronchogram or a computed tomography scan or magnetic resonance image to show us of your preoperative evaluation of the patient’?
You also mentioned intraoperatively changing your endotracheal tube. Were you able to upsize? G.S. Lipshurz (response): I do not have a bronchogram, CT, or MRI to show you. A similar-size endotracheal tube was used in the operating room.