Tracheal resection with primary anastomosis in children

Journal of Pediatric Surgery FEBRUARY 1973

VOL. VIII, NO. 1

Tracheal Resection With Primary Anastomosis in Children By M. Carcassonne,

V. Dor, J. Aubert,

and P. Kreitman

I

N ADULTS, resection of tracheal stenosis has become the treatment of choice during the past 20 yr, but in children the procedure is not used as much because of the danger of postoperative stenosis. As far as we know, there is still no study that deals with that particular problem. Louhimo et al.,l from Helsinki, have reported acquired laryngotracheal stenosis in children. Their paper is concerned mainly with posttracheostomy stenosis in infants submitted to intensive respiratory care. The authors advocate laryngological plastic procedures, especially that of Aboulker.2 In the 5 yr, 1967-1971, we submitted 524 infants and neonates to intensive respiratory care, with intubation or tracheostomy and ventilation for more than 48 hr and we observed nine patients with stenosis who were treated by simple endoscopic procedures and bouginage, with perfect results. However, in this paper we shall only deal with the possibility of tracheal resection in older children being followed by primary anastomosis. CASE REPORTS Our experience is limited to four children, all older than 5 yr. Case I: A boy 12 yr old was admitted in January 1967 to a general hospital with a very severe brain and thoracic trauma. A tracheostomy was done, and the boy was ventilated for 30 days. Extubation was impossible. After neurosurgery, he was admitted with a severe middle tracheal stenosis requiring a permanent tracheostomy. He was first operated upon on February 7; four tracheal rings were resected by a transthoracic approach. A postoperative stenosis appeared with increasing respiratory diffkulties. On April 16, at a second procedure, by a transternal approach, three more tracheal rings were resected with a small patch of innominate artery that could not be dissected away. The trachea and artery were reconstructed. Postoperative recovery was uneventful. The patient was checked 6, 43, and 56 mo after, and showed a perfect local and general result and normal growth. M.D.: Professor of Pediatric Surgery, and Surgeon in Chief, Pediatric Department, School of Medicine, University of Marseille, Marseille, France. V. Dor, M.D.: Associate Professor of Thorucic Surgery, Thorucic Surgery Clinic, School of Medicine, University of Marseille, Marseille, France. J. Aubert, M.D.: Assistant Surgeon, Pediatric Surgery Department, School of Medicine, University of Marseille, Marseille, France. P. Kreitman, M.D.: Assistant Surgeon, Thorucic Surgery Clinic, School of Medicine, University of Marseille, Marseille, France. Address for reprint requests: M. Curcassonne, Professor of Pediatric Surgery, 26 Cows Lieufaud, Marseille, France, 13001. 0 1973 by Grune 6 Stratton, Inc. M. Carcassonne,

Surgery

Journal of Pediatric

Surgery, Vol. 8, No. 1 (February),1973

1

CARCASSONNE

2

ET AL.

Case 2: A boy born in 1964 was admitted on July 30, 1969, for mild respiratory distress. Two months before, he had been tracheostomized for severe damage following brain trauma. He was still intubated with a Krishaber cannula, and a tube within. He previously had had some bouginage in the laryngology department. With simple medical care, and the removal of the cannula, the boy was discharged on September 10. He was assessed each month, and developed a granuloma at the tracheostomy site. Treatment with steroids was begun on March 10, 1970; later tracheoscopy confirmed a &cm-long stenosis, fibrous and undilatable. The granuloma had disappeared. on March 25, the tracheal stenosis W~LI resected with three tracheal rings; a primary anastomosis was carried out. The innominate vein was reconstructed. Postoperative recovery was uneventful. The patient was checked in 1971 and 1972, with a perfect clinical, tracheographic, and tracheoscopic resuit. His growth was normal. Case 3: A boy of 14 yr was admitted to another general hospital, for severe brain trauma, in January 1971. A tracheostomy was performed for ventilation, but poor respiratory care led to a left lung abscess with empyema. A left lobectomy was performed on June 19. Respiratory distress began on June 30. On August 13, a very severe low tracheal stenosis was confirmed. On August 24, a tracheal resection of four rings was performed by a transternal approach. The immediate postoperative course was uneventful. On the tenth postoperative day, an unfortunate tracheoscopy produced a rupture of the anastomosis and of the innominate artery. At emergency operation the artery and the trachea could be repaired. Cardiac massage was necessary. Unfortunately, the brain damage was so severe that the child died decerebrate 20 days after the second procedure. Case 4: In July 1971 a boy of 16 was admitted to the laryngology department for a direct Iaryngotracheal fracture at the level of the cricoid cartilage. Treatment was by suture, with a tube left within the larynx, and a tracheostomy below. Forty-five days later, it was still impossible to extubate the boy. Two strictures were diagnosed, one just below the vocal cords, the other at the level of the stoma. On October 28, a resection of the cricoid cartilage and four tracheal rings was performed. Anastomosis was done between the thyroid cartilage and the low trachea. The boy remained intubated for t day after operation. The postoperative course was uneventful. In February 197t, the boy was doing well. The voice was clear and the trarheocinematographic study result was fair.

ANALYSIS

OF PATIENT

MATERIAL

Four patients were admitted to our intensive care unit with very severe respiratory distress. They came from other hospitals where a very poor primary procedure had been done. In three of the cases, tracheostomy had been performed in the emergency room for prolonged uncounsciousness due to severe cranial trauma; in one case (NO. 4), for a direct laryngotracheal fracture. In two cases (No. 1 and z), the first thing we did was to remove the tube; in the two other cases, we changed to a more suitable tube. In two cases (No. 1 and 3), primary tracheostomv was the reason for the stenosis; in one case (No. 4), it was intubation followed by tracheostomy; and one case (No. 2), it was intubation performed through a Krishaber tube.3 The interval between the primary procedure and the acquired stricture varies from none to 4.5 days. The diagnosis was confirmed in each instance by endoscopy and the length of the stenosis by tracheograms. Two children (No. 2 and 4) had preoperative bouginage and medical treatment. In the other two, we found it unnecessary, impossible, or even dangerous. All children had appropriate care, which permitted the tracheostomv to heal in two cases (No. 1 and 2) before reconstructive procedure. The obstruction was high, at the stoma, in two cases (2 and 4), in the

TRACHEAL

3

RESECTION

middle portion at the level of the cuff in one case (No. l), and low at the site of the tip of the cannula in one case (No. 3). In one case (No. 4), we observed two stenoses, one at the level of cricoid cartilage, just below the vocal cords; the other at the site of the stoma (Fig. 1). DISCUSSION

Technique

of Tracheal Resection

Three problems must be solved in order to perform tracheal resection with primary anastomosis. Anesthesia: In two cases (1 and 3), we could pass a narrow tube (No. 4) through the stenosis and ventilate the lungs after inflating the cuff. In case No. 2, we inserted a portex tube above the stenosis, and after opening the trachea could insert it further inferiorly. In case No. 4, we were not able to do so. We began the operation with the tube in the trachea above the stricture. As soon as the trachea was dissected open, we inserted, directly from the operating field, a Sjoberg No. 7 tube in the lower trachea. When the stenosis was resected, and the posterior part of the anastomosis completed, we removed the Sjijberg tube and pushed down a superior cuffed tube. We never used a cardiopulmonary bypass. In fact, we think that this procedure is not indicated in tracheal resection in children. However, Louhimo et a1.l used it successfully in two cases of tracheal resections.

LARYNGEAL

STENOSIS

TRACHEAL

STENOSIS

Fig. 1. Etiology and site of stenoses.

STOMA

2

HIGH

CUFF

1

MIDDLE

TIP

1

LOW

4

CARCASSONNE

Appronch

and Dissection:

Except

for the first procedure

ET AL.

in case No.

1,

we used the transternal approach, which we found very convenient. In two cases (No. 1 and 2), we divided the innominate vein. In cases No. 3 and 4, it was not necessary. In one case (No. 2), we reconstructed the vein but the anastomosis was not patent, on angiography, 6 mo later. The major problems are caused by the innominate artery, which is intimately connected with the tracheal stenosis. To be able to dissect it gently, we were obliged to pass tapes around the aorta, carotid, and, of course, innominate artery above and below the stenosis. In one case (No. I), we could not do anything except resect a part of the artery wall involved in the tracheal stricture. In one case, the innominate artery was perforated by the tracheoscopic tube, which was the cause of the child’s death.e Tracheal Resection and Restoration: In 1958, with J. Dor,5 we published an experimental study on tracheoplasties in 120 dogs. Stressing the poor results of all types of plastic material used, we strongly advocated tracheal resection with primary anastomosis. The outstanding study of tracheal resection was done by Grille. He demonstrated that it was possible to resect either 5 to 9 cm of trachea or nine to seven rings. To perform a primary anastomosis over such a wide gap after resection, Grill0 advocated dissection of the main stem bronchi, and of the pulmonary vessels within the pericardium. We never had to use these procedures, probably because of the great elasticity of trachea in children.‘-lo

4 Fig. 2. Surgical technique.

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RESECTION

The dissection must be very wide along the anterior and lateral parts of the tracheal wall, but limited on the posterior wall. The resection must remove the entire strictured and fibrotic part of the trachea, leaving only normal cartilages for the anastomosis. The anastomosis is done by extramucosal stitches of vascular 00000 coated thread. The posterior stitches are passed first on the right, and then on the left side of the ventilation tube. The anterior row of stitches is then done easily (Fig. 2). All anastomoses were immediately airtight. In three cases, no tube was left in the trachea after operation. In one (No. a), a tube was left for one postoperative day. Most authors think resection is not a feasible technique in. very high tracheal stenoses very close to the vocal cords and laryngeal nerves. In case No. 4, we could safely do such an anastomosis between the thyroid cardilage and the lower trachea with a good functional result. The procedure is not advocated in tracheal strictures involving the cricoi’d cartilage. indications

for Tracheal

Resection4

As mentioned already, we Which Children Should Be Operated Upon? did not find it necessary to resect the trachea in any infant and our nine infants with stenoses had good results with conservative methods. It is probable that these stenoses were of a different type, involving only the tracheal mucosa. The stenoses we resected in older children were all circumferentially thick and fibrous and involved the whole tracheal wall. Endoscopic treatment was impossible or dangerous in two cases. In two cases, bouginage maintained for a long time did not improve the airway. We estimate that it is necessary to operate upon children who suffer from a permanent tracheal stenosis if there is respiratory distress, with severe dyspnea and wheezing, if the stenosis involves the whole tracheal wall, and if endoscopic and medical treatment is ineffective, useless, or dangerous. When Should Resection Be Carried Out? Two of our cases were emergencies, but we think that one could avoid this situation with correct care of the primary tracheostomy. It is desirable to operate when there is no infection and after careful preoperative medical treatment and postural drainage to get the lungs and bronchi clean and empty of secretions. Except in the cases where extubation is impossible, we should wait for complete healing of the tracheostomy scar. RESULTS

In the immediate postoperative period, we lost one patient, 20 days after the second procedure, with severe brain damage following perforation of the trachea on endoscopy and cardiac arrest. When we operated upon him for the second time, we were able to check his tracheal anastomosis, We may assume that the first operative procedure had nothing to do with the child’s death. We did not observe any other postoperative complications of any kind.l’ (See Table 1.)

CARCASSONNE ET AL.

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Table 1. Results of Tracheal Stenoses Resected in Children, 1967-1972 Preoperative Case

Age

Site

1

12

2

6

High

3 4

14 16

Low High

Middle

Etiology

Treatment

Length

PostoperaOve lntubation

Tracheostomy, intubation Tracheostomy, intubation Tracheostomy Tracheostomy, intubation

-

3-l-4

0

56 mo

0

24 mo

Bouginage

3

Bouginage

4 4+

0 ‘I2

1

day

Follow-up

Died 5mo

We followed our patients from 4 mo to 56 mo, and we checked our results with tracheoscopy and tracheography. In the live three children, the result was considered to be excellent by the endoscopist, not only anatomically but also functionally (Fig. 3). In our first case, we observed an immediate postoperative stenosis; but in this first case, our technique was far from good, and our tracheal resection was inadequate. The secondary resection gave an excellent and permanent

Fig. 3. cheogram.

Postoperative

tra-

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7

RESECTION

result. From our short experience, we believe that, using a correct technique and an adequate tracheal resection, secondary tracheal stenosis should appear in the first three postoperative months. Tracheal resection had no apparent effect on the growth of the children. It was particularly interesting in case No. 2, the youngest of all, to note that he stopped growing during his respiratory distress, but his growth curve returned to normal after the reconstructive procedure. SUMMARY

We observed nine tracheal stenoses following intensive respiratory care in 524 neonates and infants. For all but four of them, we used medical and endoscopic treatment only, with satisfactory immediate and late results. In four children between 6 and 16 yr, we were obliged to perform a tracheal resection with primary anastomosis. All four children had primary tracheostomies as emergency procedures. Subsequent respiratory distress was the result of a dense fibrotic stenosis resistant to medical and endoscopic management. The technique of resection is described, especially, in dealing with the innominate artery. Three to five rings were resected. Cardiopulmonary bypass, was found to be unnecessary. One patient died 1 mo after operation, from an endoscopic accident. The remaining three had excellent results assessed clinically and by endoscopy and radiocinematography. Iatrogenic tracheal stenosis in children is a serious lesion, which can be prevented by correct intensive respiratory care. ACKNOWLEDGMENT We are indebted to the Clinic of Respiratory Tract Diseases (Dr. Charpin), and particularly to Dr. Arnaud, who did the tracheographic studies for our patients. We wish to thank Dr. J. Dor, chief of the Thoracic Surgery Clinic, who gave us the opportunity to treat some of our patients.

REFERENCES 1. Louhimo, I., Grahne, B., Parila, M., and Suutarinen, T.: Acquired laryngotracheal stenosis in children. J. Pediat. Surg. 6:730, 1971.

5. Dor, J., and Carcassone, M.: Contribution expbrimentale 21la Gparation des pertes de substance de la trachCe et des branches. Ann. Chir. 12:1041, 1958.

2. Aboulker, P., and Demandent, J. E.: Aspects cliniques et traitement des stCnoses trachCales et laryngo-trachCales apr&s trachCotomie. Ann. Chir. Thorac. Cardiovast. 6:411, 1967. 3. Chevalier, P.: Les Stenoses TrachCales Apres TrachCotomie. Bordeaux, ThPse de MCdecine, 1968. 4. Couraud, L., Chevalier, I’., Bruneteau, A., and DuPont, I’.: Le traitement des St&noses trachCales apr&s trachCotomie; indications thCrapeutiques ?I propos de 9 rCsections pour 15 cas en insuffisance respiratoire aigui+. Ann. Chir. Thorac. Cardiovasc. 8~3, 1969.

6. Duval, J. M., Etienne, P., and Boullier, G.: Le tronc artCrie1 brachiocCphalique et les hbmorragies cataclysmiques de la trachCotomie. Ann. Chir. 23:437, 1969. 7. Grillo, H. C., Dignan, E. F., and Miura, T.: Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft: an anatomical study in man. J. Thorac. Cardiovasc. Surg. 48:741, 1964. 8. -: Surgical approaches of the trachea. Surg. Gynec. Obstet. 129 :347, 1969. 9. -: Management of the cervical and mediastinal lesions of the trachea. JAMA 197:1085, 1966.

8 10. -, Dignan, E. F., and Miura, T.: cervical Experimental reconstruction of trachea and circumferential excision. Surg. Gynec. Obstet. 122:733, 1966. 11. Dor, V., Kreitmann, P., Arnaud, A.,

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ET AL.

Dumon, J. F., and Pans, R.: R§ion Ctendue de la trachCe pour tumeur et &nose. RCsultats immCdiats et contrbles 4oignCs B propos de 16 cas. Presse MCd. 79:1843, 1971.