figure 6-24 Surgical techniques for treatment of congenital tracheal stenosis. A, Resection and reconstruction, suitable only for shorter stenosis. B, Patch tracheoplasty. Incision of long stenosis and widening of trachea with free cartilage or pericardial grafts.
port, a later modification proposed by this group was anterior division of the stenosis, and excision of a central piece of trachea to be used for part of the "gusset," augmented with pericardium. This complicated repair offers little over simple slide tracheoplasty, described below.
Heimansohn and colleagues also used pericardium in a group of 12 patients, and noted only 2 patients with granulations and requiring re-operation of the 10 patients who survived long term.96 Importantly, normal growth of the trachea was noted in longer-term results (1 to 11 years, mean 5 years).97 In 2 patients examined postmortem 13 and 18 months, respectively, after pericardial patch tracheoplasty, it was found that the pseudostratified columnar epithelium had lined the dense mature collagenous scar tissue that had replaced the pericardial patch.98 Jaquiss and colleagues returned to cartilage patch tracheoplasty, with granulation and dehiscence in 1 of 6 patients, all of whom survived.99 Mechanical ventilatory support was provided for a mean of 11 days, with a median postoperative hospitalization of 17 days. In time, cartilage grafts are also replaced by mature scar tissue and reepithelized by ciliated columnar epithelium.100 The luminal enlargement is maintained. Linear sections of cadaver trachea, chemically fixed so that the tissue is not viable, have been used as a patch to widen long stenoses of various etiologies.101 Both the biological processes of healing and the benefits of this technique compared with the use of native tissues are unclear (see Chapter 45, "Tracheal Replacement").
Slide tracheoplasty (see Chapter 33, "Repair of Congenital Tracheal Lesions"), first proposed by Tsang and colleagues and successfully employed by Grillo, meets the problems of long segment congenital stenosis by using tracheal tissue alone to widen the lumen, giving stability, minimizing granulation tissue formation, and assuring more likely prompt healing.102,103 A complete epithelial surface is also immediately provided. The stenosis is divided horizontally in its midpoint, and the upper and lower segments of stenosis are incised vertically through their entire extent, one anteriorly and one posteriorly. Corners are trimmed and the two segments slid together for suturing (Figure 6-24C). The circumference of the trachea is doubled and the cross-sectional area approximately quadrupled (Figure 6-25). Since the ends of the cartilaginous walls tend to curl inward, a lobulated cross-sectional appearance of a figure 8 character may be produced, so that the area is slightly less than quadrupled (Figure 6-26). Since the affected segment of the trachea is halved in length, even stenosis of the entire length of trachea does not preclude the procedure.
This operation was performed in 8 patients ranging in age from 9 days to 19 years (Figure 6-27).73 Five were done with simple cross-field ventilation and 3 with a period of bypass necessary to reimplant a divided pulmonary artery sling, to perform other cardiac procedures or because of myocardial disease. Segments resected were between 36 to 83% of tracheal length. Two had anomalous right upper lobe bronchi. Only 1 required 3 days of intubation for ventilatory support, principally for airway clearance. Hospitalization ranged from 8 to 13 days. One minute granuloma appeared late and was removed bronchoscopically. Follow-up between 1 and 10 years shows good growth of the reconstructed trachea in the younger patients.73 Functional results, which can be measured in older patients, are excellent (Table 6-2) (Figure 6-28).
figure 6-24 (continued) C, Slide tracheoplasty, reconstructing the trachea with (unresected) native trachea, providing fourfold widening of the lumen. Probably preferable even for most shorter stenoses as well as for long stenosis.
figure 6-25 Bronchoscopic views before (A) and after (B) slide tracheoplasty in a 3-month-old boy with stenosis of one-half of his tracheal length. In A, "O" rings are clearly visible. In B, the widening of the lumen allows the carina to be seen distantly. The irregular margins of the tracheoplasty are evident. The child was completely relieved of severe symptoms and his trachea grew well.
figure 6-26 A, Roentgenogram of a long congenital stenosis treated by slide tracheoplasty B, Preoperative and post slide tracheoplasty computed tomography scans of the patient. The reconstructed trachea has a bilobed appearance due to the natural curvature of the tracheal wall segments. The enlargement is therefore less than fully fourfold, but it fully relieved obstructive symptoms.
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