Congenital and Pediatric Lesions

Concern as to whether growth would occur following resection and anastomosis of the trachea in infants and small children was early allayed by experiment, although occasional success had also been noted clinically. Kiriluk and Merendino had observed growth of main bronchi after anastomosis experimentally.45 Borrie had found stenosis to occur after excision of more than three tracheal segments in lambs.275 Sorensen and colleagues, in 1971, noted somewhat limited growth in anastomotic sites in puppies, after resection of zero to five rings.276 Maeda and Grillo, in 1972, noted only mild narrowing of the anastomotic site in puppies without resection, at full growth (Figure 9).277 They found that, after resection, growth also occurred, but the safe anastomotic tension permitting predictable healing was 58% of that acceptable in adult dogs (1,000 g versus 1,750 g).278 Kotake and Grillo observed in puppies that tracheal "stay sutures" reduced anastomotic tension.279 In 1973, Murphy and colleagues noted unpredictably variable growth at anastomosis in piglets, after resection of only two rings.280 Mendez-Picon and colleagues confirmed anastomotic growth in puppies, in 1974.281 In 1978, Burrington found that cartilage grew continuously by proliferation on the convex surface without specific growth centers.282 Vertical incisions, hence, do not interrupt growth.

figure 9 Mazazumi Maeda, MD, pictured in his research laboratory. In 1970 and 1971, he worked as a Research Fellow in Surgery at Massachusetts General Hospital with Dr. Grillo, precisely describing healing of the juvenile trachea after resection. From the University of Osaka, he went to Shikoku, as Professor of Surgery and Chief of Surgery at Kagawa University. He was a leader in introducing tracheal and bronchial surgery in Japan.

figure 9 Mazazumi Maeda, MD, pictured in his research laboratory. In 1970 and 1971, he worked as a Research Fellow in Surgery at Massachusetts General Hospital with Dr. Grillo, precisely describing healing of the juvenile trachea after resection. From the University of Osaka, he went to Shikoku, as Professor of Surgery and Chief of Surgery at Kagawa University. He was a leader in introducing tracheal and bronchial surgery in Japan.

Cantrell and Guild classified congenital tracheal stenosis in 1964 and reported a case of resection of what later was termed a "bridge bronchus," with side-to-side anastomosis.283 Tracheal resection and primary anastomosis in children were explored by Carcassonne and colleagues in 1973, Mansfield in 1980, Nakayama and colleagues in 1982, and Grillo and Zannini, and Alstrup and Sorensen, in 19 84.284-288 Couraud and colleagues demonstrated long-term growth of anastomotic scars in 1990, particularly after resection of stenosis and anastomosis.289 Monnier and colleagues showed that single-stage laryngotracheal resection and anastomosis was also applicable in small children.167 This procedure appeared likely to largely replace cartilage graft procedures developed earlier.290 However, the length of many congenital tracheal stenoses prohibited resectional treatment.

Kimura and colleagues provided a solution in 1982, by inserting a cartilage patch longitudinally the length of the stenosis.291 In 1984, Idriss and colleagues used pericardium for the same purpose.292 Heimansohn and Jaquiss and their colleagues confirmed the use of pericardium and cartilage insets, respectively.293,294 Although successful in most cases, a considerable incidence of repetitive granulations formed on the mesenchymal patch until epithelization eventually occurred, and in some patients, necrosis of the patch required reoperation or tracheostomy.295,296

Tsang and colleagues, working with Goldstraw, solved the problem with slide tracheoplasty, described in 1989.297 Grillo's report in 1994, describing 4 successful cases so treated, established the procedure.298 A subsequent publication by Grillo and colleagues, reporting a total of 8 successful patients, 1 of whom was 10 days old, confirmed that satisfactory long-term growth occurred after slide tracheoplasty.299 The procedure corrected a long stenosis by providing a firm reconstruction with tracheal tissue, lined with ciliated epithelium and hence with little tendency to form granulomas, which did not require postoperative intubation for support and (absent left pulmonary artery sling or other cardiac anomaly) did not require car-diopulmonary bypass for surgery.

Complete laryngotracheoesophageal cleft was successfully repaired in 1984 by Donahoe and Gee.300

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