Mbc

50 (40)

44 (40)

121 (79)

135 (93)

RV/TLC

0.62 (238)

0.52 (217)

0.28 (93)

0.13 (44)

FEV1 = forced expiratory volume in 1 second; MBC = maximum breathing capacity; PEFR = peak expiratory flow rate; RV = residual volume; TLC = total lung capacity; VC = vital capacity.

FEV1 = forced expiratory volume in 1 second; MBC = maximum breathing capacity; PEFR = peak expiratory flow rate; RV = residual volume; TLC = total lung capacity; VC = vital capacity.

figure 6-28 Flow volume loop in a 19-year-old patient who underwent slide tracheoplasty, pre-operatively and 1 year postoperatively. She was totally relieved of symptoms.

The results of slide tracheoplasty suggest its superiority over patch tracheoplasty.73,103 Since reports from three major children's hospitals show an average incidence of only one or two such cases yearly in each institution, a long time may be needed to establish a preferable method statistically. Nevertheless, a number of recent reports have indicated a growing acceptance of slide tracheoplasty.731 recommend this technique even over resection and reconstruction, if there is any likelihood of too much tension after resecting a lesion of borderline length. It should be unnecessary to point out that this technique has no application in acquired fibrous stenosis, where the absence of a "normal" tracheal wall would result in restenosis.

Resection and reconstruction of congenital stenosis is still the method of choice for short segments of stenosis, where lack of anastomotic tension may be confidently predicted. Resection is also uniquely applicable in the case of a short bridging bronchus, especially where maximum narrowing is located at one end of the stenotic bridging bronchus. Cantrell and Guild described this procedure and I have found it useful.16,73 Extreme caution must be used in designing the exact size and location of the anastomotic apertures proximally and distally, to avoid angulation of the bronchi (see Chapter 33, "Repair of Congenital Tracheal Lesions").

Transplantation of trachea remains impractical at present. Problems of maintenance of viability of the epithelium and cartilage, tissue rejection, and hazards of prolonged immunosuppression are discussed at length in Chapter 45, "Tracheal Replacement." A further problem with any form of transplant in juveniles, as well as with synthetic or composite grafts to replace lost trachea, is the need for growth as the child grows. Experimenters tend to forget this in their enthusiasm for "new" technology. For similar reasons, I believe that permanent or semipermanent expandable stents are to be avoided in the juvenile trachea, if the disease is not soon likely to be lethal. In addition, such stents can irreversibly damage the trachea and prove to be nearly irremovable. Silicone inlying stents, such as the Dumon stent, should be used with measured judgement. I have surgically corrected children who were seemingly condemned to indefinite periodic replacement of Dumon stents. Silicone stents cause reactive granulomas and thus extend the original pathology. The inadvisable path of repeated laser treatments should also be avoided.

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