With complex anomalies, ingenuity may be required. Congenital stenosis may be associated with anomalous right upper lobe bronchus (bronchus suis), bridging bronchi, stenotic main bronchi, degrees of figure 33-5 Tracheobronchogram showing a complex stenosis. A segment of relatively mild stenosis lies proximal to an anomalous right upper lobe bronchus. The stenotic "bridge bronchus" below shows maximal narrowing in its most proximal portion. The main bronchi are adequate in diameter.
figure 33-6 Resection of "bridge bronchus" and anastomosis shown in Figure 33-5. The apertures must be carefully designed to avoid anastomotic kinking. The patient had a tracheostomy on arrival. Reproduced with permission from Grillo HC et al.12
bronchomalacia, and, as noted, pulmonary artery sling. I have used Cantrell and Guild's technique for management of a "bridging" bronchus that was extremely narrow and funneled to a tiny diameter at its proximal end (Figure 33-5).13 Neither patch nor slide tracheoplasty would have sufficed. The bronchus was short enough so that it could be resected, and the junction of trachea and right upper lobe bronchus could be anastomosed to the residual "carina" between right and left "main" bronchi (Figure 33-6). Slide tracheoplasty was successfully used in another bridging bronchial stenosis (Figure 33-7). It should be possible to modify the slide technique to widen proximal main bronchi if necessary (Figure 33-8), although I have not yet encountered this situation. Where I encountered circular tracheal rings in the main bronchi, the narrowing was not severe enough to require bronchial enlargement.
figure 33-7 Slide tracheoplasty applied to an obstructive bridge bronchus. A moderate proximal tracheal stenosis was of no clinical importance. The anomalous pulmonary artery "sling" was also repaired, if only to provide access to the stenosis.
figure 33-8 Proposed procedure for slide tracheobronchoplasty where significant stenosis is also present in proximal main bronchi. The point of transverse division of the stenotic trachea is below the midpoint of tracheal stenosis to provide necessary length for slide bronchoplasties also. The dashed line indicates proximal extent of posterior incision of upper portion of stenosis. We have not yet encountered this situation and must emphasize that this technique is untested.
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