90 th Annual Meeting The American Association for Thoracic Surgery May 1, 2010 Toronto, Ontario, Canada. Slide Tracheoplasty

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1 90 th Annual Meeting The American Association for Thoracic Surgery May 1, 2010 Toronto, Ontario, Canada Congenital Skills Course Slide Tracheoplasty Carl Lewis Backer, MD A.C. Buehler Professor of Surgery Lauren D. Holinger, MD Professor of Pediatric Otolaryngology Children s Memorial Hospital Northwestern University Feinberg School of Medicine Chicago, IL

2 Congenital Tracheal Stenosis 40% mortality if untreated Benjamin B. et al. Ann Otol Rhinol Laryngol 1981;90(4 Pt 1):

3 Congenital Complete Tracheal Rings

4

5 3D Reconstruction CT

6 Tracheal Repairs / Yr Children s Memorial Hospital Tracheal Repair % PA Sling 25% Intracardiac anomaly

7 Farouk Idriss, M.D. May 1, 1992 First CPB for tracheoplasty First tracheoplasty with pericardium

8 Tracheal Repairs/Yr Children s Memorial Hospital Operative Technique Pericardial patch REEA Slide Autograft

9 Slide Tracheoplasty for Congenital Funnel- Shaped Tracheal Stenosis Victor Tsang, FRCS, Andrew Murday, FRCS, Charles Gillbe, FFARCS, and Peter Goldstraw, FRCS Brompton Hospital, London, England Congenital funnel-shaped trachea is a serious condition, and the survival rate in infants is poor. A slide tracheoplasty is described, with a brief revew of other methods of repair. Two cases that demonstrate the operability of congenital funnel-shaped trachea in infancy are reported. Ann Thorac Surg 1989; 48:

10 Patient #1: 10-month-old Right thoracotomy Died at 5 weeks Patient #2: 3-month-old Cervical incision Extubated postop #8 Did well Tsang et al. Ann Thorac Surg 1989;48:

11 SLIDE TRACHEOPLASTY IN THE MANAGEMENT OF CONGENITAL TRACHEAL STENOSIS STEVEN H. DAYAN, MD MICHAEL E. DUNHAM, MD CONSTANTINE MAVROUDIS, MD CARL L. BACKER, MD LAUREN D. HOLINGER, MD CHICAGO, ILLINOIS Long-segment congenital tracheal stenosis (LSCTS) is a rare condition. Originally, it was felt to be uniformly fatal; however, advances in technique have made surgical repair and survival possible. Our objective is to report results and technique of slide tracheoplasty for the treatment of LSCTS in the context of the overall experience at the Children s Memorial Hospital in Chicago. We reviewed 37 cases of infants and children with LSCTS. Thirty of the 37 infants underwent surgical intervention. Slide tracheoplasty resulted in survival in 1 of 2 infants, and pericardial patch tracheoplasty resulted in survival in 21 of 28 (75%). Of the 30 patients who had surgical repair, 7 (23%) have died, and 1 has been lost to follow-up (3%). Follow-up has ranged from 6 months to 13 years. Slide tracheoplasty is a satisfactory adjunct to existing techniques. With early diagnosis and appropriate management of LSCTS, survival is possible in a majority of patients. Ann Otol Rhinol Laryngol 1997;106:

12 Tracheal Anatomy Inferior thyroid arteries Bronchial arteries Courtesy of Professor Robert Anderson

13 Bronchial Arteries Arterial ligament Bronchial artery Right bronchial artery Courtesy of Professor Robert Anderson

14 Recurrent laryngeal nerve Vagus nerve Arterial duct Bronchial arteries Courtesy of Professor Robert Anderson

15 Tracheal Stenosis Courtesy of Professor Robert Anderson

16

17 Slide Tracheoplasty

18 Slide Tracheoplasty

19 Slide Tracheoplasty

20 17-day old, 3.5 kg, Single Left Lung

21 LPA encircles trachea (PA Sling)

22 Measure length of tracheal stenosis

23 3.5-cm stenosis

24 Trachea divided at midpoint of stenosis

25 2-mm dilator

26 Lower tracheal Incision (anterior)

27 4-mm probe

28 Upper tracheal incision

29 5-mm probe

30 Mobility of trachea

31 Anastomosis 6-0 PDS

32 Anastomosis running suture

33 Completed Anastomosis

34 18 months s/p Slide Tracheoplasty 4-mos old, 4.5 kg Repair

35 Technical Details Slide Tracheoplasty Rigid bronchoscopy in all cases prior to intubation We now leave original endotracheal tube in place throughout procedure and use flexible scope for intra- and postoperative analysis Collar incision in addition to sternotomy for tracheal exposure in the neck CPB for safety and better exposure Associated cardiac defects and pulmonary artery sling should be repaired before opening trachea (avoid contamination)

36 Technical Details Slide Tracheoplasty Must identify mid-portion of tracheal stenosis either by external examination or by bronchoscopy Any error in tracheal transection should err toward making superior portion too long; this can be corrected by trimming anastomosis as carina is completed Running suture technique is much faster and appears to better evert the tracheal edges and avoid figure of eight problem. I use 5-0 or 6-0 PDS suture. Test anastomosis to 35 cm H 2 O for air leaks

37 The Figure of 8 Problem Rutter MJ, J Pediatr Surg 2003;38:

38 Technical Details Slide Tracheoplasty I seal the anastomosis with a thin layer of fibrin sealant Small metal clips to mark top and bottom of extent of tracheoplasty No set extubation protocol Tailor to patient Early extubation is preferred Dilute Ciprodex nebs to decrease granulation tissue

39 Tracheal Reconstruction in Children with Unilateral Lung Agenesis or Severe Hypoplasia Carl Lewis Backer, MD, Angela M. Kelle, BS, Constantine Mavroudis, MD, Cynthia K. Rigsby, MD, Sunjay Kaushal, MD, and Lauren D. Holinger, MD Divisions of Cardiovascular-Thoracic Surgery, Medical Imaging, and Otolaryngology, Children s Memorial Hospital, Chicago, Illinois BACKGROUND: Infants with congenital tracheal stenosis may also have unilateral lung agenesis or severe lung hypoplasia. The purpose of this review is to evaluate our results with these patients and compare their presentations and outcomes to those of tracheal stenosis patients with two lungs. METHODS: Our database was queried for patients undergoing tracheal stenosis repair since Patients were divided into two groups based on pulmonary anatomy of single lung (SL = unilateral lung agenesis or severe hypoplasia) or two lungs (BL = bilateral lungs) and analyzed to compare presentation and outcomes. RESULTS: From 1982 to 2008, 71 patients had tracheal stenosis repair. Bilateral lungs were present in 60 patients; 9 patients had an absent (4) or severely hypoplastic (5) right lung, and 2 patients had an absent left lung (SL = 11). Age at repair was similar between groups; median age 0.42 years in the SL group (mean /- 1.0 years) versus 0.37 years in the BL group (mean /- 2.1 years, p = not significant [ns]). In the SL group 8 of 11 (73%) were intubated preoperatively versus 15 of 60 (25%) in the BL group (p = 0.004). In the SL group 4 of 11 (36%) patients had pulmonary artery sling versus 20 of 60 (33%) of BL patients (p = ns). In the SL group 2 of 11 (18%) versus 14 of 60 (23%) in the BL group had intracardiac anomalies requiring simultaneous repair (p = ns). Procedures included pericardial tracheoplasty (2 vs 26), tracheal autograft (4 vs 16), slide tracheoplasty (3 vs 8), and tracheal resection (2 vs 10). Overall mortality (operative and late) was 2 of 11 (18%) SL versus 10 of 60 (17%) BL (p = ns). Median postoperative length of stay was 43 days SL (mean /- 40) versus 30 days BL (mean /- 65) (p = ns). The incidence of postoperative tracheostomy (SL group) was 0 of 3 for slide tracheoplasty and 5 of 8 for the other techniques (p = 0.12). CONCLUSIONS: Despite the increased severity of pathology and increased critical presentation of tracheal stenosis patients with unilateral lung agenesis or severe hypoplasia, outcome measures of mortality and length of stay were similar to patients with two lungs. The incidence of associated pulmonary artery sling (1 of 3) and intracardiac anomalies (1 of 4) was similar. Unilateral lung agenesis or severe hypoplasia should not preclude operative repair of tracheal stenosis. Slide tracheoplasty is our current procedure of choice for these infants. Ann Thorac Surg 2009;88:

40 Agenesis Right Lung 13-day-old girl, 2.2 kg

41 Axial Image - CT

42 n = 10

43 n = 2

44 Completed Repair

45 Incidence of single lung with tracheal stenosis = 12/75 (16%) Mortality and length of stay SL = BL Similar incidence of PA sling (1/3) and intracardiac anomalies (1/4)

46 Special Techniques M. Toma et al. J Pediatr Surg 2009;44:

47 Special Techniques Le Bret et al. Ann Otolaryngol Chir Cervicofac 2006;123:

48 1-month-old with tracheal and right mainstem bronchial stenosis Brazdil J, Tlaskal T. Ann Thorac Surg 2008;85:

49 Slide Crico-tracheoplasty Le Bret et al. Ann Otolaryngol Chir Cervicofac 2006;123:

50 Slide Tracheobronchoplasty Le Bret et al. Ann Otolaryngol Chir Cervicofac 2006;123:

51 Slide tracheoplasty with tracheal right upper lobe Le Bret et al. Ann Otolaryngol Chir Cervicofac 2006;123:

52 Slide tracheoplasty with tracheo-esophageal fistula repair Le Bret et al. Ann Otolaryngol Chir Cervicofac 2006;123:

53 Slide Tracheoplasty Literature Analysis (2010) Institution # Patients Operative Mortality Children s Memorial Hospital 14 1 Marie Lannelongue 5 0 Massachusetts General Hospital 8 0 Cincinnati Children's Hospital 40 2 Kobe Children s Hospital 17 4 Great Ormond Street 15 2 Seoul National University

54 Pediatric Tracheal Surgery Literature Meta-Analysis (2010) Procedure Patient # Mortality *Slide Tracheoplasty (10%) Cartilage Tracheoplasty (36%) Pericardial Tracheoplasty (23%) Tracheal Homograft 31 5 (16%) Tracheal Autograft 30 6 (20%) *Tracheal Resection 73 5 (7%) * Current procedure of choice (16%)

55 Pediatric Tracheal Surgery Key is Collaboration Otolaryngology/ CV Surgery

56 Children s Memorial Hospital 2012

57 Ann & Robert H. Lurie Children s Hospital of Chicago

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