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J Thorac Cardiovasc Surg 1996;112:188-190
© 1996 Mosby, Inc.
BRIEF COMMUNICATIONS |
Newark, N.J.
From The Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Children's Hospital of New Jersey, and University of Medicine and Dentistry, New Jersey Medical School, Newark, N.J.
Received for publication Sept. 6, 1995 Accepted for publication Oct. 3, 1995. Address for reprints: J. Rodrigo Oyarzun, MD, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, 185 South Orange Ave., MSB G 595, Newark, NJ 07l03.
Congenital vascular rings are often complicated by tracheomalacia. Even after release of the tracheal compression, the tracheomalacia may be severe enough to result in postoperative morbidity and mortality.
1 Therefore aortopexy or tracheopexy, or both, may be required to lessen respiratory insufficiency, especially in the immediate postoperative period. 2 We observed an unusual complication—a tracheopexy suture that caused phrenic nerve compression and resulting diaphragmatic paralysis. The phrenic nerve was successfully released by video-assisted thoracoscopic surgery (VATS).
An 8-month-old infant weighing 8.2 kg was admitted to Children's Hospital of New Jersey for correction of a congenital vascular ring and associated tracheomalacia. The child had had respiratory difficulties shortly after birth. At the age of 10 days laryngomalacia was diagnosed. The patient subsequently had two hospital admissions for treatment of upper respiratory tract infections and bronchiolitis. Eventually, a vascular ring was suspected and a barium swallow confirmed the diagnosis. A nuclear magnetic resonance study revealed a double aortic arch with an atretic anterior segment. Operative correction was then indicated.
After induction of anesthesia, an examination with a rigid bronchoscope demonstrated severe malacia of the anterior tracheal wall at the level of the vascular ring. The left side of the chest was opened by means of a standard posterolateral incision. On exploration, a much larger thymus than normal was noted. The atretic anterior aortic arch and the ligamentum arteriosum were divided. The vessels were then dissected free, which cleared the anterior and lateral tracheal walls from any vascular compression. At the same time, this maneuver provided complete exposure of the trachea. The segment of tracheomalacia was easily identified and suspended to the back of the sternum with a 3-0 nonabsorbable suture. The course of this suture transversed the enlarged thymus, encroaching on the left phrenic nerve, without obvious compression (Fig. 1).
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To avoid a second thoracotomy, we elected to use a VATS approach. The videoscopic equipment included a Dyonics 4.0 mm wide-angle 30-degree arthroscope (Smith & Nephew Dyonics, Inc., Andover, Mass.). The scope was inserted through the chest tube site with the lungs hypoventilated. A second port (4 mm long) was created at the anterior end of the thoracotomy incision for introduction of instruments. No additional port was necessary, because the scope could also be used to retract the hypoventilated lung. The polypropylene suture was identified and divided with orthopedic endoscopy scissors.
Postoperatively, the left hemidiaphragm resumed function in a matter of hours, as identified by a chest x-ray film and confirmed by means of a fluoroscopic study on the first postoperative day. Although the patient was able to be extubated immediately after the operation, he had persistent problems related to tracheomalacia, which were adequately managed medically. The patient was discharged to his home within a week of the VATS procedure.
Tracheomalacia is often associated with vascular rings and can result in severe respiratory compromise in children. Several surgical techniques have been described to treat severe tracheomalacia. 2 Depending on the anatomy, either aortopexy or tracheopexy can be performed. Aortopexy was not applicable in this patient, because the only residual aortic arch was posterior to the trachea; thus tracheopexy was chosen. In general, tracheopexy can be performed through either a median sternotomy or a lateral thoracotomy. In cases of tracheomalacia associated with vascular rings, the entire procedure is approached through a left thoracotomy. The trachea is suspended by placing one or more nonabsorbable sutures between the anterior tracheal wall and the sternal periosteum. The procedure is generally well tolerated and operative complications have been unusual. 2,3
In our patient, hyperplasia of the thymus displaced the phrenic nerve laterally and thus exposed it to compression by the tracheopexy suture. In retrospect, the suspending suture should have been passed through the thymus, medial to the phrenic nerve, which would have avoided its compression and, consequently, diaphragmatic paralysis. This complication often causes life-threatening respiratory insufficiency in infants. Therefore it necessitates early aggressive treatment, which is usually performed through a lateral thoracotomy. 4
With the recent development of smaller endoscopy instruments, the list of indications for VATS in pediatric cardiothoracic conditions is expanding. 5 The immediate resolution of the diaphragmatic paralysis and the early recovery of the patient, without the need for a second thoracotomy, is another example of the efficacy of VATS when applied to selected pediatric cases.
References
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