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J Thorac Cardiovasc Surg 2006;132:181-183
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Service des cardiopathies congénitales, Centre chirurgical Marie Lannelongue, Le Plessis Robinson, France
b Département d'ORL pédiatrique, Hôpital d'enfants Armand Trousseau, Université Paris VI, Paris, France
c Département d'imagerie médicale, Scanner, Centre chirurgical Marie Lannelongue, Le Plessis Robinson, France
Received for publication December 16, 2005; accepted for publication January 13, 2006. * Address for reprints: Emmanuel Le Bret, MD, PhD, Service des Cardiopathies Congénitales, Centre Chirurgical Marie Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis Robinson, France. (Email: e.lebret{at}ccml.fr).
Initially described by Tsang and colleagues in 1989,
1
slide tracheoplasty has become the technique of choice to treat long-segment tracheal stenosis.
2
The advantages of this technique are avoidance of graft materials, avoidance of tension on the sutures, satisfactory enlargement of the trachea, and avoidance of impairment of the anatomic and functional growth of the trachea.
3
The association of tracheal resection and slide tracheoplasty was recently reported by our team
4
as a possible treatment for an infant presenting with tracheal hypoplasia associated with partial critical stenosis. However, surgical management of a tracheal hypoplasia extending down to the bronchus is still challenging.
We report a variant of the slide tracheoplasty that allowed us to treat this difficult case.
Case
Patient and Anatomic Lesion
A 3-month-old infant weighing 3.5 kg was primarily referred for tracheal hypoplasia. The child had been intubated for 1 month in his birth country. The infant was admitted to our department with tracheal septic contamination. Endoscopy and computed tomography scan analysis showed a severe tracheal hypoplasia starting at the middle of the trachea and extending to the main bronchi and carina. After administering intense anti-biotherapy to the infant for 1 week, we decided to perform surgery.
Surgical Technique
A transverse cervical incision combined with a median sternotomy was performed. Dissection of the entire trachea was accomplished. Care was taken to respect the vascularization of the lower part of the trachea, carina, and main bronchi, but the upper trachea was circumferentially dissected. The patient was then heparinized, and a normothermic cardiopulmonary bypass was established between the right atrium and the aorta. Dissection of the carina and main bronchi was then completed. The main bronchi were freed anteriorly right to their division, respecting their posterior walls. The trachea was first transversally transected at the junction between the lower third and the upper two thirds of the hypoplasia (Figure 1). The distal end of the trachea was longitudinally sectioned along its anterior wall down to the carina. The carina and the origin of the main bronchi were opened superoanteriorly (Figure 2,
A). The proximal end of the trachea was also longitudinally split along its posterior wall, along the entire length of the hypoplasia. The anterior wall of the proximal end of the trachea was also split half-length. The tracheal walls were trimmed to make a gently sloping autologous tracheal patch. The anastomosis was performed with interrupted sutures of 5-0 and 6-0 Polydioxanone suture (PDS, Ethicon Inc, Somerville, NJ). Suturing was initiated proximally between the inferior tongue of the trachea and the normal trachea. The final sutures were placed at the distal end of the tongue of the anterior wall of the trachea, which was sutured down to the anterosuperior part of the main bronchi and carina (Figure 2, B). The endotracheal tube was replaced, ventilation was reestablished, and the patient was weaned from cardiopulmonary bypass.
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Comments
The slide tracheobronchoplasty is the latest extension of the slide tracheoplasty technique. This modification was proposed by Grillo in 2004
5
for patients in whom significant stenosis is present in the proximal main bronchi.
In this particular case, it was important to choose the option before incising the trachea. Because the point of transverse division of the hypoplastic segment is below the midpoint of the tracheal stenosis, it also has to provide the necessary length for slide bronchoplasty. In this case, the section of the trachea was performed in the lower third of the hypoplastic zone, and half of the upper hypoplastic segment was used to enlarge the anterior part of the main bronchi origin. If a longer segment of the bronchi were to be enlarged, a longer segment of the trachea would be necessary, and the primary section of the trachea would have to be much lower.
Care must be taken to connect the 2 tongues of the trachea, which must fit perfectly to the anterior part of the bronchi with no tension and no disrotation.
Conclusion
Extended slide tracheoplasties enable successful tracheal reconstruction even when main bronchi are involved in the hypoplasia. Use of the patient's own tracheal tissues and avoidance of foreign materials should enable good tracheobronchial growth in the same way that slide tracheoplasty enables good tracheal growth.
| See related brief communication on page 179.
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References
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  S.-C. Huang, E.-T. Wu, C.-C. Wang, C.-A. Chen, C.-Y. Chen, S.-J. Chen, and M.-H. Wu Repair of Complex Tracheobronchial Stenosis With Left Pulmonary Artery Sling and Bridging Bronchus Ann. Thorac. Surg., October 1, 2010; 90(4): 1379 - 1381. [Abstract] [Full Text] [PDF]
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J. Brazdil, T. Tlaskal, P. Vojtovic, P. Pohunek, and M. Cihar Slide Plasty of Trachea and Right Main Bronchus in a Newborn Ann. Thorac. Surg., March 1, 2008; 85(3): 1096 - 1097. [Abstract] [Full Text] [PDF]
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