J Thorac Cardiovasc Surg 2009;137:e44-e46
© 2009 The American Association for Thoracic Surgery
Latero-lateral slide tracheoplasty for upper airway stenosis: An 8-year follow-up
Erdal Tasci, MDa,
Halil Ciftci, MDa,
Farzin Periovi, MDb,
Cemal Asim Kutlu, MD, FETCSa,*
a Department of Thoracic Surgery, Sureyyapasa Chest Diseases and Chest Surgery Teaching and Research Hospital, Istanbul, Turkey
b Medica Imaging Centre, Istanbul, Turkey
Received for publication February 5, 2008; accepted for publication March 20, 2008.
* Address for reprints: Cemal Asim Kutlu, MD, FETCS, Medkon, Hakki Yeten Cad. 12/12, 
i
li 34394, Istanbul, Turkey. (Email: cakutlu{at}tnn.net).
Since slide tracheoplasty (ST) was defined in 1989,1
the scope of the technique has been further extended, as evidenced by reported cases of satisfactory outcomes. ST has been used for almost all types of long-segment tracheal stenosis, including "bilateral main bronchus stenosis"2 and "congenital laryngeal atresia (slide thyrocricotracheoplasty)."3 We slightly modified the original technique and performed latero-lateral ST in a patient who presented with an acquired long-segmental stenosis. We report the patients' long-term follow-up.
Clinical Summary
A 46-year-old man presented with a long-segment stenosis involving the subglottic area and proximal trachea caused by tracheobronchopathia osteochondroplastica. Spirometry showed a forced expiratory volume in 1 second of 1.46 L (43% predicted) and a forced vital capacity of 3.06 L (81% predicted). Bronchoscopy relieved that the stenosis involved the subglottic area and proximal half of the trachea. Modified ST was undertaken via median sternotomy, and the anterior surface of the trachea was exposed to adjust the oblique (right to left) and longitudinal tracheal cuts along the stenosis. The longitudinal cut on the lateral surface of the proximal tracheal segment was extended superiorly up to the thyroid cartilage; the distal segment was then slid up after trimming both margins. Contrary to our routine technique for anastomosis, the cartilaginous part of the trachea was anastomosed with polyglycolic acid using an interrupted suture technique because of the thick and calcified tracheal wall.
Postoperatively, the main concern was the suture line healing in the oldest patient undergoing ST among the reported patients. Bronchoscopy was performed 2 times for bronchial toilet in the early postoperative course. This case was reported 15 months after the surgery when the patient had resumed his normal life without any respiratory problems or restrictions in his daily activities.4 Since then, he has not required any hospitalization, and chest x-rays taken by his primary physician showed no abnormality. He did not receive any medication, including bronchodilators and steroids. We invited him to our outpatient clinic 8 years after the operation to investigate the long-term results of the operation. On examination, no abnormality was detected; breath sounds were within normal limits. Spirometry showed a forced expiratory volume in 1 second of 1.91 L (69% predicted) and a forced vital capacity of 2.6 L (74% predicted). A computed tomography scan revealed no stricture in the lumen (
Figure 1), and the tracheal cartilages were clearly seen at the inferior part of the thyroid cartilage on the left side (
Figure 2). In regard to clinical and radiologic findings, bronchoscopy for only academic purposes seems inappropriate to perform.
View larger version (155K):
[in this window]
[in a new window]
|
Figure 2. Appearance of the trachea on control computed tomography scan. On the left, the tip of the distal tracheal segment that slid up to the thyroid cartridge is seen.
|
|
Discussion
A 2-fold increase in the number of capillary vessels in newborn trachea may explain the low rate of ischemic complications after ST despite extensive mobilization and long suture lines. Despite the satisfactory outcome in the long term,5 ST has yet to be confirmed for the management of acquired tracheal stenosis. Furthermore, ST has been performed in babies and young adults. Therefore, for our middle-aged patient, we modified the original technique by dividing the trachea from the right to the left to preserve the lateral longitudinal tracheal vessels, which are unavoidably damaged in the original technique. Our modification allows preserving the tracheal vessels on one side, which supply the entire tracheal segment through the anterior anastomosis.
This modification also enables widening of the proximal part of the stenosis involving the subglottic area4 by sliding the tip of the distal segment to the inferior edge of the thyroid cartridge. The outcome of our case suggests that ST may be undertaken not only for acquired stenosis but also for subglottic stenosis. Kim and colleagues3 recently extended the limits of the original technique and adopted a similar approach in a 7-month-old baby who presented with a congenital laryngeal atresia. In their technique, the lower third of the thyroid cartilage and cricoid was dissected and the tip of the distal tracheal segment was slid anteriorly to widen the laryngotracheal stenosis. The postoperative course was uneventful, and 18 months after the operation, satisfactory outcome was reported.
Conclusions
This result confirms our observation that ST may be considered for the management of proximal airway stenosis involving the subglottic area. The satisfactory long-term outcome of the latero-lateral modification suggests that ST may be a reasonable option for an acquired long segmental tracheal stenosis. Despite the hypothetic advantages, the beneficial effect of our modification remains to be confirmed.
References
- Tsang V, Murday A, Gilbe C, Goldsraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis. Ann Thorac Surg 1989;48:632-635.[Abstract/Free Full Text]
- Beierlein W, Elliot M. Variations in the technique of slide tracheoplasty to repair complex forms of long-segment congenital tracheal stenosis. Ann Thorac Surg 2006;82:1540-1542.[Abstract/Free Full Text]
- Kim SM, Han SJ, Choi HS, Nam YT, Oh JT, Choi SH. Slide thyrocricotracheoplasty: a novel technique for congenital laryngeal atresia. Pediatr Surg Int 2008;24:383-386Epub 2007 May 24.[Medline]
- Kutlu CA, Yeginsu A, Ozalp T, Baran R. Modified slide tracheoplasty for the management of tracheobronchopathia osteochondroplastica. Eur J Cardiothorac Surg 2002;21:140-142.[Abstract/Free Full Text]
- Kutlu CA, Goldstraw P. Slide tracheoplasty for congenital funnel shaped tracheal stenosis (a 9-year follow-up of the first case). Eur J Cardiothorac Surg 1999;16:98-99.[Medline]
