New cervical approach for tracheopexy

Aortopexy for tracheomalacia via a suprasternal incision

AIM

Tracheomalacia is flaccidity of the tracheal wall leading to tracheal collapse, particularly on expiration. When severe it can warrant surgical intervention. Aortopexy is one surgical option and has been described using a variety of approaches. We report outcomes of aortopexy performed via a suprasternal incision in a single centre by a single surgeon.

METHODS

All patients undergoing aortopexy between February 2016 and May 2018 were prospectively included. Patients were managed by a multi-disciplinary team (MDT) and underwent standardized work-up, including dynamic flexible bronchoscopy (DFB) and contrast enhanced CT. Aortopexy was performed via a suprasternal skin crease incision. Surgery was guided by intra-operative flexible bronchoscopy. Data regarding pre-operative symptoms, degree of tracheomalacia, and outcomes were recorded.

RESULTS

Twenty-two patients were included, 18 boys, median age 5 months (range 1 month-5 years). Two aortopexy sutures were used in all cases, and three patients required an additional tracheopexy suture. Median operating time was 1 h 24 min (range 47 min-2 h 35 min). Median pre-operative tracheal collapse on DFB was 85% (range 80-95%), improving to 35% (35-80%) intra-operatively. Median length of stay was 4 days (range 1-118).

CONCLUSIONS

Aortopexy via a suprasternal incision is a useful treatment modality for tracheomalacia with short operating times and rapid recovery. Outcomes vary with the best results in the TOF and premature groups. Careful patient selection and MDT work-up are essential to optimize outcomes.

LEVEL OF EVIDENCE

Level 3 (Case Series).

Pediatric airway surgery

Pediatric airway surgery is a challenging field in pediatric surgery. Laryngotracheal stenosis has a variety of congenital and acquired conditions that require precise assessment and tailored treatment for each individual patient. About 90% of acquired conditions are represented by subglottic stenosis (SGS) resulting as a complication of tracheal intubation. Congenital tracheal stenosis (CTS) is a rare and life-threatening malformation, usually associated with complete tracheal rings along a variable length of the trachea. Tracheomalacia (TM) is a process characterized by flaccidity of the supporting tracheal cartilage, widening of the posterior membranous wall, and reduced anterior-posterior airway caliber. The clinical presentation can vary from almost asymptomatic patients to near fatal airway obstruction. There is considerable variation in both the morphologic subtypes and the prognosis of pediatric airway. The patients are divided into three clinical groups (mild, moderate, and severe). A further division was proposed according to the presence or absence of associated anomalies. The definitive diagnosis of pediatric airway was made by means of rigid bronchoscope and computed tomography scan with three-dimensional reconstruction (3D-CT). Rigid bronchoscopy and 3D-CT confirmed the diagnosis in all the cases. Other associated anomalies include congenital heart disease, vascular anomalies, and BPFM (maldevelopment of aerodigestive tract). After definitive diagnosis of pediatric airway lesions, surgical intervention should be considered. Surgical strategy was presented on each lesion.

Pediatric tracheomalacia

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the tracheal cartilage and/or posterior membrane. Tracheomalacia has a wide range of etiologies but is most commonly present in children born with esophageal atresia and tracheal esophageal fistula. Clinical symptoms can range from minor expiratory stridor with typical barking cough to severe respiratory distress episodes to acute life-threatening events (ALTE). Although the majority of children have mild-to-moderate symptoms and will not need surgical intervention, some will need life-changing surgical treatment. This article examines the published pediatric literature on TM, discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.

Tracheomalacia in a patient with unilateral pulmonary and renal agenesis

We report the case of an eight-month-old boy with tracheomalacia secondary to impingement by the right pulmonary artery, together with congenital agenesis of the left lung and the left kidney. Aortopexy and right pulmonary arterypexy were successful in improving lung function by more than 100%, and the patient remained free of complications in the long term.

Tracheomalacia in esophageal atresia. Usefulness of preoperative imaging evaluation for tailored surgical correction

Tracheomalacia (TM) associated with esophageal atresia (OA) generally is located in the thoracic segment of the trachea, and the close anatomical relationships it has with the aortic arch and the other mediastinal structures play a remarkable role in the dynamic obstruction of the airways. Only correct preoperative imaging studies permit a precise anatomic description of TM, reducing the risk of incomplete treatment owing to the persistence of other undervalued problems. This report describes the usefulness of preoperative imaging by dynamic fiberoptic bronchoscopy and spiral multilayer computed tomography with 3-dimensional reconstruction in 7 symptomatic children with segmentary TM associated with esophageal atresia and treated surgically "case by case" based on dynamic fiberoptic bronchoscopy and computed tomography data.

Tracheomalacia and Tracheobronchomalacia in Children and Adults

Tracheomalacia and tracheobronchomalacia are disorders that are encountered in both pediatric and adult medicine. Despite increasing recognition of these disease processes, there remains some uncertainty regarding their identification, causes, and treatment. This article is intended to be a comprehensive review of both the adult and pediatric forms of the diseases, and includes sections on the historical aspects of the disorders, and their classification, associated conditions, histopathology, and natural history. We also review the various modalities that are used for diagnosis as well as the state of the art of treatment, including airway stent placement and surgical intervention.

Aortic suspension (aortopexy) for severe tracheomalacia in infants and children

BACKGROUND

Tracheomalacia with anterior great vessel compression is a common disorder in infants and children, which can lead to life-threatening airway occlusion. In this study, a large number of patients underwent anterior aortopexy to provide a more normal distal airway.

METHODS

Thirty-two infants and children with tracheomalacia associated with esophageal atresia-tracheoesophageal fistula (18), vascular ring (8), abnormal innominate artery takeoff (4), and primary (2) were evaluated with bronchoscopy, magnetic resonance imaging, and pulmonary functions. Aortopexy was accomplished through left thoracotomy and suture fixation of the aorta and innominate artery to the posterior sternum.

RESULTS

Intraoperative bronchoscopy showed marked improvement in airway caliber and rigidity, and no patients had further obstructive episodes. Forced expiratory volume improved from 52% +/- 4% of predicted to 82% +/- 3%.

CONCLUSIONS

Aortopexy is a simple procedure for the treatment of distal tracheomalacia that is immediately effective and provides permanent relief of obstructive episodes.

Surgical treatment of tracheomalacia by bronchoscopic monitored aortopexy in infants and children

BACKGROUND

Aortopexy has become an established surgical procedure for the treatment of severe tracheomalacia (TM) in infancy. However, postoperative outcome may be improved by intraoperative bronchoscopic control of the aortopexy.

METHODS

Between 1992 and 2000, 16 infants and children (2 female, 14 male) with TM were treated by pexis of the aorta via a right (15 patients) or left (1 patient) anterior thoracotomy. Patients age ranged from 4 to 122 months (mean, 26 mon). Three infants had previous surgery for esophagus atresia and tracheoesophageal fistula. Another four patients were operated for gastroesophageal reflux. In all cases, the aortopexy was monitored intraoperatively by bronchoscopy. Respiratory function was verified for each patient by comparing pre- and postoperative tidal expiratory flow values (TEF 25% in ml/sec).

RESULTS

Mean follow-up was 36 months (range, 2 to 60 mo). There was no intraoperative or postoperative mortality. 13 patients showed permanent relief of symptoms. Postoperative median TEF 25% increased significantly compared with preoperative values (81 ml/sec vs. 56 ml/sec; p = 0.016). In one patient repeat aortopexy was necessary.

CONCLUSIONS

Aortopexy through a right anterior thoracotomy is an efficient and feasible method in the surgical treatment of TM in infancy and, therefore, can improve postoperative respiratory function. Intraoperative bronchoscopy is advantageous.

The anterior mediastinal approach for management of tracheomalacia

BACKGROUND

Tracheomalacia occurs as a primary developmental defect or may be secondary to vascular compression. It is common in association with esophageal atresia and tracheoesophageal fistula. Collapse of the weak trachea is a cause of recurrent respiratory symptoms but may be severe and life threatening.

METHODS

Between 1978 and 1999 at Sheffield Children's Hospital and The Royal Manchester Children's Hospital, of 16 children with clinically significant symptoms of tracheomalacia 8 underwent combined aortopexy and tracheopexy, 1 had aortopexy alone, 4 only had a tracheopexy, and 3 had tracheal reinforcement with free costal cartilage ring grafts. The surgical approach was limited to a low cervical skin crease incision with a midline manubrial split providing extrapleural access to the anterior mediastinum and allowing for all surgery under direct unimpaired vision.

RESULTS

Ten children did not require postoperative ventilatory support. Four underwent ventilation for a few hours or days. One child required CPAP for 4 months for residual tracheomalacia and a further child, who had 3 operations to insert 11 costal cartilage ring grafts, underwent ventilation intermittently for 6 months. Adequate tracheal patency could be verified by intraoperative tracheoscopy and was sustained postoperatively so that only 1 child with associated bilateral vocal cord paralysis came to tracheostomy. Four children required prolonged hospitalization because of residual tracheomalacia, 2 for bronchomalacia and 2 because of esophageal narrowing leading to further surgery. All other children were fit for discharge within 10 to 30 days of surgery. Long-term follow-up has confirmed sustained tracheal improvement and resolution of the life-threatening features of tracheomalacia.

CONCLUSIONS

The authors recommend the low skin crease transmanubrial approach, as described by Vaishnav and MacKinnon, for tracheopexy, aortopexy and for tracheal reconstruction for tracheomalacia. The approach gives excellent access for surgery under direct vision through a relatively avascular plane. It is associated with less morbidity than a conventional thoracotomy and leaves a more acceptable aesthetic scar.

Advances in the management of major airway collapse: the use of airway stents

The management of major airway collapse in the pediatric age group has evolved and continues to evolve over time. Tracheobronchomalacia, either primary or secondary, is still the most frequent cause of major airway collapse. This article reviews tracheobronchomalacia and discusses several treatment options; from traditional aortopexy to the more recent introduction of tracheobronchial stenting. Various types of stents are discussed and the authors' preferences are included.

Intratracheal granuloma formation: a late complication of Marlex mesh splinting for tracheomalacia

External splinting of the trachea has been used alone or in combination with aortopexy for the treatment of severe tracheomalacia. The authors describe the case of a 12-year-old boy who had a Marlex mesh splint placed because of life-threatening primary tracheomalacia at 6 months of age. He presented at 12 years of age with a 5-month history of shortness of breath on exertion, dry cough, and audible wheeze. Radiological and endoscopic examinations showed near-complete obstruction of the orifice of the right mainstem bronchus by a large polypoid granuloma. Initially the patient was treated with endoscopic resection on two occasions, but the granuloma and bronchial obstruction recurred each time. He underwent a right thoracotomy, which showed that the lower edge of the mesh had eroded through the trachea wall and was acting as a nidus for granuloma formation. After removal of the mesh, the resulting defect at the site of erosion of the trachea was closed with a pericardial patch. The postoperative course was uncomplicated, and the patient remains well 2 years after surgery. External splinting of the trachea has been shown to be effective in the treatment of complicated tracheomalacia, but one must be aware of the potential long-term complications, as demonstrated in this case.

Tracheoaortopexy via midline sternotomy in tracheomalacia

Symptomatic tracheomalacia associated with congenital tracheoesophageal fistula requires active treatment. When symptoms are severe, consideration should be given for surgical correction. Aortopexy via a lateral thoracotomy and tracheopexy via an anterior cervical approach have been described. We present two patients with extensive tracheomalacia who benefited from combined tracheoaortopexy via a midline sternotomy approach.