Download - The Annals of Thoracic Surgery

Peter B. Manning, MD, Michael J. Rutter, MD, and William L. Border, MBChB
Divisions of Cardiothoracic Surgery, Otorhinolaryngology, and Cardiology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio
Background. A single-institution experience with slide
tracheoplasty for management of tracheal stenosis in children with emphasis on identifying predictors of prolonged
postoperative mechanical ventilation is reviewed.
Methods. Patient characteristics, hospital course, and
outcomes for children undergoing slide tracheoplasty
were recorded. Univariate and multivariate analysis was
performed to identify factors leading to prolonged mechanical ventilation (>48 hours postoperatively).
Results. Since April 2001, 40 children underwent slide
tracheoplasty utilizing cardiopulmonary bypass (CPB)
support at a median age of 6.2 months (range, 7 days to 15
years), and median weight of 6.1 kg (range, 1.9 to 57 kg).
Thirteen patients had undergone prior operations. Thirteen patients (32.5%) were mechanically ventilated before operation. Thirteen patients underwent additional
procedures at the time of the slide tracheoplasty. Mean
CBP support time was 123 minutes. Seven patients required aortic cross-clamping (mean, 69 minutes). There
were 2 early and 2 late deaths, none related to the
tracheoplasty. One patient required repair of a recurrent
tracheal stenosis, 4 patients required tracheotomy, and 3
required temporary stent placement. Twenty-one patients (52.5%) were extubated within 48 hours after tracheoplasty. Univariate and multivariate analysis revealed only preoperative mechanical ventilatory support
(odds ratio 28.4, p ⴝ 0.015) and duration of CPB support
(odds ratio 1.06, p ⴝ 0.007) to be significant predictors of
the need for prolonged intubation.
Conclusions. Slide tracheoplasty utilizing CPB support
is a versatile and effective treatment for tracheal stenosis
in children even when combined with repair of congenital cardiac anomalies. Most children can be successfully
weaned from mechanical ventilatory support early after
repair.
T
diac defects has been adopted as the technique of choice
at most centers that have reported a significant experience managing these complex children [5]. At Cincinnati
Children’s Hospital, we have followed this surgical approach since 2001 after disappointing experience with
other surgical techniques [4]. We have also followed a
strategy to attempt to discontinue mechanical ventilatory
support as soon after reconstructive operation as possible
based on the principal that the airway after slide tracheoplasty is significantly larger and more stable than
preoperatively.
In this report, we review our experience with slide
tracheoplasty for the management of tracheal stenosis in
infants and children to document associated anomalies
and outcomes, and also to specifically focus on factors
that led to the need for prolonged postoperative mechanical ventilatory support (⬎48 hours).
racheal stenosis in infants and children is typically
characterized by the presence of complete cartilaginous tracheal rings, and often involves significant
lengths of the trachea. In infancy, the initial management
of such patients can be very challenging owing to the
unstable nature of the stenotic airway with the need for
paralysis to facilitate mechanical ventilatory support.
Surgical reconstruction of long-segment tracheal stenosis
has been achieved using a number of techniques including simple resection, pericardial, rib cartilage, or tracheal
autograft patching, and slide tracheoplasty [1– 4]. Outcomes have been promising in recently reported series,
yet this population still experiences significant postoperative morbidity and mortality, related not only to the
reconstruction of the trachea, but also to associated
anomalies, the majority of which are cardiovascular.
Slide tracheoplasty utilizing cardiopulmonary bypass
support with simultaneous treatment of associated carAccepted for publication Nov 2, 2007.
Presented at the Fifty-third Annual Meeting of the Southern Thoracic
Surgical Association, Tucson, AZ, Nov 8 –11, 2006.
Address correspondence to Dr Manning, Division of Cardiothoracic
Surgery, MLC 2004, Cincinnati Children’s Hospital Medical Center, 3333
Burnet Ave, Cincinnati, OH 45229; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons
Published by Elsevier Inc
(Ann Thorac Surg 2008;85:1187–92)
© 2008 by The Society of Thoracic Surgeons
Patients and Methods
Forty infants and children underwent slide tracheoplasty
at Cincinnati Children’s Hospital Medical Center from
April 2001 through March 2006. Twenty boys and 20 girls
underwent operation at a median age of 6.2 months
(range, 7 days to 15 years) and a median weight of 6.1 kg
0003-4975/08/$34.00
doi:10.1016/j.athoracsur.2007.11.019
GENERAL THORACIC
Slide Tracheoplasty in Infants and Children:
Risk Factors for Prolonged Postoperative
Ventilatory Support
GENERAL THORACIC
1188
MANNING ET AL
SLIDE TRACHEOPLASTY IN INFANTS AND CHILDREN
Fig 1. Age distribution of slide tracheoplasty patients.
(range, 1.9 to 57 kg). Age distribution is shown in Figure
1. Patient characteristics, hospital course, and outcomes
were reviewed. Institutional Review Board approval with
waiver for the need to obtain individual consent was
obtained on April 4, 2006. Univariate logistic regression
and multivariate step-wise forward logistic regression
analyses were performed to identify factors associated
with the need for prolonged mechanical ventilation (⬎48
hours postoperatively).
Preoperative evaluation always included bronchoscopy to document the degree and length of the tracheal
stenosis. Bronchoscopy was usually performed within
1 week of the slide tracheoplasty, with the child initially spontaneously ventilating. The airway is then
gently suctioned using a 6F soft suction catheter placed
directly through the cords to clear secretions. A Propofol bolus is then given to minimize respiratory efforts,
and a 1.9-mm Hopkins rod telescope inserted, taking
great care to not traumatize the trachea. In no case did
the preoperative evaluation compromise the child’s
airway. Echocardiograms were performed to assess for
associated cardiac anomalies. Contrast chest computed
tomography with three-dimensional reconstruction
was often performed to assist with documentation of
vascular anomalies and to add information about the
length of the tracheal stenosis, although this study was
never substituted for careful, yet thorough endoscopic
airway examination.
All tracheal reconstructions were performed through a
median sternotomy utilizing cardiopulmonary bypass
(CPB) support. Repair of associated cardiovascular
anomalies was performed during the same operation
when such defects were present. At the commencement
of the procedure, the airway was carefully suctioned, and
bronchoscopy repeated. It is rare for the first two tracheal
rings to be stenotic, so intubation was usually with an
age-appropriate endotracheal tube placed transnasally
into the subglottis so the Murphy eye was below cord
level, allowing positive pressure ventilation to be maintained. If the child had stenosis to the cricoid, a bluntended armored tube (without a Murphy eye) was used.
Frequently, children with complete tracheal rings have a
degree of congenital subglottic stenosis, so the size of
Ann Thorac Surg
2008;85:1187–92
endotracheal tube chosen was not necessarily age appropriate, but rather what size best accommodated the
subglottis.
In the absence of the need for intracardiac repair, CPB
was established with aortic and single venous cannulation (through the right atrial appendage) with maintenance of normothermia. The anterior surface of the
trachea from the cricoid cartilage to the proximal mainstem bronchi was exposed, typically before initiation of
CPB if airway management was stable. After initiation of
CPB, fiberoptic bronchoscopy was repeated to identify
the proximal extent of the stenosis, which was confirmed
from the mediastinal side by passing a fine needle
through the anterior tracheal wall. The trachea was
divided at the mid level of the stenotic length and the
posterior aspect of both proximal and distal segments
were dissected to facilitate mobilization. Dissection of
lateral attachments to the tracheal segments was avoided
to preserve blood supply and prevent injury to the
recurrent laryngeal nerves. Opposite sides of each tracheal segment were opened longitudinally to points just
beyond the extent of the stenosis, typically down to
carina distally. In 2 patients, we slid beyond the carina
and down a bronchus to alleviate bronchial stenosis. If
both bronchi were stenotic, we would preferentially slide
down the bronchus to the largest lung with the best
blood supply, typically the right side. In cases in which
the child had previously undergone placement of a
tracheotomy tube, the upper segment was opened anteriorly through the tracheotomy stoma to allow incorporating this into the slide repair. Oblique, side-to-side
anastomosis was performed using a running polydiaxanone suture. The endotracheal tube was typically repositioned in the center of the reconstruction just before the
completion of the anastomosis. The repair was leaktested under saline to an airway pressure of 35 cm water.
Additional sutures to repair leaks were rarely required.
Patients were weaned from CPB with inotropic support
only if simultaneous cardiac repair had been performed.
Fiberoptic bronchoscopy was repeated before transfer to
the intensive care unit to confirm tube position and to
clear the airway of secretions. Weaning from mechanical
ventilation was initiated after stabilization in the intensive care unit, with a goal to extubate by the first
postoperative morning.
Results
Twenty patients had associated cardiovascular anomalies, of which left pulmonary artery (LPA) sling was the
most common (11). Six patients had ventricular septal
defects (1 with left pulmonary artery sling also and
another with pulmonary vein stenosis also). There were 3
cases of tetralogy of Fallot or double-outlet right ventricle
with tetralogy physiology, 1 common atrium, and 1 LSVC
to the left atrium without intra-atrial communication.
Thirteen patients had undergone prior operations including prior tracheal reconstruction in 3 patients (3 prior
tracheal operations in 1 patient, 1 each in the other 2),
LPA sling repair (4), tracheotomy tube (3), tetralogy of
1189
MANNING ET AL
SLIDE TRACHEOPLASTY IN INFANTS AND CHILDREN
Table 1. Univariate Analysis of Variables Predicting the Need for Postoperative Ventilatory Support More Than 48 Hours
Variable
Sex
Age
Weight
Height
Cardiovascular anomaly
Prior operation
Prior tracheal operation
Preoperative ventilation
CPB time
Cross-clamp (yes/no)
Simultaneous additional operation
Odds Ratio
95% Confidence Interval
Standard Error of the Mean
p Value
0.55
1.00
0.90
0.97
7.00
1.48
3.75
13.06
1.04
9.23
5.4
0.155–1.91
0.998–1.00
.0792–1.01
0.944–1.00
1.74–28.2
0.366–5.96
0.355–39.58
2.34–72.81
1.01–1.06
0.99–85.77
1.18–24.64
0.035
0.0004
0.056
0.015
4.97
1.05
4.51
11.45
0.013
10.5
4.18
0.34
0.11
0.08
0.067
0.006
0.584
0.27
0.003
0.004
0.051
0.029
Fallot/double-outlet right ventricle repair (2), ventricular
septal defect (VSD) closure (1), bidirectional Glenn procedure (1), patent ductus arteriosus ligation (1), ventriculoperitoneal shunt (1), and anorectal pull-through (1).
Thirteen patients (32.5%) were mechanically ventilated
immediately before their operation. Excluding patent
ductus arteriosus ligation, which was performed in 8
cases, 13 patients underwent simultaneous repair of
associated cardiovascular defects. These included repair
of LPA sling (7), VSD closure (5), septation of common
atrium (1), repair of tetralogy of Fallot (1), repair of
pulmonary vein stenosis (1), and aortopexy for associated
bronchomalacia (1). One patient who had closure of a
VSD also underwent simultaneous placement of a saline
tissue expander in the right chest to recenter the mediastinum owing to congenital aplasia of the right lung.
Mean CPB time was 123 minutes (range, 56 to 318). Seven
patients required aortic cross-clamp time for management of intracardiac defects for a mean of 68.7 minutes
(range, 16 to 132).
There were 2 early and 2 late deaths in this series, none
directly related to the tracheal reconstruction. One patient with a full-length stenosis and multiple associated
anomalies including hydrocephalus and low imperforate
anus underwent repair at 14 days of life. Despite what
appeared on multiple endoscopic examinations to be a
widely patent repair, the infant had progressive respiratory insufficiency postoperatively thought to be due to
bilateral lung hypoplasia that was suggested by chest
computed tomography. She died on postoperative day
12. The other early death was of a child with Shone’s
variant characterized by mild hypoplasia of the left
ventricular outflow tract, mitral valve, arch hypoplasia
without coarctation, VSD, and stenosis of all four pulmonary vein ostia. Slide tracheoplasty was performed at 3
months of age with simultaneous VSD closure and “sutureless repair” of his pulmonary vein stenoses. He was
weaned from ventilatory support on the eighth postoperative day, but progressive, severe restenosis of his
pulmonary veins developed, resulting in his death 6
weeks after operation.
Both late deaths occurred 9 months after tracheal
reconstruction. One was due to acute leukemia in a girl
with Down syndrome who had undergone uncomplicated tracheal reconstruction at 18 month of age. The
other was an infant with multiple anomalies including
hydrocephalus, bilateral choanal atresia, partial duplication of chromosome 8, and prematurity who underwent tracheal reconstruction at 7 days of life (youngest
patient in the series) along with VSD closure. She was
initially weaned from ventilatory support 4 days after
operation, but had a long and complicated initial
hospitalization related to numerous associated anomalies. She required placement of a tracheostomy at 6
months of life owing to recurrent upper airway obstructive episodes. Repeat evaluations of her lower
airway revealed a good repair. She died at home at 9
months of age, her death related to an inadvertent
tracheal decannulation.
One patient required reoperation for a discreet restenosis at the distal end of the tracheoplasty that was
successfully treated with resection and reanastamosis.
Four patients required tube tracheostomy at some time
after their reconstruction, and 3 required temporary
stenting of the airway using Palmaz stents. Children
requiring Palmaz stents included 2 of the children who
had undergone previous tracheoplasty elsewhere, and
the 1 patient who had recurrent tracheal stenosis. In all 3
cases, the stents were placed to support a segment
dynamic collapse, and in all 3 cases, were removed within
2 to 4 weeks. While unenthusiastic about the use of
Palmaz stents in the airway, we have found that if the
stent is relatively underexpanded, and removed in a
timely fashion, that granulation tissue is minimal and
stent removal straightforward.
Twenty-one patients (52.5%) could be weaned from
mechanical ventilatory support within 48 hours after
tracheal reconstruction. Univariate analysis of variables
predicting the need for mechanical ventilation beyond 48
hours postoperatively is displayed in Table 1. Multiple
step-wise forward logistic regression analysis revealed
only the need for preoperative mechanical ventilation
(odds ratio 28.4, p ⫽ 0.015) and CPB time (odds ratio 1.06,
p ⫽ 0.007) were predictive of the need for prolonged
postoperative ventilatory support.
GENERAL THORACIC
Ann Thorac Surg
2008;85:1187–92
GENERAL THORACIC
1190
MANNING ET AL
SLIDE TRACHEOPLASTY IN INFANTS AND CHILDREN
Comment
Congenital long-segment tracheal stenosis is a challenging problem. Although it may become symptomatic
across a variety of ages, the most common presentation is
in the first months of life. We have often been surprised
how well some of these infants may appear clinically at
the time of initial diagnosis despite the severity of luminal narrowing of the trachea. In fact, quite a number of
patients escaped recognition until they were found either
to have difficulty with intubation for a nonairway operation, or failed to wean from ventilatory support after
another operation. That these children are often quite
complex, with a number of associated anomalies, predominantly cardiovascular, is emphasized in our experience. Given the high rate of associated anatomic tracheal
stenosis seen in cases of left pulmonary artery sling (50%
in reported series) [6, 7], careful airway evaluation before
pulmonary artery reimplantion is mandatory. Four patients in the current series underwent prior LPA sling
repair at outside institutions before tracheal stenosis was
diagnosed, with severe consequences resulting in 2 cases.
We therefore emphasize the necessity of preoperative
bronchoscopy in any child with an LPA sling as part of
the initial evaluation despite the apparent lack of airway
symptoms.
We advocate, as have others [5], that simultaneous
repair of tracheal stenosis and cardiac anomalies is preferable to a staged approach. Achieving as normal a
cardiopulmonary physiologic state as surgically feasible
maximizes the chance for the most rapid, complicationfree recovery. Although prolonged CPB time did correlate with a higher failure rate for early extubation, that
finding likely reflects the presence of associated cardiac
anomalies. Prolonged CPB time did not, however, correlate with poorer survival or the need for further surgery.
This population is complex owing to both the nature of
their airway anomaly and the high incidence of significant associated anomalies. While our overall survival is
excellent (95% early, 90% late), the hospital course for
many patients was prolonged and associated with significant morbidity. We found that early extubation also
typically predicted a relatively smooth recovery period,
however, and that was achieved in more than half of our
population.
Excellent results with such complex patients can only
be achieved through the collaboration of a multidisciplinary team of specialists sharing an organized and
consistent approach to patient care. This has been emphasized by others [3], and we believe it is the cornerstone of our current program. Although some centers
have advocated repair of congenital tracheal stenosis
through a cervical approach or limited sternotomy without CPB support [8], we have found major advantages to
a routine application of median sternotomy and CBP
support. Excellent visualization of the entire tracheal
length is seen with this exposure. If there are no associated cardiac anomalies and the lower third of the trachea
is normal, cervical approach to slide tracheoplasty without the use of CPB support may be appropriate, an
Ann Thorac Surg
2008;85:1187–92
approach we have employed in 4 additional patients not
included in the current series. Mobilization of the tracheal segments to allow tension-free reanatomosis can be
best achieved through sternotomy, even in cases of
full-length tracheal stenosis. In the current series, we did
not have to employ hilar release techniques and only
once utilized a hyoid release to achieve adequate mobilization. The patients who posed the most significant
challenges for mobilization were those who had undergone prior tracheal reconstruction and the older patients.
Maintaining adequate ventilation during reconstruction
in the smallest infants whose stenoses typically extend to
the level of the carina is challenging and may potentially
compromise the adequacy of the tracheal anastomosis.
We experienced no complications directly related to the
use of CPB support in this series.
Our adoption of the slide tracheoplasty [9] as our
preferred method for reconstruction evolved after disappointing results with other techniques, although it also
corresponded to the initiation of our team approach to
managing these cases. The appeal of the slide tracheoplasty technique lies mainly in its versatility: we have
successfully employed it in both short-segment and fulllength tracheal reconstructions, in patients who have
undergone prior reconstructions using other techniques,
and in cases where the orientation of the slide must be
modified to deal with proximal bronchial stenosis or the
presence of a tracheal origin of the right upper lobe
bronchus. In this series, more than 50% of the patients
had long-segment tracheal stenosis involving more than
50% of the trachea, and length of stenosis was not found
to influence outcome. The inherent stability of a repair
that uses only cartilage-supported tissue led us to an
approach to strive for early extubation in this patient
group. The use of only local, autologous, vascularized
tissue in the reconstruction should result in the best
prospect for tracheal growth in this young population, an
observation we have made in longer follow-up of our
youngest infants.
Successful early extubation in more than half of the
patients in the current series testifies to the quality of
the slide tracheoplasty in management of congenital
tracheal stenosis. One report has advocated postoperative support using venovenous extracorporeal membrane oxygenation [10], a practice we consider is completely unnecessary in the face of an adequate airway
reconstruction. In all of these patients, their airway
should be dramatically better than it had been immediately preoperatively, and two thirds of patients did
not require mechanical ventilation before operation.
Failure to achieve early separation from mechanical
ventilatory support was most strongly influenced by
the need for preoperative ventilatory support in our
study. Although in some cases that certainly reflected
the severity or complexity of the underlying airway
anatomy, in many cases, failure to wean was related to
the patients’ having required heavy sedation and paralysis preoperatively for days to weeks (often owing to
delays associated with referral from outside centers),
which resulted in significant atrophy of their intrinsic
MANNING ET AL
SLIDE TRACHEOPLASTY IN INFANTS AND CHILDREN
ventilatory capacity. The association of prolonged duration of CPB support with failure to achieve early
extubation reflects the overall complexity of the case,
often the presence of associated cardiac anomalies that
were repaired simultaneously. Reoperative tracheal
reconstruction was also typically associated with
longer bypass times.
In conclusion, slide tracheoplasty utilizing CPB support is a versatile and effective treatment for tracheal
stenosis in children even when combined with repair of
congenital cardiac anomalies. Most children can be successfully weaned from mechanical ventilatory support
early after repair.
approach improve outcomes and reduce costs. J Thorac
Cardiovasc Surg 2004;128:876 – 82.
Rutter MJ, Cotton RT, Azizkhan RG, Manning PB. Slide
tracheoplasty for the management of complete tracheal
rings. J Ped Surg 2003;38:928 –34.
Loukanov T, Sebening C, Springer W, Ulmer H, Hagl S.
Simultaneous management of congenital tracheal stenosis
and cardiac anomalies in infants. J Thorac Surg 2005;130:
1537– 41.
Fiore AC, Brown JW, Weber TR, Turrentine MW. Surgical
treatment of pulmonary artery sling and tracheal stenosis.
Ann Thorac Surg 2005;79:38 – 46.
Backer CL, Mavroudis C, Dunham ME, Holinger LD. Pulmonary artery sling: results with median sternotomy, cardiopulmonary bypass, and reimplantation. Ann Thorac Surg
1999;67:1738 – 44.
Grillo HC, Wright CD, Vlahakes GJ, MacGillivray TE. Management of congenital tracheal stenosis by means of slide
tracheoplasty or resection and reconstruction, with longterm follow-up of growth after slide tracheoplasty. J Thorac
Cardiovasc Surg 2002;123:145–52.
Tsang V, Murday A, Gilbe C, Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis. Ann
Thorac Surg 1989;48:632–5.
Hines MH, Hansell DR. Elective extracorporeal support for
complex tracheal reconstruction in neonates. Ann Thorac
Surg 2003;76:175–9.
4.
5.
6.
7.
8.
References
1. Backer CL, Mavroudis C, Gerber ME, Holinger LD. Tracheal
surgery in children: an 18-year review of four techniques.
Eur J Cardiothorac Surg 2001;19:777– 84.
2. Chiu PPL, Kim PCW. Prognostic factors in the surgical
treatment of congenital tracheal stenosis: a multicenter analysis of the literature. J Ped Surg 2006;41:221–5.
3. Kocyildirim E, Kanani M, Roebuck D, et al. Long-segment
tracheal stenosis: slide tracheoplasty and a multidisciplinary
9.
10.
DISCUSSION
DR CONSTANTINE MAVROUDIS (Chicago, IL): Thank you
for the opportunity to discuss this paper and congratulations,
Peter. This is an outstanding presentation. Obviously these
patients present with difficult problems, and a careful multidisciplinary collaborative approach is necessary just like you determined, and clearly your group has developed this to a high
degree with superb results.
At our institution at Children’s Memorial Hospital, we
performed two slide tracheoplasties in 1996. One of those died
and the other had a prolonged hospital course. This was
related to the granulation tissue and the figure-of-eight configuration of the trachea that led to recurrent stenosis and
tracheomalacia. We had much better success with the tracheal
autograft at that time, and we have now used this technique in 20
patients with 2 operative deaths and 2 late deaths. Because of the
outstanding results reported by the late Hermes Grillo at Massachusetts General Hospital and Martin Elliot at Great Ormond
Street, we began using the slide tracheoplasty technique again in
2002. Since that time we have used this technique in 5 patients and
all have done quite well with shorter intubation times and hospital
stays as compared with our previous experience with the pericardial patch tracheoplasty and the tracheal autograft.
I believe another outgrowth of the slide tracheoplasty has
been the realization that many of these patients can be treated
successfully with tracheal resection. Since that early experience
with slide tracheoplasty, we have performed 12 tracheal resections with only 1 mortality in a patient who died awaiting a liver
transplant.
In summary, at Children’s Memorial Hospital, we have moved
from pericardial patch tracheoplasty in 28 patients through the
autograft experience in 20 patients, and now, in most cases,
applying either the slide tracheoplasty or tracheal resection. I
have several questions.
In the time period of this series, what number of patients had
a simple tracheal resection? What are your indications for a
tracheal resection rather than a slide tracheoplasty? What per-
cent of the trachea needs to be involved for you to move from
resection to slide tracheoplasty? We have a 30% rule: more than
30% stenosis, we do a slide tracheoplasty. There were 2 early
deaths and 2 late deaths in your series, none related to tracheoplasty. What were these deaths secondary to? We have always
been concerned about tracheoinnominate fistula in these patients, given that the suture line of this slide tracheoplasty is
frequently adjacent to the innominate artery. Have any of your
patients had a tracheoinnominate fistula? We have had 1 patient
who died because of this problem.
Again, congratulations, Peter, you have done an outstanding
job with this difficult set of patients, and we all look forward to
your comments and answers to the questions.
DR MANNING: Thank you for your remarks, Gus. I will try to
be expedient in answering your questions. The most direct
answer to your question about resection is that I wouldn’t
characterize any of the cases we have done as classic resection
with end-to-end anastomosis. The difference between a resection and a slide may be semantic for a short stenosis, because we
still prefer to perform a slide. Even for relatively short segments,
the anastomosis is never a circumferential, straight across anastomosis. It is always going to be an overlapped, oblique anastomosis. So we refer to some kids as a short slide when they are a
relatively short segment, which you are probably characterizing
as a resection and reanastomosis. What appeals to us with the
slide technique is its versatility. You can handle very short
segments, very long segments and still, I think, distribute the
anastomosis over a larger area.
You commented about the figure-eight deformity. We see that
a lot. We found that it tends to relax as time goes on. Sometimes
our ear, nose, and throat surgeons will go back periodically, even
as often as weekly, and sometimes encourage the figure eight to
open up using gentle balloon dilations.
Regarding the issue of tracheoinnominate fistulas, we have
seen none in this series. As for the deaths, 1 case was a child who
GENERAL THORACIC
1191
Ann Thorac Surg
2008;85:1187–92
GENERAL THORACIC
1192
MANNING ET AL
SLIDE TRACHEOPLASTY IN INFANTS AND CHILDREN
was our youngest in the series in whom the airway reconstruction seemed fine, but in retrospect the child never exchanged
gas well, and we figured that he probably had significant
bilateral lung hypoplasia. One child had a lot of associated
anomalies, including four-vein pulmonary stenosis. His tracheal
reconstruction went well. He had concomitant VSD closure and
a sutureless repair of pulmonary venous stenoses, and then
went on within about 6 to 8 weeks to refibrose and stenose his
pulmonary veins and died of right ventricular failure. One late
death was a child with Down’s syndrome who died of leukemia
about 9 months postoperatively with absolutely no airway problems, and the other was a more complex child who ended up
having a tracheostomy tube in for long-term ventilatory support,
more related to choanal atresia, and died after a decannulation
episode at home.
DR JOHN W. BROWN (Indianapolis, IN): Very nice presentation, Peter, excellent results. In the half of your patients who
weren’t extubated in 48 hours, how long were they intubated?
DR MANNING: As you would expect, there is a long tail to that
group, and some of them were very long. Some children, as I
said, ultimately required a tube tracheostomy and chronic
ventilatory support, and a few children ended up bouncing back
off and on the ventilator. But by and large, if you throw out a lot
of the outliers, many of them were extubated within a week to 10
days. The things that seemed to really prevent early extubation
were if they had undergone a significantly complex cardiac
repair as well, or more often, some of these children came to us
after having been ventilated, on high-dose steroids, and paralyzed for weeks at a time before they got to us, and their
Ann Thorac Surg
2008;85:1187–92
ventilatory mechanics were totally atrophied, and it just took a
week or two to get them strong enough to breathe on their own.
DR BROWN: My second question is, what was the average
number of tracheal rings in your patient population?
DR MANNING: We didn’t specifically count but based on the
length of the total trachea, the most typical cases were somewhere between a half to two thirds the length of the trachea. I
don’t think there were any that were an ultrashort length, and
we had a handful of children who maybe had a single ring, or a
single noncomplete ring at the top and the bottom but everything else in between was a complete ring.
DR BROWN: Our experience continues to be with the pericardial tracheoplasty, and many of our patients have the entire
trachea involved. Will the slide tracheoplasty work when all 20
tracheal rings are involved, and if so, what happens to the blood
supply when you stretch them that far?
DR MANNING: We have done it in those children. We have not
found it to be a problem. It is a lot easier in the younger children;
just like with a lot of other types of reconstructions, in a newborn
you can mobilize things very well. I think a lot of people in the
days of a straight resection would teach us you can remove half
the length of the trachea and still get the ends together, which
means with the slide technique you can slide the full length and
still get the ends together. And again, we try to avoid lateral
dissection to preserve blood supply, and in the follow-up we
have not had significant problems that we have been able to
recognize specifically related to devascularization of the tracheal
segments.