Partial cricotracheal resection with primary anastomosis in the pediatric age group

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.     

Early and late airway complications after lung transplantation: incidence and management

BACKGROUND: Airway anastomosis complications continue to be a source of morbidity for lung transplant recipients. METHODS: This study analyzes incidence, treatment, and follow-up of airway anastomotic complications occurring in 127 consecutive lung transplant airway anastomoses (77 single lung and 25 bilateral sequential lung). Complications were categorized as stenosis (11), granulation tissue (8), infection (7), bronchomalacia (5), or dehiscence (3). Follow-up after treatment ranged from 6 months to 4 years. RESULTS: Nineteen airway anastomosis complications (15.0%) occurred in 18 patients. Telescoping the airway anastomosis reduced the complication rate to 12 of 97 (12.4%), compared with 7 of 30 (23.3%) for omental wrapping, (p = 0.15). Complications developed in 13 of 77 single-lung airway anastomoses (16.9%) versus 6 of 50 bilateral sequential lung recipients (12.0%). Treatment consisted of stenting (9 airway anastomoses), bronchodilation (8), laser debridement (4), rigid bronchoscopic debridement (2), operative revision (2), and growth factor application (2). There was no difference in actuarial survival between patients with or without airway anastomosis complications (p = 1.0). CONCLUSIONS: Airway anastomosis complications can be successfully managed in the immediate or late postoperative period with good outcome up to 4 years after intervention.     

Difficult tracheal intubation with von Recklinghausen disease

We experienced a case of difficult tracheal intubation in a 15-year-old boy with von Recklinghausen disease scheduled for resection of a right neck tumor. His scoliosis made it difficult to intubate and to manage airway because he easily developed dyspnea. We tried nasotracheal intubation with the patient awake under sedation using a bronchofiberscope, but we found an unexpected tumor jeopardizing his airway patency near his vocal cord. Preoperative examination of a tumor in the airway is essential in the anesthetic management of the patients with von Recklinghausen disease.     

Long-term follow-up of immunosuppressive treatment for obstructive airways disease after allogeneic bone marrow transplantation

BACKGROUND: Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. METHODS: A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. RESULTS: Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. CONCLUSIONS: These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.     

Prosthetic reconstruction of the trachea and carina

Twenty-six patients with tracheal stenosis owing to benign stricture and malignancy have had airway reconstruction with a molded silicone rubber prosthesis. In 8 patients the distal trachea and carina were replaced with a bifurcated graft. One individual with respiratory insufficiency could not be weaned from the respirator and died in 3 weeks. Two other patients with malignancy died 15 and 18 months following operation from disseminated cancer. The remainder are living from 1 to 5 years postoperatively. Eighteen individuals have had the trachea reconstructed with a straight graft of silicone rubber. In 5 patients with long strictures the prosthesis was invaginated into the upper and lower ends of the trachea. Thirteen individuals had circumferential resection of the airway with end-to-end anastomosis of the graft to the trachea. There was one early death from erosion of the innominate artery and 5 late deaths unrelated to the prosthesis.     

Management of difficult airway during induction of anesthesia in a patient with Hallermann-Streiff syndrome

An 18-year-old female with Hallermann-Streiff syndrome underwent the fixation of prolapsus recti. She had significant microgenia, mental retardation and pharyngeal airway stenosis. During induction of anesthesia with halothane and nitrous oxide, severe upper airway obstruction and respiratory depression occurred. The mask ventilation with jaw lift maneuver was impossible. Lowering anesthetic level restored her spontaneous breathing and airway patency. Although the direct laryngoscopic view under light anesthesia with halothane was limited to the epiglottic tip, blind orotracheal intubation using stylet was accomplish after several attempts. At the end of anesthesia, the tracheal tube was extubated after the patient had become fully awake and had recovered completely from neuromuscular blockade monitored by electromyography.     

Left ventricular volume reduction for end-stage heart failure: new horizon or false dawn?

The topography of the cricoid area (CA) of the subglottic larynx was studied in serial plastinated sections of 21 normal adult specimens. The cricoid area was seen to contain adipose tissue and blood vessels and was located between the internal perichondrium of the cricoid cartilage and a medial and lateral fiber layer of the conus elasticus. The lateral fiber layer was pierced by numerous blood vessels cranially and ventrally, providing connections of the CA with neighboring laryngeal areas and the anterior extralaryngeal region. Dorsocranially, the CA continued into the adipose tissue surrounding the cricoarytenoid joint and was adjacent to early ossifying regions of the cricoid lamina. Caudally, the CA was occasionally connected to the extralaryngeal area by projections of adipose tissue piercing the cricotracheal ligament. As shown previously, the relationship of the CA with adjacent anatomical regions facilitates certain growth patterns of subglottic cancer.     

High-pressure destruction kinetics of Listeria monocytogenes on pork

OBJECTIVE: To define the incidence of complications of endotracheal intubation and the factors associated with these complications. STUDY DESIGN: During a 22-month period, 227 intubated infants weighing <1,501 g were followed prospectively in a neonatal intensive care unit. Detailed records of events associated with airway management were kept after every intubation, in addition to clinical data. RESULTS: Eleven infants (4.8%) developed respiratory stridor after extubation which was treated with either systemic corticosteroids, racemic epinephrine and/or reintubation for respiratory failure. Four infants were submitted for bronchoscopy, mild subglottic stenosis with tracheal edema was found in 1 patient, granulation tissue and airway edema were noted in 3 infants. Traumatic intubation, prolonged ventilation, multiple intubations and bacterial colonization of the endotracheal tube were the factors associated with postextubation stridor. CONCLUSIONS: Subglottic stenosis is an infrequent complication of endotracheal intubation with current airway management of very-low-birth-weight infants. Less severe complications are still common, but they are usually amenable to clinical treatment. Bronchoscopy should be performed selectively only in infants with clinical evidence of airway obstruction after extubation.     

Nitinol alloy endotracheal stent used in treatment of tracheal stenosis: experimental and clinical applications

A new method used in treatment of tracheal stenosis by means of nitinol alloy intraluminal tracheal stent (Ni-Ti ITS) is introduced. Altogether 7 stents were implanted into tracheas of 7 mongrels each with a model of tracheal stenosis. The observation periods ranged from 2 to 6 months. The experimental results showed: The Ni-Ti ITSs could maintain long term patency without severe infection or obstruction by granulations or secretion. No displacement was found. There were no signs of either generalized or localized corrosion on the surface of stents. The shape memory character remained unchanged. On the basis of animal experimental study, the stents were successfully used in treatment of 2 patients with tracheal stenosis. One was caused by advanced tracheal tumor, the other was due to recurrent anastomotic stricture.     

A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis

This prospective, nonrandomized, observational study of 76 infants with pyloric stenosis was conducted at an academic children's hospital and compared awake versus paralyzed tracheal intubation in terms of successful first attempt rate, intubation time, heart rate (HR) and arterial hemoglobin oxygen saturation (SpO2) changes, and complications. Three groups were determined by intubation method: awake (A) with an oxygen-insufflating laryngoscope, after rapid-sequence induction (R), or after modified rapid-sequence induction (M) including ventilation through cricoid pressure. Successful first attempt intubation rate was 64% for Group A versus 87% for paralyzed Groups R and M (P = 0.028). Median intubation time was 63 s in Group A versus 34 s in Groups R and M (P = 0.004). Transient, mild decreases in mean HR and SpO2 and incidences of significant bradycardia and decreased SpO2 did not vary by group. Complications, including bronchial or esophageal intubation, emesis, and oropharyngeal trauma, were few. Senior anesthesiologists intervened in four tracheal intubations. We advocate anesthetized, paralyzed tracheal intubation because struggling with conscious infants takes longer, often requires multiple attempts, and prevents neither bradycardia nor decreased SpO2. After induction, additional mask ventilation with O2 confers no advantage over immediate tracheal intubation in preserving SpO2. Implications: In our children's hospital, awake tracheal intubation was not superior to anesthetized, paralyzed intubation in maintaining adequate oxygenation and heart rate or in reducing complications, and should be abandoned in favor of the latter technique for routine anesthetic management of otherwise healthy infants with pyloric stenosis.     

Experimental study of tracheal allotransplantation with cryopreserved grafts

OBJECTIVE: Tracheal reconstruction is necessary in patients with extensive tracheal stenosis caused by neoplasm, trauma, and congenital disease. We investigated the possibility of tracheal allotransplantation with cryopreserved grafts in a canine model. METHODS: A seven-ring section of thoracic trachea was removed in 19 adult mongrel dogs. In group A (n = 4), a five-ring tracheal autograft was implanted. In group B (n = 6), a five-ring allograft was implanted without immunosuppression. In group C (n = 9), a five-ring cryopreserved tracheal allograft was implanted without immunosuppression. Omentopexy wrapping around the grafts and both anastomotic sites was used in all animals. RESULTS: All grafts survived without any evidence of atrophy or stenosis in group A. All animals in group B died of severe airway obstruction within 1 month, and postmortem examination of these grafts showed epithelial defect and necrotic tracheal cartilage in the scar tissue. In group C, no animals died of asphyxia caused by severe stenosis of the grafts. The graft epithelium was no longer present 20 days after transplantation, and the graft was covered with regenerated epithelium within about 60 days after the operation. CONCLUSION: These findings show that cryopreserved tracheal allografts can be transplanted by means of omentopexy without immunosuppression and that cryopreservation may reduce tracheal allogenicity.     

Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study

BACKGROUND/AIMS: To clarify whether the pancreatic duct remains patent during long-term follow-up of patients after pancreaticogastrostomy. In a previous study of pancreaticogastrostomy with post-operative follow up for 3 years after surgery, we found that the orifice of the pancreatic duct was difficult to detect in some patients because of swelling of the gastric mucosa. Previous studies have not examined pancreatic duct patency during long-term follow-up. METHODOLOGY: Between July 1985 and August 1989, 20 patients underwent a pylorus-preserving pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy. Five of these patients were followed up post-operatively for more than 9 years to determine the patency of the pancreatic duct. All pancreatic anastomoses were performed by the telescopic method. RESULTS: All 5 patients were female, with a mean age of 65.4 years (range: 54-75). Median post-operative follow-up was 10.8 years (range: 9-12). The indications for surgery were carcinoma of the ampulla of Vater in 4 patients and chronic pancreatitis in 1 patient. Pancreatic duct patency was confirmed in 4 patients by gastroscopy and pancreatography. However, the anastomotic orifice could not be detected in the remaining patient because of complete coverage by the gastric mucosa. In this patient, pancreatic exocrine and endocrine function deteriorated with dilation of the distal pancreatic duct. The patient underwent a second operation involving dissociation of the pancreatico-gastric anastomosis and resection of about 1 cm of the fibrous, proximal portion of the pancreas. Reconstruction was performed with a Roux-en-Y pancreaticojejunostomy and a mucosa-to-mucosa anastomosis. CONCLUSIONS: Although pancreaticogastrostomy has been applied as a safe and straightforward method for reconstruction after pancreaticoduodenectomy, anastomotic stenosis is a potential late complication of this approach.     

Repair of inflammatory tracheoesophageal fistula

Benign acquired tracheoesophageal fistula is uncommon. Erosin of the membranous wall of the trachea and the anterior esophageal wall by the high-pressure cuff on a tracheostomy tube, often against the anvil of a nasogastric tube, may produce such fistulas. Techniques for closure have included patching the tracheal defect with muscle and, often, multiple staged procedures, planned or unplanned. Since any cuff lesion severe enough to cause a fistula necessarily damages the trachea circumferentially at the same level, definitive correction must include circumferential tracheal resection as well as closure of the fitstula. Five patients with tracheoesophageal fistula due to cuff perforation had repair by such a single-stage procedure. Through an anterior approach the involved trachea was resected, primary anastomosis was done, and the esophagus was closed in layers. In 3 of these 5 patients muscle was interposed for added security. One patient had undergone a prior attempt at repair elsewhere. One required a second resection of trachea for subsequent stomal stenosis. Repair in 2 additional patients with fistulas of complex origin related to direct trauma, sepsis, and foreign body involved adaptation of the basic technique to the special problem; 1 of these procedures was necessarily staged. Results in all 7 patients have been good.     

Clinical results after en block double lung transplantation with direct bronchial revascularization. The first three and a half years' experience in Denmark

En-bloc double lung transplantation with tracheal anastomosis and direct revascularization of the bronchial arteries to the left internal mammary artery has been carried out in Denmark since June 1992. Forty-seven patients (32 with alfa-1 antitrypsin deficiency, 11 with chronic obstructive pulmonary disease, two with cystic fibrosis and two with primary pulmonary hypertension), 25 men and 22 women, average age 39 years (17-64 years), have received their first double-lung transplant with bronchial artery revascularization. Arteriography of the internal mammary artery and bronchial arteries was performed in 42 (89%) of the patients from 1-150 days after the operation. Successful bronchial artery revascularization was demonstrated arteriographically in 40 patients, in two patients the arteriography failed to show bronchial artery revascularization. Arteriography was not performed in five patients due to early complications and death. Bronchoscopy showed rapid, uncomplicated airway healing in 42 patients. Mucosal necrosis under the tracheal anastomosis was found in three patients, and severe obstructive endobronchial growth of the fungus Aspergillus fumigatus was diagnosed in the last two patients. The one- and two-year survival is 83% (Kaplan-Meier). Eleven patients are dead, five due to pulmonary causes and six due to extra-pulmonary causes. Pulmonary function became normal in nearly all surviving patients between three to six months after the transplantation. In conclusion, en-bloc double-lung transplantation with bronchial artery vascularization has shown good short-term results, and the one- and two-year survival gives hope that a successful bronchial artery revascularization will improve the long-term survival following lung transplantation.     

Bypass to the perigeniculate collateral vessels. A useful technique for limb salvage: preliminary report on 22 patients

PURPOSE: We describe our initial experience with the use of perigeniculate vessels as outflow tracts in infrainguinal revascularizations for critical limb ischemia. METHODS: Twenty-two such reconstructions were carried out in 20 patients over a 2-year period. Indications for surgery consisted of tissue loss in 9 patients and rest pain in the other 13 patients. Inflow was obtained from the femoral vessels. A variety of graft materials were used, including saphenous vein (16 patients), polytetrafluoroethylene (2 patients), composite (1 patient), and arterial homografts (3 patients). The perigeniculate vessels used were the medial sural artery to the gastrocnemius (arteria suralis) in 16 patients and the highest genicular artery (arteria genu suprema) in the other 6 patients. These vessels were approached via a medial above-the-knee popliteal-type exposure. RESULTS: There were three postoperative deaths. Mean follow-up for the other 17 patients averaged 12 months (range, 3 to 37 months). Three grafts failed (thrombosis) during follow-up, leading to two above-the-knee amputations. One graft stenosis was treated with percutaneous angioplasty. The average postoperative increase in the ankle-brachial index was 0.20. CONCLUSION: These early results appear promising with a 1-year primary patency rate of 77%, assisted primary patency rate of 85%, and a limb-salvage rate of 90% according to the Kaplan-Meier life-table method. This technique is particularly useful when adequate length saphenous vein is not available, no other outflow vessels are available, or other outflow vessels are very calcified and not safely clamped. The continued study of the long-term effectiveness is warranted.     

Resection of the trachea infiltrated by thyroid carcinoma

Twenty-four thyroid carcinoma patients with infiltration of the trachea were treated surgically. The histological diagnosis in these cases included papillary adenocarcinoma in 22 different patients, medullary carcinoma in one patient, and undifferentiated carcinoma in one patient. In 19 of the patients hemoptysis was noted, and dyspnea was present in ten patients. In 14 of the 24 patients the carcinoma was diagnosed by radiographs of the neck, while in seven patients it was demonstrated bronchoscopically. In three patients tracheal infiltration by thyroid carcinoma was diagnosed by biopsy of the tracheal wall at operation. When the tracheal wall was infiltrated by thyroid carcinoma, treatment consisted of circumferential resection of the involved segment of the trachea followed by an end-to-end anastomosis. Of the 24 patients, 17 survived and six died. In the 17 patients who survived, 13 were disease free. Of this number, six survived more than five years after the initial tracheal resection.     

Secondary obstructive sleep apnea syndrome in a patient with tracheal stenosis and bilateral recurrent paresis. Successful treatment with nasal continuous positive airway pressure therapy

HISTORY AND ADMISSION FINDINGS: A 67-year-old woman complained of marked daytime sleepiness, as well as loud snoring and apnoeas during sleep. She was known to have had 3 thyroidectomies for goitre 41, 23 and 12 years ago, with known tracheal stenosis and recurrent nerve palsy for 11 years. Physical examination revealed marked stridor, hoarse voice and slightly enlarged and palpable recurrent right thyroid. INVESTIGATIONS: Polysomnography demonstrated a clearly elevated obstructive sleep apnoea activity (apnoea index: 34/h, apnoea-hypopnea index: 40/h, desaturation index: 31/h, minimal saturation: 63%). Selective tracheal imaging showed subglottic tracheal stenosis with an inspiratory luminal diameter of 4 mm and an expiratory luminal diameter of 8 mm. Lung function analysis revealed marked flattening of the flow-volume curve as sign of a functionally effective tracheal stenosis. These findings indicated a secondary obstructive sleep apnoea (OSA) due to tracheal stenosis and bilateral recurrent nerve palsy. The patient declined further studies, such as bronchoscopy. TREATMENT AND COURSE: As the patient did not want any surgical treatment, nasal continuous positive airway pressure therapy (CPAP) was instituted as a trial. No apnoea occurred at a pressure of 12 mm H2O and this was well tolerated. She has now continued CPAP at home for 12 months and her vigilance was markedly improved. CONCLUSIONS: Tracheal stenosis or recurrent nerve palsy is a rare cause of OSA which can be effectively treated by nasal CPAP.     

Combined tracheal resection and aortic valve replacement with a cryopreserved aortic valve allograft

A 69-year-old patient presented with an association of tracheal squamous cell carcinoma and severe aortic valve stenosis. As there was no evidence of metastatic spread a potentially curative resection could be considered. The patient underwent tracheal resection and aortic valve replacement in a one-stage procedure. In light of the potential risk of infection to a prosthetic valve, a cryopreserved aortic valve homograft was implanted. The patient made a full recovery and is doing well after 2 years of follow-up.     

Intergenerational gamete donation: ethical and societal implications

The incidence of hemodynamic and airway complications associated with tracheal reintubation after an unplanned extubation has not been established. Patients whose tracheas were emergently intubated outside the operating room were reviewed over a 27-mo period via a quality improvement vehicle to evaluate hemodynamic and airway complications. Data from a subset of patients (n = 57) who underwent tracheal reintubation after unplanned (self-) extubation were collected for analysis. Of the reintubations, 93% took place within 2 h of self-extubation. Of the patients, 72% had hemodynamic alterations and/or airway-related complications, including hypotension (35%), tachycardia (30%), hypertension (14%), multiple laryngoscopic attempts (22%), difficult laryngoscopy (16%), difficult intubations (14%), hypoxemia (14%), and esophageal intubation (14%). In addition, one surgical airway and one case of "cannot ventilate, cannot intubate" leading to cardiac arrest and death were recorded. These findings suggest that patients requiring reintubation will likely do so soon after self-extubation and that reintubation can be fraught with significant hemodynamic and airway complications. Less than one third of patients undergo a mishap-free reintubation. Strategies to decrease the self-extubation rate in the intensive care unit are needed to improve patient safety and to lessen the potential impact of emergency airway management. Implications: Self-extubation by patients requiring mechanical ventilation can be life-threatening, and replacing the breathing tube often leads to hemodynamic and airway complications. Using this quality improvement audit, 57 self-extubating patients and the complications associated with replacing the breathing tube, which are numerous and can lead to significant morbidity and mortality, were analyzed.     

Revision of previous Fontan connections to extracardiac or intraatrial conduit cavopulmonary anastomosis

BACKGROUND: In patients who have received an atriopulmonary Fontan connection, complications such as right pulmonary vein obstruction, atrial arrhythmias, and thromboembolism are often secondary to right atrial enlargement. When such complications develop despite good ventricular function, there are few management options available. Extracardiac or intraatrial conduit cavopulmonary anastomosis, which improves central systemic venous flow patterns, avoids atrial distention, and does not involve the extensive atrial suturing required by other forms of cavopulmonary anastomosis, may provide relief for this group of patients. METHODS: Between October 1992 and October 1995, 7 patients presented 8 to 20 years after atriopulmonary connection with severe right atrial dilatation (7), Fontan pathway obstruction (4), progressive congestive heart failure (4), atrial tachydysrhythmias (3), right atrial thrombus (1), obstruction of right pulmonary veins by an enlarged right atrium (1), and subaortic stenosis (1). After evaluation of the options, they underwent revision of the atriopulmonary connection to extracardiac (5) or intraatrial (2) conduit cavopulmonary anastomosis. RESULTS: One patient with severe cachexia, in whom transplantation was contraindicated for social reasons, died in the early postoperative period of massive effusions. Two patients eventually required permanent pacing for atrial dysrhythmias (1) or complete heart block secondary to subaortic fibromuscular resection (1), and 2 demonstrated marked improvement in unstable preoperative rhythm disturbances. At a median follow-up of 17 months, 4 of the 6 survivors were functioning at higher New York Heart Association levels than preoperatively, and 1 had recently undergone heart transplantation. CONCLUSIONS: In properly selected patients with atrial complications, revision of a prior Fontan connection to extracardiac or intraatrial conduit cavopulmonary anastomosis appears to be a viable option.