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Tracheal stenosis in infants and children is typically characterized by the presence of complete cartilaginous tracheal rings and often involves significant lengths of the trachea. Although it may become symptomatic across a variety of ages, the most common presentation is in the first months of life. In infancy, the initial management of such patients can be very challenging due to the unstable nature of the stenotic airway with the need for paralysis to facilitate mechanical ventilatory support.
In our recent experience, quite a number of patients escaped recognition until they either were found to have difficulty with intubation for a nonairway operation or failed to wean from ventilatory support following another operation. That these children are often quite complex, with a number of associated anomalies, predominantly cardiovascular, is also emphasized in our experience.
Outcomes of surgical reconstruction of the stenotic trachea have been promising in recently reported series utilizing a number of techniques, yet this population still experiences significant postoperative morbidity and mortality, related not only to the reconstruction of the trachea, but also due to associated anomalies, the majority of which are cardiovascular. Since 2001, our program at Cincinnati Children’s Hospital has employed the technique of slide tracheoplasty, utilizing cardiopulmonary bypass support with simultaneous treatment of associated cardiac defects following disappointing experience with other surgical techniques.
Preoperative evaluation always includes bronchoscopy to document the degree and length of the tracheal stenosis. Echocardiograms are performed to assess for associated cardiac anomalies. Contrast chest computed tomography with 3D reconstruction is often performed to assist with documentation of vascular anomalies and to add information about the length of the tracheal stenosis, although this study has never substituted for careful, yet thorough, endoscopic airway examination.
In the intensive care unit, the child is kept sedated and ventilated with the lowest peak pressures that deliver adequate tidal volumes. The head is positioned on a pillow to encourage neck flexion, but no other maneuvers are employed to avoid tension on the trachea. 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. In our recent experience with 40 patients undergoing slide tracheoplasty at a median age of 6.2 months, over 50% of patients could be extubated within 48 hours of their reconstruction.
Analysis revealed only the need for preoperative mechanical ventilation and longer CPB duration were predictive of the need for prolonged postoperative ventilatory support. Follow-up bronchoscopy is performed weekly before discharge, which is commonly about 2 weeks following repair.
The appeal of the slide tracheoplasty technique lies mainly in its versatility: we have successfully employed it in both short-segment and full-length 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. 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 over half of the patients in our recent experience testifies to the quality of the slide tracheoplasty in management of congenital tracheal stenosis.