Eur J Cardiothorac Surg 2002;21:140-142
© 2002 Elsevier Science NL
Modified slide tracheoplasty for the management of tracheobroncopathia osteochondroplastica
Cemal Asim Kutlua*,
Ali Yeginsua,
Tevrat Ozalpa,
Reha Baranb
a Department of Surgery, Yedikule Chest Surgery Centre, Istanbul, Turkey
b Department of Chest Medicine, Sureyyapasa Chest Disease Hospital, Istanbul, Turkey
Received 13 June 2001;
received in revised form 25 October 2001;
accepted 31 October 2001.
* Corresponding author. Nispetiye Cad., Saydam Sok., 20/1, Levent 80600, Istanbul, Turkey. Tel.: +90-212-269-2369; fax: +90-212-547-2233
e-mail: cakutlu{at}turk.net
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Abstract
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In this paper we report a case with tracheobroncopathia osteochondroplastica presented with a long segmental tracheal stenosis. Modified slide tracheoplasty was undertaken for the management of the stenosis. In our modification, the oblique tracheal cut was performed from left to right to widen the latero-lateral dimension of tracheal lumen. We assume that preservation of the lateral longitudinal vessels of the trachea results in better healing at the suture line. Postoperative course was uneventful and the patient remains on clinical follow-up for 15 months without any problem.
Key Words: Tracheal stenosis • Slide tracheoplasty
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1. Introduction
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Slide tracheoplasty (ST) is defined by Goldstraw for the management of congenital funnel-shaped tracheal stenosis in 1989 [1]. The satisfactory early results of the technique are reported in literature and the late result of the first case proves that the ST is a good option in the long term [2,3]. In this paper, we report a case who underwent modified ST for the management of acquired long segmental tracheal stenosis.
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2. Case report
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A 46-year-old male was referred to our unit with progressive dyspnoea over the last 2 years. He was diagnosed tracheobroncopathia osteochondroplastica (TO) at the age of 41. His past medical history was otherwise unremarkable. On admission, his excersize tolerance was extremely limited despite oral methilprednisolone (40 mg/day). Physical examination was entirely normal apart from moderate stridor on forced expirium. Spirometry showed upper airway obstruction on flow-volume curve with FEV1:1.46 ml (43% of predicted), FVC:3.06 ml (81%) and FEV1/FVC:47 (79%). Thorax CT and 3-D CT of the trachea showed the long segmental stenosis involving the subglottic area and proximal half of the trachea. Tracheal wall was extremely thickened and calcified (Fig. 1). The external diameter of the trachea was 1.2 cm at the narrowest point (A–B) and widened along the trachea.
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Fig. 1. 3-D CT of the trachea shows the stenotic segment. The external diameter of the stenotic segment was 1.2 cm (A–B); 1.7 cm (C–D); and 2.1 cm (E–F) along the trachea.
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It was not possible to quit cortisone preoperatively due to dispneic attacks but reduced to 10 mg/day. We performed rigid bronchoscopy under general anasthesia using the pediatric scope preoperatively. The stenotic segment was 6 cm in length (50% of the total tracheal length) starting from the subglottic area. The lumen was 0.7 cm at the narrowest point which was 3.5 cm distal to the vocal cords. The diameter of distal trachea, carina and main bronchi were relatively normal.
On operation, the trachea was exposed via median sternotomy with a skin incision extended up to the lower edge of the thyroid cartilage. The thyroid gland and strap muscles were reflected from the midline to expose the upper airway. The trachea was circumferentially mobilized at the narrowest part of the stenosis where oblique incision from left to right was undertaken (Fig. 2a). On sagittal section, the length of the incision was 1 cm. Ventilation was obtained through a sterile cross-field tube inserted into the distal segment. The left recurrent laryngeal nerve was identified and a 2.5 cm longitudinal incision extending upward to the thyroid cartilage was undertaken at the left side of the proximal segment (Fig. 2b). The second longitudinal incision at same length was undertaken at the right side of the distal segment. The orifice of the segments was trimmed and slid one over the other. Tracheal cuts were performed using a bone cutter due to extremely thick and calcified trachea. The anastomosis was performed starting from the tip of the distal segment sutured to the lower part of the thyroid cartilage to widen the subglottic stenosis. The posterior part of the anastomosis was accomplished using continuous suture technique with 2/0 Polipropylen (Ethicon Inc., Somerville, NJ). It seemed unsafe to use monofilament suture material for the thick and calcified tracheal wall. Thus, we prefered interrupted suture technique using 2/0 Polyglactin 910 (Ethicon Inc., Somerville, NJ) for the cartilaginous part (Fig. 2c). The suture line was immersed in saline to check air leak after completion of the anastomosis. Sternotomy was closed in usual manner with a mediastinal tube. His chin was fixed to the anterior chest wall with two sutures.
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Fig. 2. (a) The oblique incision from left to right was undertaken at the narrowest part of the stenosis. (b) Longitudinal incisions were undertaken at the left side of the proximal segment and the right side of the distal segment. The orifice of the segments was trimmed. (c) The anastomosis was performed starting from the tip of the distal segment.
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He was extubated on the same day of the surgery. Histological examination of the trimmed tracheal tissue revealed normocelluler bone marrow metaplasia and osteoid metaplasic changes. On postoperative day 15, check bronchoscopy was performed. The lumen was widened through the entire stenosis and the suture line seemed well healed without granulation formation. He remains on clinical follow-up for 15 months without any problem.
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3. Discussion
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Experience with the surgical management of acquired long segmental stenosis, which is a rare condition, is limited in the literature. Most of the acquired tracheal stenosis affected a short segment of the trachea, which can deal with a segmental resection with a low mortality and morbidity rates [4].
There are number of techniques in literature to deal with the long segmental tracheal stenosis in children. ST is undertaken in the limited number of cases with favorable results [3,5]. Rigid tracheal wall with respiratory epithelium provides not only stable and patent airway also minimize postoperative morbidity [3]. ST is not an option for the cases whose stenotic lesion has to be removed or stenosis results from tracheomalacia regardless of the etilogy.
The reports in literature show that there is a twofold increase in number of capillary vessels in the newborn trachea comparing with adult counterparts [6]. This observation may explain the low rate of ischemic complications following ST in spite of extensive mobilization of the trachea. In the original technique, the oblique tracheal cut is performed antero-posteriorly and the postero-anterior diameter of the trachea is widened. Grillo slightly modified the original technique by dividing the trachea postero-anteriorly and protected the blood supply of the distal stenotic segment.
In our modification, incising the trachea from left to right widen the latero-lateral dimension of tracheal lumen. This modification allows us to preserve the lateral longitudinal anastomosis of the tracheal vessels that nourish the suture line through the transverse intercartilaginous arteries. Furthermore, tracheal segments are prepared for the anastomosis with minimal circumferential mobilization comparing with the original technique and Grillo's modification.
We conclude that modified ST may be a safe option for the management of benign long segmental tracheal stenosis in adult cases of which resection and primary anastomosis of the trachea is not possible.
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References
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Tsang V., Murday A., Gilbe C., Goldsraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis. Ann Thorac Surg 1989;48:632-635.[Abstract]
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Grillo H. Slide tracheoplasty for long-segment congenital tracheal stenosis. Ann Thorac Surg 1994;58:613-621.[Abstract]
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Kutlu C.A., Goldstraw P. Slide tracheoplasty for congenital funnel-shaped tracheal stenosis (a 9 year follow-up of the first case). Eur J Cardiothoracic Surg 1999;16:98-99.
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Grillo H., Mathisen D.J. Surgical management of tracheal strictures. Surg Clinic North Am 1988;68:511-524.
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Lang F.J.W., Hurni M., Monnier P. Long-segment tracheal stenosis: treatment by slide-tracheoplasty. J Pediat Surg 1999;34:1216-1222.[Medline]
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Abstract
1. Introduction
