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Eur J Cardiothorac Surg 2006;30:201-202
© 2006 Elsevier Science NL

Letter to the Editor

Geometry of the edges of the tracheal anastomosis: is it an important issue?

Division of Thoracic Surgery, Department of Surgery, University Medical School of Pecs, Hungary

Received 1 March 2006; accepted 20 March 2006.

^_* Corresponding author. Address: University Medical School of Pecs, Clinic of Surgery, Department of Thoracic Surgery, H-7632 Pecs, Ifjusag u. 13, Hungary. Tel.: +36 72 536 126; fax: +36 72 536 496. (Email: mft{at}iseb.pote.hu).

Key Words: Tracheal reconstruction

We congratulate Azorin and associates [1] on their report on successful clinical application of previous tracheal prosthesis research [2]. However, the technicalities of the anastomosis and the geometric relation of the graft edges to the host trachea did not get the attention they deserve. Working on similar problems we had some peculiar observations [3] difficult to explain. The way to a successful tracheal reconstruction is a narrow course between the Scylla of infection and Charybdis with overgrowth of granulation tissue. In four groups with five dogs in each 6 cm segments of trachea were resected and replaced with ringed vascular prosthesis. In Group I end-to-end anastomoses were sewn. In Group II telescopic anastomosis was applied in external position of the perforated prosthesis to facilitate neoepithelisation. In Group III the externally telescoped prosthesis had a solid wall. In Group IV the prosthesis was telescoped internally. Absolute survivals were measured to evaluate the viability of the best method. There were no survivors over 3 weeks in Group I. An average survival of 40.6 days was achieved in Group II. The average survival was 68.4 days (49–80) when externally telescoped but not perforated grafts were applied (Group III). Three hundred and sixty-day average survival was observed in Group IV, when endoluminally telescoped prosthesis was applied. Complete neoepithelisation was revealed without ciliary function in this latter group where the absolute survivals were 127, 135, 190 and 257 days. The fifth dog in this group was living for 971 days. The influence of geometric relation of the host trachea to the neotrachea on survival seemed to be disproportional. The experiments were repeated on rabbits too. The length of survival differed from 13 to 89 days (mean 48 days), with significantly longest survivals in Group IV (mean 77.8 days). Granulation tissue formation caused narrowing of the lumen in a different degree in 18/20 cases. Three mild narrowings were observed in Group IV. The most severe cases developed in Group I with external telescopic anastomosis. In Groups II and III progressive granulation tissue formation was observed at the anastomotic sites. Telescopic anastomosis geometry influences the tendency for granulation tissue overgrowth. Our findings related to a rarely investigated detail contradict to the expectations as endoluminal position of the edges of the neotrachea proved to be a key factor in better outcome. Out of Belsey's original criteria [4] creation and maintenance of the patency of the (neo)windpipe have priority over continuous internal lining of respiratory mucosa. There is another indirect promising feature of the French team's work. They previously reported development of cartilaginous tissue in the neotrachea [2] a strange phenomenon, observed and documented by us in dogs, too. This is another observation we can build on in the future clinical application.

Congratulating the French team on their result and sharing their enthusiasm about the technique we only wanted to contribute with our similar experiences gained in a different setting.

References

1. Azorin JF, Bertin F, Martinod E, Laskar M. Tracheal replacement with an aortic autograft. Eur J Cardiothor Surg 2006;29:261-263.[Abstract/Free Full Text]
2. Martinod E, Seguin A, Pfeuty K, Fornes P, Kambouchner M, Azorin JF. Carpentier AF long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572-1578.[Abstract/Free Full Text]
3. Molnar TF, Szanto Z, Rth E, Horvath OP. Experimental trachea replacement. The Pecs experience. Proceedings of the eighth European Conference on General Thoracic Surgery, Final Programme and Abstracts, O3.1. 2000. pp. 152.
4. Belsey R. Resection and reconstruction of the intrathoracic trachea. Br J Surgery 1950;38:200-205.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas F. Molnar Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Szanto, Z. Articles by Molnar, T. F. Search for Related Content PubMed PubMed Citation Articles by Szanto, Z. Articles by Molnar, T. F. Related Collections Trachea and bronchi