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Surgical relief of tracheobronchial obstruction in infants and children
J F McCarthy1, J P Hurley, M C Neligan
1National Cardiac Surgical Unit, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland.
Insights
Congenital tracheobronchial obstruction (TBO) in children can be effectively managed with single-stage surgery. Concurrent repair of airway and cardiac defects is recommended, with cardiopulmonary bypass facilitating complex procedures.
Area of Science:
- Pediatric surgery
- Thoracic surgery
- Congenital anomalies
Background:
- Congenital tracheobronchial obstruction (TBO) presents diverse etiologies and associated anomalies, complicating surgical management.
- Early diagnosis and intervention are crucial for improving outcomes in infants and children with TBO.
Purpose of the Study:
- To review a single center's experience in managing congenital tracheobronchial obstruction (TBO) in pediatric patients.
- To evaluate the effectiveness of surgical strategies and identify predictors of mortality.
Main Methods:
- Retrospective review of 24 infants and children with TBO over a 12-year period.
- Analysis of etiologies including vascular rings, anomalous innominate artery, tracheal stenosis, and bronchial stenosis.
- Surgical interventions included ring division, aortopexy, tracheal resection, and concurrent cardiac defect repair.
Main Results:
- Hospital mortality was 8.7%, with associated cardiac anomalies being the primary predictor of mortality.
- Nineteen patients were alive and symptom-free at a mean follow-up of 40 months.
- No anastomotic strictures were observed after tracheobronchial resection.
Conclusions:
- Congenital tracheobronchial obstruction (TBO) can be effectively managed with single-stage operations without compromising tracheal growth.
- Concurrent repair of tracheobronchial and cardiac lesions is advocated.
- Cardiopulmonary bypass facilitates simultaneous correction of cardiac defects and tracheal resection.
Objective:
Congenital tracheobronchial obstruction (TBO) presents a complex problem both in terms of diverse aetiology, presence of associated anomalies and the operative strategy to be adopted. We report a single centre experience in managing this difficult problem.
Methods:
Twenty-four infants and children with TBO referred to our unit over a 12-year period are reviewed. Aetiology of TBO included vascular rings (n = 9), anomalous innominate artery (n = 6), congenital tracheal stenosis (n = 5), segmental bronchial stenosis (n = 2) and pulmonary artery compression of the main bronchi (n = 2). Seven patients had concurrent cardiac anomalies. Stridor was the commonest presenting symptom (67%). Mean delay from onset of symptoms to referral was 19 months. One patient died preoperatively due to acute airway obstruction. Mean age at operation was 33.1 +/- 42 months (range 4 days-156 months) and 11 children were under 1 year at the time of surgery. In cases of TBO secondary to vascular rings, division of the ring resulted in relief of symptoms in seven cases, with two requiring further surgery for resultant tracheomalacia. Four of the five patients having tracheal resection were operated on with the use of cardiopulmonary bypass; three of these patients had concurrent correction of cardiac lesions, with two survivors. Tracheobronchial anastomoses were carried out using continuous polydioxanone (PDS). Patients with anomalous innominate arteries required aortopexy in five and innominate artery suspension in one, while those with pulmonary artery compression of the main bronchi had correction of their intracardiac defects (n = 2).
Results:
Hospital mortality was 8.7% and there has been one late death due to Eisenmenger syndrome secondary to pulmonary regurgitation, atrial septal defect (ASD) and patent ductus arteriosus (PDA). On follow-up (mean 40 +/- 31 months), 19 patients are alive and symptom free. There have been no anastomotic strictures following tracheobronchial resection. The single most important predictor of mortality was the presence of associated cardiac anomalies.
Conclusions:
TBO can be managed effectively by a single operation in both infants and children without a detrimental effect on tracheal growth. We advocate consideration of concurrent repair of the tracheal and cardiac lesions. Cardiopulmonary bypass (CPB) allows this concurrent correction of cardiac lesions and also facilitates tracheal resection.