Original article: general thoracic
Elective extracorporeal support for complex tracheal reconstruction in neonates

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.
https://doi.org/10.1016/S0003-4975(03)00129-2Get rights and content

Abstract

Background

Congenital obstructive anomalies of the trachea present unique challenges in reconstruction and perioperative airway management. Complications include anastomotic breakdown, leak and granulation formation related to the complexity of the repair, and difficulties with perioperative airway management. We describe our technique of elective intraoperative and postoperative extracorporeal support to improve surgical exposure and postoperative healing.

Methods

We have performed complex tracheal reconstructions in 4 newborns (2.2 to 4.3 kg) for long segment tracheal stenosis and complete tracheal rings, diagnosed with bronchoscopy and computerized tomography. Three of the 4 infants had other significant anomalies including complex congenital heart disease, hydrocephalus, encephalomalacia, left lung agenesis, facial anomalies, vertebral anomalies, and hand and hip anomalies. The repairs were performed through a median sternotomy using an extracorporeal membrane oxygenation circuit for support. Venoarterial support was used for the sliding tracheoplasty reconstruction. Extracorporeal membrane oxygenation was converted to venovenous for postoperative “airway rest.” After diuresis, the lungs were reexpanded and the 4 patients were ventilated and removed from extracorporeal membrane oxygenation at 4, 5, 8, and 9 days postoperatively. Bronchoscopy was performed to evaluate the airway.

Results

All patients had excellent healing of the trachea without granulation tissue. There were no complications of extracorporeal membrane oxygenation support or bleeding issues. All 4 patients survived the surgery and immediate postoperative period with 2 late deaths. The child with congenital heart disease expired after 8 weeks after having hepatorenal failure develop. The child with Goldenhar’s syndrome and a single left lung died after 5 months in the hospital. The other 2 patients survived. Two of the infants required late tracheostomy for facial and laryngeal anomalies.

Conclusions

Extracorporeal membrane oxygenation provides an excellent environment for complex tracheal reconstruction and promotes postoperative healing by minimizing trauma to the reconstructed airway.

Section snippets

Patient population

Four neonates presented to our institution with severe respiratory distress requiring early intubation. All 4 infants were maintained on mechanical ventilation and required heavy sedation or paralysis, or both. Early rigid bronchoscopy was performed documenting the presence of long segment tracheal stenosis with varying amounts of complete rings and funnel type stenosis measuring no greater than 2 mm. Because of the tenuous airways, all the children were kept sedated to maintain endotracheal

Results

All 4 neonates survived the surgery without intraoperative complication and were removed from ECMO on postoperative days 4, 5, 8, and 9 (Table 2). There were no bleeding complications or tamponade despite sternal closure with ongoing heparinization. There were no neck infections, subcutaneous or mediastinal air, suture line leaks, or breakdown. The only complication possibly attributable to the intraoperative venoarterial ECMO run was transient acute tubular necrosis in the infant with a single

Comment

Numerous serious complications have been reported after complex tracheal reconstruction including tracheal leak or breakdown, infection and deep neck abscesses, airway obstruction and bleeding from granulation tissue, and restenosis 4, 5, 12, 13, 14. Extended paralysis and mechanical ventilation 2, 3 prevent trauma from motion, but they do not avoid positive pressure ventilation and manipulation of the airway to maintain pulmonary toilet and adequate gas exchange. Intraoperative extracorporeal

References (17)

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