Innovative management of severe tracheobronchomalacia using anterior and posterior tracheobronchopexy

Abstract

Objectives/Hypothesis Combined anterior and posterior tracheobronchopexy is a novel surgical approach for the management of severe tracheobronchomalacia (TBM). We present our institutional experience with this procedure. Our objective was to determine the utility and safety of anterior and posterior tracheopexy in the treatment of severe TBM. Study Design Retrospective chart review. Methods All patients who underwent anterior and posterior tracheopexy from January 2013 to July 2017 were retrospectively reviewed. Charts were reviewed for indications, preoperative work‐up, tracheobronchomalacia classification and severity, procedure, associated syndromes, synchronous upper aerodigestive tract lesions, and aberrant thoracic vessels. Main outcomes measured included improvement in respiratory symptoms, successful extubation and/or decannulation, vocal fold immobility, and new tracheotomy placement. Results Twenty‐five patients underwent anterior and posterior tracheopexy at a mean age of 15.8 months (range, 2–209 months; mean, 31 months if 2 outliers of 206 and 209 months included). Mean length of follow‐up was 26.8 months (range, 13–52 months). Indications for surgery included apneic events, ventilator dependence, need for positive pressure ventilation, tracheotomy dependence secondary to TBM, recurrent pneumonia, and exercise intolerance. Many patients had other underlying syndromes and synchronous upper aerodigestive tract lesions (8 VACTERL, 2 CHARGE, 1 trisomy 21, 1 Feingold syndrome, 17 esophageal atresia/tracheoesophageal fistula, 20 cardiac/great vessel anomalies, 1 subglottic stenosis, 1 laryngomalacia, 7 laryngeal cleft). At preoperative bronchoscopy, 21 of 25 patients had >90% collapse of at least one segment of their trachea, and the remaining four had 70% to 90% collapse. Following anterior and posterior tracheopexy, one patient developed new bilateral vocal‐fold immobility; one patient with a preoperative left cord paralysis had a new right vocal‐fold immobility. Postoperatively, most patients had significant improvement in their respiratory symptoms (21 of 25, 84%) at most recent follow‐up. Three patients with preexisting tracheotomy were decannulated; two patients still had a tracheotomy at last follow‐up. Two patients required new tracheotomy for bilateral vocal‐fold immobility. Conclusions Combined anterior and posterior tracheopexy is a promising new technique for the surgical management of severe TBM. Further experience and longer follow‐up are needed to validate this contemporary approach and to minimize the risk of recurrent laryngeal nerve injury. Level of Evidence 4 Laryngoscope, 130:E65–E74, 2020

Early Infant Symptomatic Patients With Tetralogy of Fallot With Absent Pulmonary Valve: Pulmonary Artery Management and Airway Stabilization

“…Posterior tracheopexy is performed by directly suturing the posterior trachea to the anterior spinal ligament, and anterior tracheopexy is performed by directly suspending the anterior trachea to the sternum. [8][9][10] Tracheal resection, slide tracheoplasty, or external splints is occasionally necessary and beneficial, particularly in patients with the congenital absence of cartilage or severe cartilage deformation. After sternal closure, completion…”

“…Based on our multidisciplinary team experience and treating premature infants and those with esophageal atresia with severe TBM, we have developed procedures to directly address this airway disease. [8][9][10]23,24 Tracheobronchomalacia is a disease state characterized by collapse or compression of the trachea and mainstem bronchi on exhalation. Tracheal or bronchial collapse can result from intrinsic weakness of the airway or from extrinsic compression, [25][26][27] and commonly occurs in TOF-APV patients.…”

“…Our current approach includes a preoperative extensive airway evaluation with a computed tomography scan to identify any external compressing factors and a dynamic bronchoscopy to understand the functional status of the airway. When there are areas of significant TBM, they are surgically addressed with posterior or anterior tracheopexy or bronchopexy 10 or external splints. 25 That has become a very important aspect in the early management of these patients.…”

Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review

“…RLN injury during surgery for esophageal atresia (EA), tracheoesophageal fistula (TEF), and tracheobronchomalacia (TBM) is established in the literature as the RLN often courses through the operative field (Figure 1). The incidence ranges from 11 to 50% and varies by approach, the patient's anatomy, and concurrent cardiac procedures (8)(9)(10)(11)(12)(13). Identifying and protecting the RLN is particularly difficult in the surgery of neonates and in revision cases (13).…”

“…The incidence ranges from 11 to 50% and varies by approach, the patient's anatomy, and concurrent cardiac procedures (8)(9)(10)(11)(12)(13). Identifying and protecting the RLN is particularly difficult in the surgery of neonates and in revision cases (13). Similarly, there are a number of associations of RLN injury with heart disease and cardiac surgery.…”