Surgical relief of tracheobronchial obstruction in infants and children

Abstract

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.