Summary
Slide tracheoplasty is a surgical technique originally designed by Goldstraw in the 1980s to repair congenital tracheal stenosis caused by complete tracheal rings. It is a versatile operation with expanding indications in the setting of congenital tracheal stenosis, tracheoesophageal fistulas, or acquired tracheal injury. It consists of overlapping stenotic segments of the trachea, shortening it but doubling the diameter of the narrowed area, and can be performed through a sternotomy or through the neck. Slide tracheoplasty is a safe and reliable technique, with a high success rate. Its morbidity and mortality are related to the underlying health status of the child.
53 Slide Tracheoplasty
53.1 Introduction
Slide tracheoplasty was originally described by Tsang et al 1 and popularized by both Grillo et al 2 and by our team at Cincinnati Children’s Hospital. 3 This operation overlaps stenotic segments of the trachea, shortening it but doubling its diameter (▶ Fig. 53.1). Slide tracheoplasty is currently the operation of choice for tracheal stenosis attributed to complete tracheal rings (CTRs), but its indications has been broadening and recent publications show that it can be used for the treatment of acquired tracheal stenosis, absent tracheal rings, sleeve trachea, and tracheoesophageal fistulas (TEFs). 4
This technique has a number of advantages relative to other methods. These advantages include immediate tracheal reconstruction with rigid, vascularized tissue with a normal mucosa; ability to extubate patients early in many cases; less postoperative granulation tissue formation; less risk of dehiscence; and growth potential of the reconstructed trachea. 2 In addition, it is a versatile technique: one can perform a short-segment slide, an oblique slide, or even an inverse slide if circumstances dictate. The slide can also extend into the membranous trachea or into the carina if required. The whole length of the trachea may be slid, even past the carina.
At Cincinnati Children’s, we have been performing slide tracheoplasty under cardiopulmonary bypass since 2001, mainly for patients with distal tracheal stenosis and those who require concomitant cardiovascular repair. Cervical slide tracheoplasty has also been performed since 2003. This procedure is an adaptation of the standard slide procedure and can be used for cervical tracheal stenosis, tracheal “A frame” deformities, and multilevel laryngotracheal stenosis.
Our experience has demonstrated that the slide tracheoplasty can be performed with very low mortality despite the complexity of the patient population. In our 2011 cohort study with 80 patients who underwent slide tracheoplasty on bypass, 48 patients (60%) had associated cardiac or great vessels anomalies, and only 5 (6.2%) required a revisional open surgery. Twenty-three percent of our population required endoscopic airway re-intervention within 12 months of the initial procedure, which involved balloon dilation, endoscopic resection of granulation tissue, or temporary stent placement. Four deaths (5%) were reported. 5 This mortality rate was much lower than the previously reported mortality rate of up to 24% in some series. 6 , 7 More recently, we published our series with 130 patients, which included 76 (58%) patients with associated cardiac or vascular anomaly and 18 (13.8%) with pulmonary malformations. The stenosis rate was again very low (6.9%), with a mortality rate of 6.1%. 8
A series of 101 children who underwent a slide procedure at Great Ormond Street Hospital was published in 2014. Seventy-two of their patients (71.3%) had associated cardiovascular anomalies. Thirty-three children (33%) had residual stenosis at 3 months, and 8 (8%) had residual stenosis at 9 months after the surgery. Stenting was required in 21.8%, mainly in patients with preoperative bronchomalacia. The mortality rate was 11.8%, and bronchomalacia and the need of preoperative extracorporeal membrane oxygenation (ECMO) were associated with this outcome. 9
In our cohort published in 2012 about cervical slide tracheoplasties, we described 29 patients who underwent this procedure. Operation-specific success rate was 79% (23 of 29 patients), including all 10 patients with long-segment acquired tracheal stenosis. Lower operative success occurred in patients with concomitant subglottic stenosis, posterior glottic stenosis, and multilevel airway lesions. Four patients (14%) experienced complications: one patient had a minor wound infection; one had a dehiscence that was managed with a revision tracheoplasty; one had an innominate artery injury that was successfully treated intraoperatively without sequelae; and one had a symptomatic “figure 8” deformity that required revision therapy. 10
53.2 Preoperative Evaluation and Anesthesia
Optimal management of children with tracheal stenosis requires comprehensive evaluation prior to repair. The temptation is to proceed straight to definitive repair should the child deteriorate. However, if the airway permits intubation with a 2.0 endotracheal tube or bigger, this should be performed via nasotracheal route in order to temporarily stabilize the child. When this approach is not possible, an endotracheal tube sized to accommodate the cricoid cartilage, but placed shallow and proximal to the complete rings, can still permit positive pressure ventilation. It is rare that the first two tracheal rings are affected in children with CTR, and therefore most children can be intubated proximal to the complete rings. If ventilation remains difficult, ECMO is advisable but should not be taken lightly. Clearly, tracheotomy is rarely helpful as the smallest CTRs tend to be more distal, and the smallest available commercial tracheotomy tube is 3.6 mm in outer diameter. In an airway compromised enough to consider tracheotomy, the stenotic segment is typically 2.0 to 2.5 mm in diameter, and therefore not amenable to tracheotomy placement. More importantly, tracheotomy may further compromise the options of subsequent operative repair.
Preoperative bronchoscopy is universally relied on for the diagnosis and definition of airway anatomy. Both flexible and rigid instrumentation can be used to determine the type of lesion, localization, extension, and severity. However, this evaluation must be the most careful as possible, not to cause edema of the airway and to turn a stable airway into an emergency.
Contrast chest computed tomography scans with three-dimensional reconstruction and echocardiography should be performed in all cases to aid in defining airway and great vessels anatomy and also to define cardiac malformations.
All patients with a tracheotomy (typically older children with acquired cervical tracheal stenosis) should undergo methicillin-resistant Staphylococcus aureus (MRSA) screening and treatment before the surgery. MRSA infection in open airway procedures can be a devastating complication, resulting in dehiscence, and weakening of the cartilaginous structure of the laryngotracheal complex.
Regarding the anesthetic technique, although current methods, including jet ventilation, may allow for repair of distal and long-segment tracheal stenosis, these can often be obtrusive and cumbersome for the surgeon. Cardiopulmonary bypass is a safe alternative that allows partial deflation of the heart and lungs so that exposure of the complete trachea is optimized. Conversion of ECMO to cardiopulmonary bypass is also recommended for the procedure for this same reason. Successful surgical management thus depends upon close collaboration of the airway surgeon and the cardiovascular surgeon. For the cervical slide tracheoplasty, endotracheal intubation should be used.
53.3 Surgical Techniques
53.3.1 Intrathoracic Slide Tracheoplasty
▶ Fig. 53.2 illustrates the surgery technique. Typically, a sternotomy allows for exposure of the trachea, placement of atrial and aortic cannulas (if cardiopulmonary bypass is required) (▶ Fig. 53.3a), and repair of any coexisting cardiovascular anomalies. The trachea is exposed by dissecting between the ascending aorta and the superior vena cava. In the process, removal of the right paratracheal lymph nodes facilitates tracheal exposure. The carina is identified deep to the right pulmonary artery and the anterior trachea is exposed from the carina to the upper aspect of the CTRs.
Intraoperative bronchoscopy is then performed to define the upper and lower limits of the CTR segment. A 30-gauge needle is placed through the anterior tracheal wall as it is visualized by a 2.8-mm flexible bronchoscope to define the proximal and distal CTRs. At this point, with the patient stabilized on cardiopulmonary bypass, a more comprehensive evaluation of the distal airway can also be performed if desired.
The length of the stenosis is then measured and the trachea is transected at the midpoint of the segment of complete rings (▶ Fig. 53.3b). Each end of the transected trachea is then mobilized. The lateral vascular attachments to the trachea are preserved in this process. The anterior wall of the proximal tracheal segment is incised vertically (▶ Fig. 53.3c). The posterior wall of the distal segment is cut vertically toward the carina. Cartilage is then trimmed from the corners of the proximal and distal segments, and the segments then slid over each other. Depending upon the length of the stenotic segment, this requires additional tracheal mobilization from both superior and inferior attachments. The carina is displaced superiorly by temporary stay sutures.
The anastomosis is commenced from distal posterior (carinal) in a running fashion using appropriate-sized double-armed polydioxanone sutures (5.0 or 6–0 PDS in infants) (▶ Fig. 53.3d). Four to six throws of the suture are generally placed at the carina and tightened with a nerve hook. The anastomosis is then continued up the left and right sides of the trachea, with the sutures placed through cartilage and mucosa, therefore being exposed intraluminally. An effort is made to evert the lateral sides of the anastomosis to prevent internal bunching of the anastomotic lines (a “figure 8” trachea). Before the anastomotic suture lines rejoin in the midline at the proximal anterior aspect of the repair, the trachea is suctioned clear and the patient is intubated with an age-appropriate endotracheal tube, and the tip of the tube positioned under direct visualization. The anastomosis is completed (▶ Fig. 53.3e) with a single proximal knot being thrown, leak tested (to 35-cm water pressure), and marked with Ligaclips applied to the proximal and distal ends of the anastomosis (to help identify the extent of the anastomosis on postoperative radiographs). Fibrin glue is then applied to the anastomosis. The patient is then removed from bypass, the chest closed, and the patient is transferred to the intensive care unit. At completion of the procedure, the airway is re-evaluated with a flexible bronchoscope to ensure that the repair is adequate and that blood and secretions are suctioned.
Even with near full-length tracheal reconstruction, it is unusual to need a suprahyoid release or chin-to-chest sutures. Extension of the slide into a bronchus or cricoid cartilage has been performed successfully at our institution and may assist with repairing these concomitant stenoses. In children with an associated pig bronchus, a modified slide can also be performed, with the rings being split slightly oblique to the midline, so as not to compromise the orifice to the bronchus. The proximal extent of the slide should extend at least 2 rings into normal trachea beyond the pig bronchus.
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