Biodegradable tracheal stents: our ten-year experience with adult patients.

BACKGROUND: Biodegradable (BD) stents made from polydioxanone have been used only in human airways. These stents combine the advantages of classical tracheal stents, and fewer side effects are expected due to their biocompatibility and their time-limited presence in airways. However, new clinical consequences have arisen. Here, the authors share their experiences with BD stents for tracheal indications, focusing on their safety and efficacy. METHODS: This was a retrospective review of a collected database of adult patients who underwent implantation of biodegradable tracheal stents between September 2013 and December 2022 at the Department of Respiratory Medicine of the 1st Faculty of Medicine in Prague and Thomayer University Hospital. The indications included functionally significant nonmalignant tracheal stenosis and tracheomalacia. Self-expandable, biodegradable, polydioxanone tracheal stents manufactured by ELLA-CS Ltd. (Hradec Kralove, Czech Republic) were implanted during rigid bronchoscopy under general anaesthesia. All patients were followed up in the department and were provided with the necessary care. The main efficacy and safety parameters and relationships were analysed using descriptive statistics and Fisher´s exact, Wilcoxon and Kruskal‒Wallis tests. RESULTS: A total of 65 stents were implanted in 47 adult patients. During the first two months after implantation, when adequate function was expected, the stent was found to be effective in 26 out of 39 patients who completed this period (66.7%). The clinical effectiveness reached 89.7%, as early restenoses were mostly mild and necessitated treatment in only 4 patients. The frequencies of significant mucostasis, migration and granulation tissue growth were 2.6%, 7.5% and 23.1%, respectively, during this period. Thirty-four participants completed the half-year follow-up period after the first or second stent insertion, and some were followed up beyond this period. Poor control of symptoms, the development of restenosis and the need for interventions were characteristic of this period as the stents degraded. Twenty-two patients who experienced remodelling or stabilization of the tracheal lumen achieved a stent-free state. Seven patients underwent subsequent surgical treatment. CONCLUSIONS: BD stents are safe and provide adequate tracheal support until they begin to degrade. The use of BD stents necessitates close monitoring of patients and accurate treatment of possible restenosis. TRIAL REGISTRATION: Based on project NT14146 - Biodegradable stents in the management of the large airways (2013-2015, MZ0/NT), registered on May 1, 2013, in the Research and Development and Innovation Information System of the Czech Republic and at ClinicalTrials.gov (reg. no. NCT02620319, December 2, 2015).

Frequency and Risk Factors of Tracheomalacia in Patients Undergoing Thyroidectomy.

It was a descriptive cross-sectional study to determine the frequency and risk factors of tracheomalacia in patients undergoing thyroidectomy. One hundred and forty-nine patients underwent thyroidectomy at MTI-Khyber Teaching Hospital Peshawar between 1st January 2021 and 1st March 2022. The frequency of post-thyroidectomy tracheomalacia and possible associated factors were determined. The inclusion criteria were patients of either gender, between 18 to 70 years fulfilling criteria of clinically diagnosed cases of thyroid disorders who underwent subtotal, hemi, near or total thyroidectomy for their respective thyroid diseases. Post-thyroidectomy tracheomalacia was recorded in 18 patients (12.1%): Seventeen patients were aged less than 30 (p-value 0.038) and 14 (77.8%) patients had a duration of surgery > three hours (p-value <0.001). Young female patients with multinodular goitre who had a longer duration of surgery developed post-thyroidectomy tracheomalacia more frequently. Hence, the incidence of post-thyroidectomy tracheomalacia can be markedly reduced with proper preoperative assessment and postoperative measures. Key Words: Thyroid gland, Thyroid disorders, Tracheomalacia, Thyroidectomy.

[Surgical and Percutaneous Dilatational Tracheostomy - Technique and Pitfalls]. / Plastische und dilatative Tracheostomie ­ Technik und Fallstricke.

A tracheostomy is usually necessary for long-term mechanical ventilation or complicated weaning. Other indications include swallowing disorders with recurrent aspiration in neuromuscular disease and high-grade subglottic stenosis. The tracheostomy can be performed as a percutaneous dilatational tracheostomy or as a surgical tracheostomy. The complication rate is low, and intraoperative complications are differentiated from early and late postoperative complications. This article aims to present the indications, the techniques and complications of percutaneous dilatational and surgical tracheostomy, and highlights the long-term complications of tracheal stenosis and tracheomalacia.

Open and Thoracoscopic Aortopexy for Airway Malacia in Children: 15 Year Single Centre Experience.

OBJECTIVES: The objective was to report and analyse the characteristics and results of open aortopexy and thoracoscopic aortopexy for the treatment of airway malacia in a paediatric population. METHODS: We report a retrospective consecutive case series of paediatric patients undergoing aortopexy for the treatment of airway malacia at a quaternary referral centre between December 2006 and January 2021. Outcome measures included days to extubation, continued need for non-invasive ventilation, further intervention in the form of tracheostomy and death. RESULTS: 169 patients underwent aortopexy: 147 had open procedures (135 via median/limited median sternotomy and 12 thoracotomy) and 22 thoracoscopic. Mean follow up was 8.46 yrs (range 1-20 yrs). Most common site of airway malacia was the trachea (n = 106, 62.7 %), and 48 (28.4 %) had additional involvement at the bronchi with tracheobronchomalacia (TBM). 15 (8.9 %) had bronchomalacia (BM) only. Incidence of bronchial disease was lower in the thoracoscopic than open group (13.6 % vs 40.82 %; p < 0.0001). Mean time to extubation was 1.45 days, 2.59 days, 5.23 days in tracheomalacia, TBM and BM groups, respectively (p = 0.0047). Mean time to extubation was 1.35 days, 2 days, 3.67 days, and 5 days in patients with external vascular compression, TOF/OA, primary airway malacia, and laryngeal reconstruction, respectively (p = 0.0002). There were 21 deaths across the cohort, and all were in the open group. 71.4 % (n = 15) had bronchial involvement of their airway malacia. CONCLUSIONS: Open and thoracoscopic aortopexy are effective treatments for airway malacia in children. We have identified that involvement of the bronchi is a risk factor for adverse outcomes, and the optimum treatment for this patient cohort is still debatable. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective Study.

Update on aortopexy and posterior tracheopexy for tracheomalacia in patients with esophageal atresia.

Despite improving the survival after repair of esophageal atresia (EA), the morbidity of EA repair remains high. Specifically, tracheomalacia (TM) is one of the most frequent complications of EA repair. Continuous positive airway pressure is generally applied for the treatment of TM. However, surgical intervention is required against an apparent life-threatening event or inability to perform extubation for a long period. According to our review, most cases of TM showed symptom improvement after aortopexy. The ratio of the trachea's lateral and anterior-posterior diameter at the brachiocephalic artery crossing the trachea, which reflects the compression of the trachea by the brachiocephalic artery, is a good indicator of aortopexy. Our finding suggests that most TM cases associated with EA may not be caused by tracheal fragility alone, but may involve blood vessel compression. Posterior tracheopexy (PT) is also an effective treatment for TM. Recently, open or thoracoscopic PT was able to be performed simultaneously with EA repair. In many cases, aortopexy or PT is a safe and effective surgical treatment for TM with EA. Other surgical procedures, such as external stenting, should be considered for patients with diffuse-type TM for whom aortopexy and PT appear relatively ineffective.

Predictors of response to endoscopic management of subglottic/tracheal stenosis in patients without tracheostomy.

INTRODUCTION: Subglottic and tracheal stenosis (SGTS) in adults is an acquired or idiopathic condition that can lead to dyspnea, and even life-threatening airway obstruction. Endoscopic techniques have advanced and largely eclipsed open surgery, with open surgery now reserved for refractory cases (Hseu et al., 2013; Feinstein et al., 2017). Currently, there is no accepted guideline for the endoscopic treatment of SGTS. Thus, the aim of the present study is to examine the impact of various clinical and pathological characteristics on outcomes to endoscopic treatment in a cohort of SGTS patients. DISCLOSURE: None of the authors have any financial or personal relationship that could cause a conflict of interest regarding this article. METHODS: Retrospective chart review was performed for 41 patients presenting with SGS without a tracheostomy over a 4-year-period (2018-2022), within a single tertiary care center. Quantitative outcomes including number of dilation procedures undergone and need for open procedures were examined. The qualitative variables included a history of pulmonary disease, prior tracheostomy/tracheal resection, presence of tracheomalacia, granulation tissue, excessive dynamic airway collapse (EDAC), and etiology of idiopathic subglottic stenosis. RESULTS: The presence of granulation tissue seen on tracheoscopy was associated with a higher number (4+) of dilation procedures (p = 0.01). A history of pulmonary disease (p = 0.037), the presence of tracheomalacia (p = 0.039), and the presence of granulation tissue (0.003) were all associated with a need for open procedures. CONCLUSION: Patients with the presence of granulation tissue, tracheomalacia, and a history of pulmonary disease were more associated with more severe disease requiring either a higher number of endoscopic procedures or need for open procedures.

A case report of tracheal tenting to the skin: An option to tracheostomy for post-thyroidectomy tracheomalacia.

Operating on a huge and long-standing goiter is challenging to the surgeon and anesthetist because of the possibility of tracheomalacia and collapse of the tracheal rings after extubation. We report our innovation of tenting the trachea to the skin using sutures (passed through the strap and sternocleidomastoid muscles) to prevent post-thyroidectomy tracheomalacia.

Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children.

OBJECTIVE: Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy. METHODS: Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison. RESULTS: Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia. CONCLUSION: For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:410-416, 2023.

Unsuspected severe tracheal stenosis and tracheomalacia after correction surgery for congenital scoliosis: A case report.

Tracheal stenosis and tracheomalacia in patients with congenital scoliosis are serious and rare conditions caused by congenital dysplasia, postintubation injury, trauma, and tracheal tumor. Anesthesia of a child with tracheal stenosis is challenging for anesthesiologists. We describe an 8-year-old female patient developed severe tracheal stenosis and tracheomalacia after growing rod implantation for congenital scoliosis. Comprehensive assessment of preoperative pulmonary function and airway morphology, which can be neglected clinically, should be performed in congenital scoliosis patients.

An Ex Vivo Model of Posterior Tracheomalacia With Evaluation of Potential Treatment Modalities.

OBJECTIVE: Posterior tracheomalacia (TM) is characterized by excessive intraluminal displacement of the tracheal membranous wall. Recently, novel surgical strategies for repair of posterior TM have been introduced. To our knowledge, these strategies have not been evaluated in a model of posterior TM. Thus, we sought to design an ex vivo mechanical model of posterior TM to evaluate potential repair interventions. METHODS: A model for posterior TM was created with partial thickness longitudinal incisions to the posterior aspect of ex vivo porcine trachea. Three groups of tracheas were tested: (1) control (unmanipulated), (2) posterior TM (injury), and (3) intervention (repair). Interventions included external splinting with 0.3 and 0.5 mm bioresorbable plates, posterior tracheopexy, and injection tracheoplasty with calcium hydroxylapatite. An airtight tracheal system was created to measure tracheal wall collapse with changes in negative pressure. A bronchoscope and pressure transducer were connected to either end. Cross-sectional area of the tracheal lumen was analyzed using ImageJ software (National Institutes of Health, Bethesda, MD). RESULTS: Average percent reduction in cross-sectional area of the tracheal lumen was compared using a two-tailed paired t-test. Significant differences were found between control and TM groups (p < 0.019). There was no significant difference between control and external splinting and posterior tracheopexy groups (p > 0.14). CONCLUSION: We describe an ex vivo model for posterior TM that replicates airway collapse. External splinting and tracheopexy interventions showed recovery of the injured tracheal segment. Injection tracheoplasty did not improve the TM. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2000-2006, 2023.

Decannulation in Trisomy 21 patients undergoing laryngotracheal reconstruction.

BACKGROUND: Down Syndrome (DS) patients are more susceptible to either congenital or acquired subglottic stenosis (SGS). This often creates a multilevel airway obstruction and can lead to tracheostomy dependence early in life. As a result, they may require Laryngotracheal Reconstruction (LTR) to achieve decannulation. The primary objective of this study was to assess decannulation rates, time to decannulation and potential barriers to decannulation in DS patients undergoing LTR. METHODS: We performed a retrospective chart review from 2008 to 2021 of 193 children who underwent LTR for treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. The relationship between clinical data and decannulation status was evaluated using multivariable logistic regression and Fisher exact tests. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression. RESULTS: We determined that DS patients carry an inherit risk for decannulation failure compared to the general population (OR: 6.112, P = . 044, CI 1.046-35.730). Of the 8 patients with DS only three were decannulated. Overall, patients with Trisomy 21 had a significantly increased time to decannulation when compared to all LTR patients (P = .008, Log-rank). We found that these patients are more likely to have both suprastomal collapse (P = .0004, Fischer's Exact) and Tracheomalacia (P = .034, Fischer's Exact) compared to all other LTR patients. While post-operative tracheomalacia did not significantly affect decannulation failure (P = .056, Fischer's Exact) it did significantly prolong decannulation in all LTR patients (P = .018, Log-rank). CONCLUSION: Trisomy 21 patients are at an increased risk for decannulation failure. Our study illustrates that these poor outcomes are likely a result of conditions more commonly found in this cohort including: narrow tracheal caliber, tracheomalacia and hypotonia.

Successful management of a tracheomalacia patient with active endotracheal bleeding due to intraoperative innominate artery injury: A case report.

RATIONALE: Intraoperative innominate artery injury is life-threatening in tracheomalacia patients with prolonged tracheostomy. Anesthetic management is challenging in cases with massive hemorrhage into the endotracheal tube. We report a case in which we successfully managed a tracheomalacia patient with acute endotracheal bleeding due to innominate artery injury. PATIENT CONCERNS: A 24-year-old patient with tracheomalacia was scheduled to undergo exploratory thoracotomy for the treatment of intermittent bleeding at the tracheostomy site. During exploration, sudden active bleeding due to innominate artery injury was observed in the endotracheal lumen. DIAGNOSES: The patient was diagnosed with tracheomalacia. INTERVENTIONS: We immediately used the bronchoscope to place the tip of the endotracheal tube at the bleeding site and hyperinflated the cuff. OUTCOMES: The ballooned cuff compressed the active bleeding site, so no additional bleeding was detected by bronchoscopy, and no additional massive bleeding was observed in the operative field. LESSONS: Immediate and appropriate overinflation of the endotracheal tube cuff by an anesthesiologist may provide improved surgical field visibility and time for critical surgical procedures in cases of massive hemorrhaging.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair ameliorate tracheomalacia in neonates: a single-center retrospective comparative cohort study.

BACKGROUND: Esophageal atresia (EA) is often associated with tracheomalacia (TM). The severity of TM symptoms varies widely, with serious cases requiring prolonged respiratory support and surgical treatment. Although we performed thoracoscopic posterior tracheopexy (TPT) during primary EA repair to prevent or reduce the symptoms of TM, few studies have investigated the safety and effectiveness of TPT during primary EA repair. Therefore, this study aimed to evaluate the safety and efficacy of TPT in neonates. METHODS: We retrospectively reviewed the records of all patients diagnosed with TM who underwent primary thoracoscopic EA repair between 2013 and 2020 at the Nagoya University Hospital. Patients were divided into two groups: TPT (TPT group) and without TPT (control group). TPT has been performed in all patients with EA complicated by TM since 2020. We compared patient backgrounds, surgical outcomes, postoperative complications, and treatment efficacy. RESULTS: Of the 22 patients reviewed, eight were in the TPT group and 14 were in the control group. There were no statistically significant differences in the surgical outcomes between the groups (operation time: p = 0.31; blood loss: p = 0.83; time to extubation: p = 0.30; time to start enteral feeding: p = 0.19; time to start oral feeding: p = 0.43). Conversion to open thoracotomy was not performed in any case. The median operative time required for posterior tracheopexy was 10 (8-15) min. There were no statistically significant differences in postoperative complications between the groups (chylothorax: p = 0.36; leakage: p = 1.00; stricture: p = 0.53). The respiratory dependence rate 30 days postoperative (2 [25%] vs. 11 [79%], p = 0.03) and the ratio of the lateral and anterior-posterior diameter of the trachea (LAR) were significantly lower in the TPT group (1.83 [1.66-2.78] vs. 3.59 [1.80-7.70], p = 0.01). CONCLUSIONS: TPT during primary EA repair for treatment of TM significantly lowered respiratory dependence rate at 30 days postoperative without increasing the risk of postoperative complications. This study suggested that TPT could improve TM associated with EA.

Posterior tracheopexy for preterm infants with severe bronchopulmonary dysplasia and severe tracheobronchomalacia: A case series.

We report a series of four patients with severe bronchopulmonary dysplasia (BPD) who underwent posterior tracheopexy for severe tracheomalacia (TM). While posterior tracheopexy is an established surgical treatment for TM associated with tracheoesophageal fistula, it has not been previously described in TM associated with BPD. There were no significant intraoperative or postoperative complications from the surgeries. Three of the four patients required tracheostomy and mechanical ventilation, which may reflect the degree of lung disease and other multisystem comorbidities in these patients. More investigation is needed to determine whether posterior tracheopexy is an effective surgical option for TM related to BPD.

An imaging study on tracheomalacia in infants with esophageal atresia: the degree of tracheal compression by the brachiocephalic artery is a good indicator for therapeutic intervention.

PURPOSE: Tracheomalacia (TM) is a frequent complication after esophageal atresia (EA) repair. This study aimed to review patients who underwent aortopexy for TM after EA repair and to compare their imaging features. METHODS: The patients who underwent thoracoscopic EA repair and contrast-enhanced computed tomography (CECT) at our hospital between 2013 and 2020 were retrospectively reviewed. The ratio of the lateral and anterior-posterior diameter of the trachea (LAR) where the brachiocephalic artery (BCA) crosses the trachea was defined. The LAR of the patients who underwent CECT for asymptomatic pulmonary disease was set as a normal reference. The Z-score of each LAR was calculated and compared between the patients that did or did not undergo aortopexy. RESULTS: A total of 51 patients represented the controls, 5 patients underwent aortopexy, and 12 patients were discharged without surgery. The mean LARs in the patients who underwent aortopexy, did not undergo aortopexy, and controls were 3.54, 1.54, and 1.15, respectively. The mean Z-score of the aortopexy group was 21.2. After successful aortopexy, each patient's LAR decreased to < 1.5. CONCLUSION: Aortopexy was preferred if the trachea was compressed by the BCA. The LAR is a useful indicator for predicting the therapeutic effect of aortopexy.

Reconstruction of the Mediastinum and Tracheopexy for Tracheomalacia in Straight Back Syndrome.

Tracheomalacia in straight back syndrome results from chronic compression of the trachea and the mainstem bronchi mainly because of decreased mediastinal diameter. The mainstay of correction is the increase of mediastinal space and the restoration of the tracheal lumen and stability. Owing to the great variability of the manifestation of this disease, individualized approaches are required. We describe our approach in a 36-year-old woman with straight back syndrome associated severe tracheobronchomalacia with reconstruction of the proximal aorta, brachiocephalic artery, sternoplasty, and anterior tracheopexy, which resulted in successful treatment of the condition.

Transoral Minimally Invasive Tracheoplasty Technique for Cervical Tracheomalacia.

We report a case of cervical tracheomalacia successfully treated by tracheoplasty. The resection of redundant posterior tracheal tissue was performed with a novel minimally invasive transoral approach.

Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children.

IMPORTANCE: Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. OBJECTIVE: We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. METHODS: The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. RESULTS: In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. CONCLUSION: Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Prolonged endotracheal intubation: a feasible option for tracheomalacia after retrosternal goitre surgery.

BACKGROUND: Tracheomalacia may be caused by long-standing compression of retrosternal goitre because of destruction of support of tracheal cartilages. Life-threatening airway collapses may occur after surgical removal of goitre. However, available literature on management methods of tracheomalacia is sparse. Our study highlights prolonged endotracheal intubation as a feasible treatment method. METHODS: This retrospective study analysed 106 thyroidectomies for retrosternal goitre performed between 1994 and 2019. We recorded each patient's clinical profile. Severe tracheomalacia was confirmed through the following: soft and floppy trachea on intra-operative palpation and the collapse of cross-sectional tracheal area measured in computed tomography (CT) images by >80%. We assessed the extent of airway stenosis of these cases. All severe cases were treated by prolonged endotracheal intubation. RESULTS: Surgical treatment was successfully performed in all 106 retrosternal goitre patients with no mortality. Seventeen severe tracheomalacia cases were confirmed. The extent of airway stenosis was assessed: the minimal tracheal diameter of compressed trachea was 0.2-0.4 [mean 0.31, standard deviation (SD) 0.06] cm, and the narrow tracheal length was 4-6.7 (mean 5.1, SD 0.6) cm. These patients underwent endotracheal intubation for 17-47 h after surgery. All patients were transferred to the general ward after extubation and successfully discharged. There were no cases of tracheal stenosis on follow-up. CONCLUSIONS: Tracheomalacia is a rare but serious complication of retrosternal goitre surgery. Based on our experience, prolonged endotracheal intubation is a feasible treatment for tracheomalacia after retrosternal goitre surgery.