Effectiveness and safety of a ventricular septal occluder device for the treatment of Gastro-tracheal fistula.

BACKGROUND: Gastro-tracheal fistula (GTF) is one of the most serious complications after esophagogastrostomy and radiotherapy, with very high disability and mortality rates. To evaluate the effectiveness and safety of ventricular septal occluder devices (VSOD) for the treatment of Gastro-tracheal fistula (GTF). METHODS: From January 2020 to May 2022, 14 patients with GTF underwent VSOD under real-time fluoroscopy. The technical success, complications, quality of life (QoL), Eastern Cooperative Oncology Group (ECOG) score, Karnofsky score, and median overall survival (mOS) were recorded and analyzed. RESULTS: Technical success, and major complication rates were 71.4%, and 14.3%, respectively. Both the ECOG and the Karnofsky score showed significant improvement at the 2-month evaluation compared with the pretreatment value (p<0.05). For QoL, general health, physical function, vitality, role physical, and social function all improved at the 2-month evaluation (p<0.05), but bodily pain, role emotion, and mental health showed no significant difference (P>0.05). During the mean follow-up of 9.6 months, eight patients were alive, and the mOS was 11.4 months (95% CI, 8.5-14.3). CONCLUSIONS: VSOD is a simple and safe technique for GTF treatment, but long-term observation is needed at multiple centers to confirm our findings.

Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap.

Tracheocutaneous fistula and tracheostomy scar are complications associated with the prolonged use of tracheostomy tubes. They have functional and cosmetic problems owing to tracheal tugging during swallowing and easily visible scars. Although many procedures exist to correct this issue, there is no consensus on the optimal surgical technique. Therefore, an ideal surgical procedure was devised. The study was performed on 12 patients between September 2016 and May 2021. All patients had persistent tracheocutaneous fistulas or hypertrophic scars on the neck after tracheostomy. All procedures were performed using a hinged flap and two myocutaneous local flaps. All patients had no complications, and their aesthetics were excellent in postoperative photographs. The scar was better on the straight scar when the flap's skin is denuded than on the VY advancement flap. It should be noted, however, that this procedure can cause the flap to become congested in a short period after head and neck surgery. This procedure is safe, reliable and simple for surgical closure. This was found to produce excellent cosmetic results with no major complications.

Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

Primary versus secondary closure of tracheocutaneous fistula in pediatric patients.

OBJECTIVE: Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS: Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS: A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION: Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.

Primary versus modified secondary closure techniques for persistent tracheocutaneous fistula in pediatric patients.

PURPOSE: This study aimed at compating two closure techniques for tracheocutaneous fistulas (TCFs) in pediatric patients. METHODS: A total of 106 consecutive pediatric patients who underwent closure of a persistent TCF between April 2007 and February 2021 at a tertiary pediatric hospital were evaluated, and 103 pediatric patients aged between 12 months and 18 years were included. The clinical characteristics, perioperative outcomes, and postoperative outcomes were compared between TCF closure by primary closure (Group 1) and a modified secondary healing technique (Group 2). RESULTS: Of the 103 patients, 58 were classified into Group 1, and 45 into Group 2. The mean age at tracheostomy and TCF closure was significantly younger in Group 2, and the interval between decannulation to TCF closure was significantly shorter in Group 2. Procedural time and hospital stay were significantly shorter in Group 2 than Group 1. Group 2 had a significantly lower complication rate, need for revision surgery, and recannulation rate than Group 1. CONCLUSIONS: Modified secondary healing was more efficient in terms of procedural time and hospital stay, and safer (i.e., fewer complications). It is an effective surgical technique for closing a persistent TCF in younger patients more quickly after decannulation compared to primary closure.

Prophylactic innominate artery transection to prevent tracheoinnominate artery fistula: a retrospective review of single institution experiences.

PURPOSE: This study aimed to investigate the optimal indication and availability of prophylactic innominate artery transection (PIAT). METHODS: We retrospectively analyzed the medical records of the patients with neurological or neuromuscular disorders (NMDs) who underwent PIAT. Meanwhile, we originally defined the tracheal flatting ratio (TFR) and mediastinum-thoracic anteroposterior ratio (MTR) from preoperative chest computed tomography imaging and compared these parameters between non-PIAT and PIAT group. RESULTS: There were 13 patients who underwent PIAT. The median age was 22 years. PIAT was planned before in one, simultaneously in five, and after tracheostomy or laryngotracheal separation in seven patients. Image evaluations of the brain to assess circle of Willis were performed in all patients. Appropriate skin incisions with sternotomy to expose the innominate artery were made in four patients. All patients are still alive except one late death without any association with PIAT. No neurological complications occurred in any patients. As significant differences (p < 0.01) between two groups were observed for TFR and MTR, objective validity of the indication of PIAT was found. CONCLUSIONS: PIAT is safe and tolerable in case of innominate artery compression of the trachea with NMDs. TFR and MTR are useful objective indexes to judge the indication of PIAT.

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.

Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction.

BACKGROUND: Large or complex trachea defects often require some tissue to reconstruct, various flaps have been reported for reconstructing this defect. However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction. Therefore, this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction. METHODS: Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed. RESULTS: All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm × 5 cm to 4 cm × 10 cm, and the size of each island of one double-island flap was 2 cm × 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities, such as diabetes, hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis. Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment. CONCLUSION: Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

[Contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation]. / Kontaminatsiya operatsionnoi rany v zavisimosti ot varianta IVL pri rezektsii trakhei.

OBJECTIVE: To analyze contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation. MATERIAL AND METHODS: There were 976 patients. Circular tracheal resection was made in 396 of these patients. RESULTS: Overall postoperative morbidity was 15.7%, mortality - 0.8%. Bacteriological examination of surgical wound was performed before tracheotomy and after formation of anastomosis depending on the method of mechanical ventilation. Surgical field was sterile before tracheotomy in all cases, contamination was confirmed after tracheotomy in all patients. Minimal contamination was observed in case of apneic oxygenation (100 times less than volumetric mechanical ventilation or high frequency mechanical ventilation). In all cases, several species of pathogenic microorganisms were identified. The number of species was also minimal in case of hypnotic mechanical ventilation. CONCLUSION: Contamination does not directly affect the development of local purulent-inflammatory process. However, this factor should not be ignored and compliance with all preventive measures is required.

Endovascular Management of Tracheo-Subclavian Fistula.

Tracheoarterial fistula is a rare complication of tracheostomy with an incidence of less than 1%. Survival of this disease entity is low, and it likely results from a major open operation in a high-risk surgical group. In our review of the literature, a tracheoinnominate artery fistula is the most commonly reported arterial fistula. However, we present a rare case of tracheo-left subclavian artery fistula. We have identified 1 previous case of tracheo-left subclavian fistula as a source of massive tracheal bleeding. In our case report, we describe the successful management of this disease by endograft placement. Owing to its rarity, there are no guidelines on the management approach to tracheoarterial fistulas, but given the difficulty of controlling this problem via median sternotomy, the placement of a covered stent may be the best therapy. Initially, case reports showed a role for endograft placement as a temporizing measure, but the risk of infection may be sufficiently low to justify this approach as a definitive therapy. Upon a 6-month follow-up, our patient remains without recurrence of bleeding or infection, and computed tomography angiography of the chest with 3D reconstruction has shown patency of the endovascular stent with resolution of the associated pseudoaneurysm.

Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases.

BACKGROUND: A tracheocutaneous fistula is a known complication following tracheostomy decannulation. Although surgical techniques for its repair are well described, there is no consensus about perioperative management and this procedure may generate significant airway and respiratory complications intraoperatively, and in the early postoperative period. We aimed to describe variations in perioperative management in tracheocutaneous fistula closure, estimate the incidence of early airway and respiratory complications, and identify any predisposing factors. METHODS: The otorhinolaryngology surgical database identified 118 tracheocutaneous fistula closures from August 1994 to September 2015. Ninety-seven case notes were located generating 96 procedures for retrospective review. The data collected included demographics, comorbidities, anesthetic, and surgical technique, and complications up to 24 hours postoperatively. RESULTS: The median age at surgery was 5 years 10 months (range 1 year 8 months to 19 years 6 months). Preoperatively, 72% of patients had a "mini" sleep study (where the tracheocutaneous fistula is covered and saturations measured overnight). Ninety percent had an inhalational induction and 96% a tracheal intubation. Intraoperatively, laryngospasm occurred in 2% and there was difficulty ventilating in another 2%. A "leak test" to check fistula repair airtightness was recorded in 35%. Postoperatively 24% had one or more episodes of oxygen desaturation. Major complications occurred in five patients (incidence 5%, 95% CI 0.8-9.7); four patients had pneumothoraxes with two needing postoperative mechanical ventilation and one patient developed life-threatening subcutaneous emphysema. CONCLUSION: Perioperative care for children undergoing tracheocutaneous fistula closure was not standardized. Advocated tests such as preoperative "mini" sleep studies and "leak test" intraoperatively were not consistently performed. Intraoperative anesthetic complications were uncommon; however, major postoperative respiratory complications were 5%.

Feasibility of Bioengineered Tracheal and Bronchial Reconstruction Using Stented Aortic Matrices.

Importance: Airway transplantation could be an option for patients with proximal lung tumor or with end-stage tracheobronchial disease. New methods for airway transplantation remain highly controversial. Objective: To establish the feasibility of airway bioengineering using a technique based on the implantation of stented aortic matrices. Design, Setting, and Participants: Uncontrolled single-center cohort study including 20 patients with end-stage tracheal lesions or with proximal lung tumors requiring a pneumonectomy. The study was conducted in Paris, France, from October 2009 through February 2017; final follow-up for all patients occurred on November 2, 2017. Exposures: Radical resection of the lesions was performed using standard surgical techniques. After resection, airway reconstruction was performed using a human cryopreserved (-80°C) aortic allograft, which was not matched by the ABO and leukocyte antigen systems. To prevent airway collapse, a custom-made stent was inserted into the allograft. In patients with proximal lung tumors, the lung-sparing intervention of bronchial transplantation was used. Main Outcomes and Measures: The primary outcome was 90-day mortality. The secondary outcome was 90-day morbidity. Results: Twenty patients were included in the study (mean age, 54.9 years; age range, 24-79 years; 13 men [65%]). Thirteen patients underwent tracheal (n = 5), bronchial (n = 7), or carinal (n = 1) transplantation. Airway transplantation was not performed in 7 patients for the following reasons: medical contraindication (n = 1), unavoidable pneumonectomy (n = 1), exploratory thoracotomy only (n = 2), and a lobectomy or bilobectomy was possible (n = 3). Among the 20 patients initially included, the overall 90-day mortality rate was 5% (1 patient underwent a carinal transplantation and died). No mortality at 90 days was observed among patients who underwent tracheal or bronchial reconstruction. Among the 13 patients who underwent airway transplantation, major 90-day morbidity events occurred in 4 (30.8%) and included laryngeal edema, acute lung edema, acute respiratory distress syndrome, and atrial fibrillation. There was no adverse event directly related to the surgical technique. Stent removal was performed at a postoperative mean of 18.2 months. At a median follow-up of 3 years 11 months, 10 of the 13 patients (76.9%) were alive. Of these 10 patients, 8 (80%) breathed normally through newly formed airways after stent removal. Regeneration of epithelium and de novo generation of cartilage were observed within aortic matrices from recipient cells. Conclusions and Relevance: In this uncontrolled study, airway bioengineering using stented aortic matrices demonstrated feasibility for complex tracheal and bronchial reconstruction. Further research is needed to assess efficacy and safety. Trial Registration: clinicaltrials.gov Identifier: NCT01331863.

[Tracheal Surgery]. / Chirurgie der Trachea.

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

[Delayed Tracheal Perforation after Pulmonary Resection for Lung Cancer].

We have experienced a case of delayed tracheal perforation after pulmonary resection using soft coagulation system. A 58-year-old male underwent operation for primary lung cancer. A soft coagulation system was used for oozing near upper mediastinal lymph nodes. The patient was discharged on postoperative day 8 in a good condition, however sudden tracheal perforation and was occurred on postoperative day 30. An emergency operation revealed that improper use of the soft coagulation system might cause a necrosis of the bronchial wall. Although, a soft coagulation system is useful to control bleeding from small vessels such as bronchial arteries and lymph nodes, this system is different from conventional electrocautery and requires some attention when using.

Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience.

BACKGROUND AND OBJECTIVE: Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis. METHODS: We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance. RESULTS: Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities. CONCLUSION: Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.

Tracheoinnominate Fistula: Endovascular Treatment with a Stent Graft in a 4-Year-Old Child.

A 4-year-old boy presented with acute and profuse bleeding at the tracheostomy site. An emergency angiography was performed and identified a pseudoaneurysm at the innominate artery. A selective catheterization of the artery was executed and 2 Advanta V12 balloon-expandable covered stents were implanted in an overlapping manner to occlude the pseudoaneurysm. Final angiography demonstrated patency of the innominate artery and no signs of bleeding. The patient had no postoperative complications and no further bleeding during follow-up. A contrasted computed tomography scan was performed after 20 days and demonstrated no signs of pseudoaneurysm or bleeding. After 4 months, the patient was readmitted to tracheal dilatation and change of T-tube and died of respiratory complications.

Tracheocutaneous Fistula Closure: Comparison of Rhomboid Flap Repair with Z Plasty Repair in a Case Series of 40 Patients.

INTRODUCTION: Tracheocutaneous fistula (TCF) is one of the recognized sequelae of a long-term tracheostomy resulting from mucocutaneous overgrowth which prevents closure of the artificial lumen at the site of tracheostomy. Primary closure of TCF has disappointing results and may lead to complications like pneumothorax, pneumomediastinum, cervicofacial subcutaneous emphysema, and depressed scar. OBJECTIVE: To compare TCF repair using fistulectomy followed by rhomboid flap versus fistulectomy followed by Z plasty repair. METHODS: In this prospective study, 40 patients of either sex with persistent TCF were included. All patients were randomly divided into two groups. Group I had 20 patients who underwent TCF repair using a technique in which fistulectomy was done followed by its closure in layers, and finally closing the defect using a rhomboid flap. The remaining 20 were included in group II who underwent TCF repair using a technique in which fistulectomy was done followed by layered closing, and final closure of the defect was done using Z plasty. The follow-up period was 3 months. RESULTS: Out of 40 patients, all but 8 experienced a successful outcome without any complications, and complete aesthetic satisfaction, with improvement in phonation, and no soiling of clothes with mucus or sputum. The 8 unsuccessful patients belonged to group II (Z plasty group). CONCLUSION: Both techniques have been described in the literature and are proven to give good results. Our study emphasizes the fact that in our experience, the rhomboid flap was a better alternative for TCF repair than Z plasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

[Complex control of the source of infection in sepsis : Extracorporeal membrane oxygenation (ECMO) as a bridging concept for tracheal fistula repair in sepsis-associated ARDS]. / Komplexe Fokussanierung in der Sepsis : Extrakorporale Membranoxygenierung (ECMO) als Bridging-Konzept zur trachealen Fistelsanierung bei sepsisassoziiertem ARDS.

Here, we present a case of a tracheal fistula due to an anastomotic insufficiency following abdominothoracic esophageal resection. Despite immediate discontinuity resection, the tracheal fistula could not be surgically closed, resulting in incomplete control of the source of infection and an alternative treatment concept in the form of interventional fistula closure using a Y-tracheal stent. However, owing to existing severe acute respiratory distress syndrome (ARDS), which is associated with a considerable risk of peri-interventional hypoxia, a temporary bridging concept using venovenous extracorporeal membrane oxygenation (ECMO) was implemented successfully.

Peripheral neurolymphomatosis with tracheal asphyxia: a case report and literature review.

BACKGROUND: Neurolymphomatosis (NL) is an extremely rare disease and tracheal asphyxia due to NL has not been previously reported. CASE PRESENTATION: A 54-year-old Chinese woman with a history of diffuse large B-cell lymphoma in her first complete remission developed peripheral neuropathy and tracheal asphyxia. Neurolymphomatosis involving the right brachial plexus and the right vagus nerve was demonstrated by PET/CT, but not by MRI. She underwent urgent tracheotomy and impact chemotherapy using rituximab combined with high dose methotrexate and involved field radiotherapy. She achieved a second complete remission. CONCLUSION: PET/CT plays valuable role in differentiating NL from other neuropathies in patients with lymphoma. Complete remission can be achieved in NL due to large B-cell lymphoma.

Tracheobronchial issues in congenital heart disease.

In children with congenital heart disease, tracheobronchial compromise is uncommon but potentially life-threatening. Airway lesions in these patients may be congenital or acquired, and may be stenotic, compressive, or malacic in nature. We present an overview of the etiologies of tracheobronchial lesions typically seen in children with congenital heart disease and review management options for these lesions.