Outcomes of Slide Tracheoplasty a 17 year experience Simone ...
Outcomes of Slide Tracheoplasty a 17 year experience Simone ...
Outcomes of Slide Tracheoplasty a 17 year experience Simone ...
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<strong>Outcomes</strong> <strong>of</strong><br />
<strong>Slide</strong><br />
<strong>Tracheoplasty</strong><br />
a <strong>17</strong> <strong>year</strong><br />
<strong>experience</strong><br />
<strong>Simone</strong> Speggiorin, Colin Butler, Friso Reinberg, Anja Fierens, Clare<br />
Mclaren ,Derek Roebuck, Samantha Chippington, Nagarajan Muthialu,<br />
Colin Wallis, Hany Gabra, Michele Torre, and Martin J Elliott<br />
the UK National Tracheal Service for Severe Tracheal Disease in Children<br />
at The Great Ormond Street Hospital for Children NHS Foundation Trust
<strong>Outcomes</strong> <strong>of</strong><br />
<strong>Slide</strong><br />
<strong>Tracheoplasty</strong><br />
a <strong>17</strong> <strong>year</strong><br />
<strong>experience</strong><br />
<strong>Simone</strong> Speggiorin, Colin Butler, Friso Reinberg, Anja Fierens,<br />
Clare Mclaren ,Derek Roebuck, Samantha Chippington, Nagarajan<br />
Muthialu, Colin Wallis, Hany Gabra, Michele Torre, and Martin J<br />
Elliott<br />
the UK National Tracheal Service for Severe Tracheal Disease in Children<br />
at The Great Ormond Street Hospital for Children NHS Foundation Trust
no commercial interests
Long Segment Congenital<br />
Tracheal Stenosis<br />
L S C T S<br />
More that 50% <strong>of</strong><br />
its length<br />
Presence <strong>of</strong> complete<br />
tracheal rings
Anatomical variety<br />
Normal<br />
Arborisation<br />
Pig<br />
Bronchus<br />
Trifurcation<br />
Single<br />
lung<br />
(52)<br />
(10)<br />
(14)<br />
(8)<br />
(2) (4)<br />
CTS<br />
(40)<br />
(10) (1)<br />
(2) (2)<br />
(2)<br />
(1)<br />
(1)<br />
CTBS<br />
(11) (1)<br />
(1) (1)<br />
(2) (2)<br />
(1)<br />
Speggiorin S, Torre M, Roebuck DJ, McLaren CA, Elliott MJ.<br />
Ann Thorac Surg 2012 93(3):958-61
Referral process<br />
Patient<br />
referral<br />
Assessment<br />
Stable<br />
Echo<br />
Bronchoscopy<br />
Bronchogram<br />
OCT<br />
CT scan<br />
MRI<br />
Unstable<br />
Ventilate<br />
ECMO<br />
Heliox<br />
…..
VALUE OF OCT<br />
Normal optical<br />
coherence<br />
tomography<br />
Complete ring<br />
No ring
SURGICAL TECHNIQUE<br />
• always on CPB (relevant technique)<br />
• cardiac lesions corrected at same procedure<br />
• LPA sling repaired by transfer to MPA<br />
• full mobilisation <strong>of</strong> trachea<br />
• divide thyroid isthmus<br />
• posterior pericardial reflection<br />
• rarely hilar release<br />
• interrupted, everting, mattress sutures (PDS)
FROM FEB 1995 TO DEC 2012<br />
101 consecutive children M/F =62/39<br />
Age<br />
Weight<br />
median 5.8 m<br />
range (5d-15y)<br />
median 5.9 kg<br />
range (1.9-<br />
38.3kg)
ASSOCIATED CV ANOMALIES<br />
71% <strong>of</strong> patients have<br />
associated cardiac<br />
defects, <strong>of</strong> which 67%<br />
are a LPA sling<br />
Left pulmonary artery sling 48<br />
Ventricular septal defect 15<br />
Tetralogy <strong>of</strong> Fallot 10<br />
Atrium septal defect 7<br />
Other* 5<br />
Vascular ring 4<br />
Persistent ductus arteriosus 4<br />
Sub Aortic Stenosis 3<br />
Atrioventricular septal defect 2<br />
Truncus arteriosus + IAA 2<br />
Hypoplastic aortic arch 2<br />
Right aortic arch 2
PREOPERATIVELY<br />
-CONGENITAL 43(43%)<br />
ANOMALIES<br />
-VENTILATION 56 (55%)<br />
-ECMO 10 (10%)
PREOPERATIVELY<br />
-BRONCHIAL STENOSIS 24 (23.7%)<br />
-DISTAL MALACIA 24(24%)
Minimum tracheal diameter (mm)<br />
mean = 2.2mm<br />
sd = 0.64<br />
Length<br />
all > 50% <strong>of</strong> trachea<br />
90% > 80% <strong>of</strong> trachea
at GOS<br />
POSTOPERATIVELY<br />
VENTILATION 11 Days (0-<br />
477)<br />
ICU LOS 20 Days (2-755)<br />
MALACIA 20 (20%)
COMPLICATIONS<br />
Site Complication Incidence<br />
Wound Mediastinitis 9 (8.9%)<br />
Airway Residual stenosis at 9 months 8 (7.9%)<br />
Dehiscence/redo 3 (3.0%)<br />
Unplanned extubation 2 (2.0%)<br />
Chest/Pulmonary Pneumothorax 6 (5.9%)<br />
Chylothorax 4 (4.0%)<br />
Pneumo -mediastinum/pericardium 4 (4.0%)<br />
PHT 2 (2.0%)<br />
Cardiac Tamponade 1 (1.0%)<br />
Nerve Phrenic nerve 4 (4.0%)<br />
RLN palsy 3 (3.0%)
POSTOPERATIVELY<br />
ENDOSCOPIC 48 (48%)<br />
PROCEDURES<br />
BALLOON DILATATION 45 (45%)*<br />
*Over first<br />
4 months<br />
3 OR > 33 (33%)<br />
STENTING 22 (22%)
STENTS<br />
Stents/patients 37/22<br />
100%<br />
90%<br />
27.5% 19.4%<br />
80%<br />
70%<br />
60%<br />
50%<br />
Stented pts<br />
non stented pts<br />
40%<br />
30%<br />
20%<br />
10%<br />
0%<br />
1995-2005 2006-2012
STENTS<br />
30<br />
25<br />
20<br />
15<br />
10<br />
balloon expandable steel<br />
Nitinol self expandable<br />
PDS reabsorbable<br />
5<br />
0<br />
1995-2008 2009-2012
100% follow-up 4.6yrs (2.7 m-<strong>17</strong> y)<br />
88.3%<br />
Overall Probability <strong>of</strong> Survival<br />
after <strong>Slide</strong> <strong>Tracheoplasty</strong>
MORTALITY<br />
Multivariable Regression Analysis<br />
HR = hazard ratio
PREOP DISTAL MALACIA VS MORTALITY<br />
94.6%<br />
p
PREOP DISTAL MALACIA VS STENTING<br />
82.6%<br />
p
What we have learnt<br />
STP for any anatomical variant<br />
Key indicators for outcome malacia<br />
and bronchial stenosis<br />
Malacia can improve over time<br />
Reabsorbable stents may help<br />
OCT and bronchogram are helpful
Comments<br />
•MDT and team work<br />
•Centralization <strong>of</strong> the service<br />
•Obsessional fup<br />
•Improving materials (ie reab sutures and<br />
stents)
Thank to
POSTOP VENTILATION
MORTALITY BY ERA
BRONCHOGRAM
OCT
<strong>Slide</strong> <strong>Tracheoplasty</strong><br />
Tsang V, Murday A, Gillbe C, Goldstraw P<br />
<strong>Slide</strong> tracheoplasty for congenital funnel-shaped<br />
tracheal stenosis<br />
Ann Thorac Surg 1989 Nov;48(5):632-5
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