Long-term outcomes of congenital tracheal stenosis treated by metallic airway stenting

doi:10.1016/j.jpedsurg.2012.11.002

Journal of Pediatric Surgery

Volume 48, Issue 2, February 2013, Pages 293-296

https://doi.org/10.1016/j.jpedsurg.2012.11.002 Get rights and content

Abstract

Aim

Congenital tracheal stenosis is an obstructive airway lesion that often presents as a life-threatening emergency. We had introduced the balloon dilatation and placement of the expandable metallic airway stent as a therapeutic option, and this study aimed to clarify the long-term outcomes in pediatric patients.

Methods

A retrospective review of five infants in whom balloon expandable metallic airway stents (10–40 mm long and 6–8 mm in diameter) were inserted in 1997 to 2000 was conducted.

Results

There was an immediate improvement of respiratory obstruction in all five infants (aged 7 days to 12 months) with four weaned from ventilation. One child died after 9 months of palliative treatment. In all inflammation and granulation tissue developed over the stents, but this could be managed by scraping or balloon compression. Metallic stents have been in place a mean of 12 years (range 6 months to 13 years) after insertion without other complications. Four children are alive and well with their stents in place. Recently, an attempt to remove the stent was done in two patients who showed dyspnea on exertion. They underwent tracheoplasty following successful complete removal of metallic stent using cardiopulmonary bypass.

Conclusion

Use of expandable metallic airway stents following balloon dilatation can be left for long periods to relieve tracheal obstruction. Development of granulation tissue is a major treatable complication. Removal of the stent was safely completed by open surgical intervention using a cardiopulmonary bypass. The airway stent may provide an important therapeutic option in selected cases with congenital tracheal stenosis.

Section snippets

Materials and methods

Five infants had been treated for congenital tracheal stenosis with severe airway obstruction between 1997 and 2000 in our institution. Informed consent was obtained for the procedure after outlining all potential complications, including airway perforation, infection, dislodgement, and obstruction.

The diagnosis of congenital tracheal stenosis was confirmed by bronchoscopy and bronchography with all procedures performed under general anesthesia with a Storz rigid bronchoscope. The balloon

Results

The study group consisted of five infants with a median age at the time of the initial procedure of 5 (range 2–12) months. In all five cases, there was immediate improvement of respiratory obstruction, and four could be weaned from ventilation. One child died after 9 months of palliation. Inflammation and granulation tissue developed over the stents in all children but could be satisfactorily managed by scraping or balloon compression.

Metallic stents have now been in place for a median of 13 years

Discussion

Airway obstruction in children is a rare, but difficult clinical problem, with no clear agreement on optimal therapeutic approach. Metallic expandable stenting of the airway had been introduced an attractive alternative in children in the 1990s [2], [3], [4], [5], [6], [7] with the aim of achieving airway patency and stabilizing tracheomalacia.

The treatment of congenital tracheal stenosis is still a challenge and we previously introduced a technique utilizing balloon dilatation and the

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Cited by (28)

Anatomic Disorders of the Chest and Airways
2023, Avery's Diseases of the Newborn
The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working toward a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, congenital pulmonary airway malformations (CPAMs), congenital diaphragmatic hernia (CDH), and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made surgical intervention on the infant airway and chest less invasive and more tolerable.
Reactivity Study of a Biodegradable Polydioxanone Tracheal Stent in a Rabbit Model
2020, Archivos de Bronconeumologia
El objetivo de este estudio es evaluar la reactividad traqueal inducida por un stent traqueal biodegradable de polidioxanona.
Veintidós conejos se dividieron en 3 grupos con diferentes tiempos de supervivencia (30, 60 y 90 días postimplantación). Se implantó un stent biodegradable en cada animal, excepto en uno de cada grupo (control negativo). La implantación se realizó a través de una pequeña traqueotomía y bajo control fluoroscópico. Al finalizar los tiempos de supervivencia programados se realizaron estudios de TC y anatomopatológicos.
Ningún animal murió durante el procedimiento ni en el seguimiento. El stent había desaparecido en el 100% de los casos a los 90 días, en el 50% a los 60 días y en ninguno a los 30 días.
En los estudios de TC se observó un grosor de la pared traqueal mayor a los 30 que a los 60 y 90 días (1,60 ± 0,41 mm en la parte central del stent frente a 1,11 ± 0,18 y 0,94 ± 0,11; p = 0,007). En el estudio anatomopatológico no se encontraron granulomas. A los 30 días se observaba cierto grado de alteración histológica, la cual se reduce a los 60 y 90 días. También se encuentran las diferencias, tanto en las TC como en la histología, entre animales con el stent presente y animales con el stent degradado.
Los stents de polidioxanona producen una leve reacción traqueal que revierte con la degradación. El uso de estos stents biodegradables en la patología traqueal benigna es prometedor.
The objective of this study was to evaluate tracheal reactivity induced by a biodegradable polydioxanone tracheal stent.
Twenty-two rabbits were divided into 3 groups assigned to different survival times (30, 60 and 90 days post-implantation). A biodegradable stent was implanted in each animal, except for 1 of each group (negative control). Implantation was performed through a small tracheotomy under fluoroscopic control. CT and histopathological studies were scheduled at the end of survival times.
No animal died during the procedure or follow-up. The stent had disappeared in 100% of the cases at 90 days, in 50% at 60 days, and in none at 30 days.
CT studies revealed a greater tracheal wall thickness at 30 days than at 60 and 90 days (1.60 ± 0.41 mm in the central part of the stent versus 1.11 ± 0.18 and 0.94 ± 0.11; P = .007, respectively). No granulomas were observed on histopathology. Some degree of histological changes were noted at 30 days, which had reduced at 60 and 90 days. Differences were also found in both CT and histology between animals in which the stent was present and animals in which it had degraded.
Polydioxanone stents produce a mild reaction that reverts with tracheal degradation. The use of these biodegradable stents in benign tracheal disease is promising.
A combination of tracheoplasty and tracheal stenting is an acceptable method of treating severe congenital tracheobronchial stenosis under extracorporeal membrane oxygenation
2019, Journal of Pediatric Surgery
Citation Excerpt :
In practice, it should be regarded as a temporizing preoperative measure, and with the availability of ECMO at specialized centers, it should be performed judiciously. Metallic stent placement in the pediatric airway for CTBS has been considered last treatment resort in patients with residual airway malacia after tracheoplasty or in patients unsuitable for surgery [1,2,11,13,14]. Ideally, postoperative transient stenting of the collapsing airway, preferably with biodegradable stents, can provide sufficient time window for pediatric patients to be weaned from sedation and support the trachea while the repair stabilizes through fibrosis [2,15].
Congenital tracheobronchial stenosis (CTBS) is a rare congenital condition characterized by complete cartilage rings covering varying lengths of the major airway. In this study, we reviewed the outcomes of patients with CTBS receiving surgical tracheoplasty in our institute.
We retrospectively analyzed the outcomes of consecutive patients with CTBS operated between 2006 and 2017 when extracorporeal membrane oxygenation (ECMO) was used perioperatively.
In total, 11 patients (median follow-up period, 4.2 years; interquartile range, 1.6–5.4) were included. Seven were symptomatic in the neonatal period, 10 had cardiorespiratory anomalies, 7 required preoperative bronchoscopic balloon dilatation, and 1 required preoperative stent placement. Slide tracheoplasty (STP) was performed in 9 patients, and 2 underwent pericardial patch tracheoplasty. Seven patients required postoperative balloon dilatation, and 6 required postoperative stent placement. Early stenting provided immediate ventilatory improvement in all patients and facilitated successful extubation in a median of 4 days after stenting in 80% of the patients.
Under ECMO, severe CTBS could be successfully treated through a combination of tracheoplasty and bronchoscopic management. STP provided excellent results for solitary trachea stenosis with a minimum diameter of ≥ 3 mm. In selected patients, postoperative tracheobronchial stent placement was crucial in minimizing the ECMO duration and facilitating extubation.
IV
Surgical management of children presenting with surgical-needed tracheal stenosis
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Laser could be associated with balloon dilation on stenosis extended to 2 to 3 rings maximum (1 cm). Tracheal stenting should be performed as a last option [23,24]. Our series does not reflect all the possibilities previously described in the literature.
The purpose of this work was to assess epidemiological aspects, surgical approach, morbidity and mortality rates of patients presenting with tracheal stenosis requiring surgery, and the evolution of surgical techniques over the last years.
We performed a retrospective observational study from 1990 to 2017 in a pediatric tertiary-care center with needing surgery for tracheal stenosis. We analyzed clinical patients' characteristics, type of stenosis, type of surgery and follow-up.
Twenty-eight children presented with tracheal stenosis, half of them with congenital stenosis (complete tracheal rings) and the other half with acquired stenosis (neoplasic or post intubation injury). 39.3% of these stenoses were associated with a vascular ring (61.5% in case of congenital stenosis). Depending on the extent of the stenosis and its origin, the surgery could be performed endoscopically or by an external approach. Enlargement tracheoplasty with an autograft (14.3%) was replaced by slide tracheoplasty with Cardio Pulmonary By-Pass (CPBP, 28.6%) with improved results for the treatment of long segment tracheal stenosis, involving more than 30% of the tracheal length (all were congenital in our study). Slide tracheoplasty has been performed since the late 90's in our institution. 25% of children have had a resection and anastomosis of the trachea because they had a stenosis involving less than 30% of tracheal length. Endoscopic surgery was performed for membranous stenoses, which were often seen after intubation or tracheotomy (32.1% of patients).
Effective treatment of surgical tracheal stenosis was performed in 28 children between 1990 and 2015. Surgical techniques have evolved over time, leading to a better management of this rare and serious disease.
Pediatric Interventional Pulmonology
2018, Clinics in Chest Medicine
Citation Excerpt :
The major disadvantages of these stents are granulation and epithelialization around and inside the stent making stent removal difficult and high risk. Although infrequent, open surgery is required for removal of these stents.43–45 Frequently these stents require repeated bronchoscopies to recanalize the stents by removing secretions and granulation blocking the stent.
Surgical Disorders of the Chest and Airways
2018, Avery's Diseases of the Newborn: Tenth Edition
The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working towards a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, CPAMS, congenital diaphragmatic hernias and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made the surgical intervention on the infant airway and chest less invasive and more tolerable.

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BAPS PaperLong-term outcomes of congenital tracheal stenosis treated by metallic airway stenting

Abstract

Aim

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Thorac Cardiovasc Surg

J Vasc Interv Radiol

BAPS Paper
Long-term outcomes of congenital tracheal stenosis treated by metallic airway stenting