Surgical relief of tracheobronchial obstruction in infants and children

OBJECTIVE: Congenital tracheobronchial obstruction (TBO) presents acomplex problem both in terms of diverse aetiology, presence of associatedanomalies and the operative strategy to be adopted. We report a singlecentre experience in managing this difficult problem. METHODS: Twenty-fourinfants and children with TBO referred to our unit over a 12-year periodare reviewed. Aetiology of TBO included vascular rings (n = 9), anomalousinnominate artery (n = 6), congenital tracheal stenosis (n = 5), segmentalbronchial stenosis (n = 2) and pulmonary artery compression of the mainbronchi (n = 2). Seven patients had concurrent cardiac anomalies. Stridorwas the commonest presenting symptom (67%). Mean delay from onset ofsymptoms to referral was 19 months. One patient died preoperatively due toacute airway obstruction. Mean age at operation was 33.1 +/- 42 months(range 4 days- 156 months) and 11 children were under 1 year at the time ofsurgery. In cases of TBO secondary to vascular rings, division of the ringresulted in relief of symptoms in seven cases, with two requiring furthersurgery for resultant tracheomalacia. Four of the five patients havingtracheal resection were operated on with the use of cardiopulmonary bypass;three of these patients had concurrent correction of cardiac lesions, withtwo survivors. Tracheobronchial anastomoses were carried out usingcontinuous polydioxanone (PDS). Patients with anomalous innominate arteriesrequired aortopexy in five and innominate artery suspension in one, whilethose with pulmonary artery compression of the main bronchi had correctionof their intracardiac defects (n = 2). RESULTS: Hospital mortality was 8.7%and there has been one late death due to Eisenmenger syndrome secondary topulmonary regurgitation, atrial septal defect (ASD) and patent ductusarteriosus (PDA). On follow-up (mean 40 +/- 31 months), 19 patients arealive and symptom free. There have been no anastomotic strictures followingtracheobronchial resection. The single most important predictor ofmortality was the presence of associated cardiac anomalies. CONCLUSIONS:TBO can be managed effectively by a single operation in both infants andchildren without a detrimental effect on tracheal growth. We advocateconsideration of concurrent repair of the tracheal and cardiac lesions.Cardiopulmonary bypass (CPB) allows this concurrent correction of cardiaclesions and also facilitates tracheal resection.