Slide tracheoplasty with pericardial patch augmentation for reconstruction of severe congenital tracheal stenosis involving carina : A case report.

Objective: Slide tracheoplasty seems to be the most efficient surgical procedure for correcting long-segment funnel-shaped congenital tracheal stenosis. However, in cases of extremely long-segment or those involve carina, slide tracheoplasty when operated alone has certain degree of limitations which often need additional operative procedure. The authors report a technique of slide tracheoplasty in combination with pericardial patch augmentation in a child with congenital tracheal stenosis involving the carina. Methods: A 3-month-old girl, previously diagnosed with Tetralogy of Fallot and congenital tracheal stenosis, presented with severe cyanosis and serious major airway obstruction after a few days of upper respiratory tract infection (URI). Because of the failure to maintain her ventilation with a high positive pressure ventilator, an emergency slide tracheoplasty with a modified right Blalock’s Taussig shunt was performed under a cardiopulmonary bypass. The intraoperative finding revealed a complete tracheal ring stenosis involving the lower half of the trachea and carina. It was transected at the middle and a vertical incision was made at the posterior wall of the upper trachea and anterior wall of the lower and extended into orifices of the main bronchus. The upper and lower tracheal flaps were slid together and sutured with interrupted Proline 5-0. Consequently, she still had significant obstruction of the main bronchi postoperatively and needed a re-operation two days later. Under cardiopulmonary bypass support, the lower anastomotic sutures were removed and an additional bronchial incision was made into the main bronchus. The anterior upper tracheal flap was separated into two, and each equal flap was pulled down and sutured to the main bronchus. Then an autologous pericardial patch was used to cover all the airway defects. Intraoperative fiberoptic bronchoscopy demonstrated adequate tracheo-bronchial lumen. Results: The child had postoperative hyperactive airway reaction and needed prolonged ventilator support and tracheostomy for tracheal toileting. Repeated postoperative bronchoscopy found moderated granulation tissue which was easily removed by catheter suction. Unfortunately, the patient expired six months after the surgery due to uncontrolled sepsis. However, a bronchoscopic finding before the patient’s death revealed adequate major airway patency. Conclusion: Combined slide tracheoplasty with pericardial patch augmentation made reconstruction of the complex congenital tracheal stenosis involving carina or tracheal bronchus possible and minimized the result of unflavoric excessive granulation tissue forming caused by pericardial tracheoplasty alone.

The Sternal Turn Over Procedure with Preservation of the Internal Mammary Vessel and Rectus Abdominis Muscle Pedicles for the Repair of Severe Pectus Excavatum.

Pectus excavatum or funnel chest is one of the most common congenital chest wall deformities. Surgical correction should be considered for all patients with moderate to severe deformities because of the significant cosmetic and psychological improvement, subjective increase in exercise tolerance, documented changes in the cardiac and respiratory status, and prevention of the development of scoliosis after surgical intervention in these patients. The sternal turn over procedure with preserved internal mammary vessels and rectus abdominis muscle pedicles for the corrective repair of severe pectus excavatum, involves resection of the deformed thoracic wall, sternum and ribs, preserving an attachment of the rectus abdominis muscle,and a vascular pedicle of the internal mammary vessel. A short segment resection above the ipsilateralcostal cartilage is mandatory to allow reposition of the vascular pedicle onto the presternal surface after turn over of the sternum. Multiple corrective osteotomy and costoplasty must be completed before refixing the sternum and ribs. The modified sternal turn over procedure restores the sternal blood supply and should be applied to the severe form of pectus excavatum which needs extensive and multiple bony resection. The procedure has been applied to a boy and a girl aged 5 years. At a three year follow up, the results obtained are excellent.