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Slide tracheoplasty for the treatment of tracheoesophogeal stulas

Matthew J. Provenzano
, Michael J. Rutter
, Daniel von Allmen
, Peter B. Manning
, R. Paul Boesch
Philip E. Putnam
, Angela P. Black
, Alessandro de Alarcon
Division of Pediatric Otolaryngology Head and Neck Surgery, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 452293026
Division of General and Thoracic Surgery, Division of Pediatric Surgery, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 452293026
The Heart Center: Cardiology Cardiothoracic Surgery, St. Louis Childrens Hospital, One Children's Place, Suite 5S50, Saint Louis, MO 63110
Pediatric and Adolescent Medicine, Mayo Clinic, 201W Center St, Rochester, MN 55902
Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 452293026
a b s t r a c t a r t i c l e i n f o
Article history:
Received 14 January 2014
Accepted 27 January 2014
Key words:
Esophageal atresia
Cardiopulmonary bypass
Purpose: The purpose of this study is to determine the surgical outcome of slide tracheoplasty for the
treatment of tracheoesophageal (TE) stula in pediatric patients.
Methods: After internal review board approval, the charts of pediatric patients (018 years old) who had
undergone slide tracheoplasty for tracheoesophageal stula were retrospectively reviewed. Patient
information and surgical outcomes were reviewed.
Results: Nine patients underwent slide tracheoplasty for correction of TE stula. In ve patients the original TE
stula was congenital. Other causes included battery ingestion, tracheostomy tube complications, foreign body
erosion, and an iatrogenic injury. The average age at repair was 48 64 months (range: 1190). Seven patients
had undergone previous TEF repair either open or endoscopically. There were no recurrences after repair. Two
patients had sternal periosteuminterposed between the esophagus and trachea. There were no TEF recurrences.
A single patient had dehiscence of the tracheal anastomosis and underwent a second procedure.
Conclusion: Slide tracheoplasty is an effective method to treat complex TE stulas. The procedure was not
associatedwithanyrecurrences. This is the rst descriptionof a novel, effective, andsafemethodtotreat TE stulas.
2014 Elsevier Inc. All rights reserved.
Complex tracheoesophageal (TE) stulas can be signicantly
challenging to surgically correct and carry signicant morbidity and
mortality if left unrepaired. These aberrant connections between the
esophagus and trachea are often associated with esophageal atresia,
dysmotility, tracheomalacia and various syndromes. Food may enter
the airway and soil the lungs. The patients, often medically fragile, are
then prone to repeat bouts of pneumonia and respiratory complica-
tions. Oral feeding becomes impossible for many. Despite refraining
fromeating, many continue to have saliva entering the airway, leading
to persistent pulmonary injury. Repair of these aberrant connections
therefore becomes essential to a healthy lower airway as well as
reestablishing oral feeds.
Surgical correction of TE stulas preserves trachea and esophagus
patency while closing the communication between these two
structures. A number of procedures have been developed to address
this problem. However, many of these procedures have had limited
success when dealing with the most complex stulas. Successful
repair was rst reported in the 1940s using an extrapleural approach
and primary anastomosis to address the stula and esophageal atresia
[1]. Since that time a number of different techniques have been
employed [24]. These procedures have sought to decrease the
morbidity associated with the approach while improving the closure
rates. Various alterations in anastomosis have been proposed [1].
Some authors have used cervical esophagostomy and gastrostomy or
replacement for treatment in patients with severe disease and atresia
[3]. Endoscopic procedures are also employed; small stulas can be
cauterized from both the esophageal and tracheal sides. Fibrin glue
can also be placed within the stula [2].
Previous techniques closed the esophageal and tracheal compo-
nents separately but continued to leave the two anastomosis lines
juxtaposed. Breakdown of one closure made it likely that the opposite
side would also fail. Some authors have used various materials, such
as vein or pleura, between the two repair sites to help prevent
breakdown of the closure [5]. Despite this interposed tissue, the two
anastomotic lines continued to be continuity. Even with the success
with these procedures, persistent and recurrent stulas remain
surgical challenges. Revision cases carry the additional difculties of
scaring, altered surgical anatomy and compromised blood supply to
the tissue. Given these reasons, repair of recurrent stulas is often
difcult and associated with signicant morbidity and mortality [3].
Slide tracheoplasty is a technique utilized to address various
etiologies of tracheal stenosis [6,7]. It has proven a safe and highly
effective treatment for patients with complete tracheal rings [6].
While this procedure has been successfully employed for tracheal
abnormalities, the literature is absent of any reports using this
Journal of Pediatric Surgery 49 (2014) 910914
Corresponding author. Tel.: +1 513 636 4355; fax: +1 513 636 8133.
E-mail address: mike.rutter@cchmc.org (M.J. Rutter).
0022-3468/ 2014 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery
j our nal homepage: www. el sevi er . com/ l ocat e/ j pedsur g
technique to address complex TE stulas. We have found success with
this technique when reserving it for complex cases or previously
repaired stulas. In this report we present the novel use of slide
tracheoplasty for the treatment of TE stulas and describe the surgical
outcomes of this procedure.
1. Materials and methods
1.1. Data collection and analysis
Data collection and patient selection were performed after
approval by the Cincinnati Childrens Hospital Medical Center
Institutional Review Board. Patients were identied who had a
diagnosis of TE stula and who had undergone repair by slide
tracheoplasty. Pediatric patients (age 018 years old) were identied
from 2000 to 2012. Demographic information, surgical data and
outcomes were recorded and analyzed using Microsoft Excel
(Redmond, WA). Patient gender, age at surgery and medical diagnosis
were recorded. Previous surgical procedures were noted as well as
intraoperative ndings, surgical outcomes and complications.
1.2. Surgical procedure
Our previous publication has described the slide tracheoplasty
technique [6]. Modications have been made to address the TE stula.
Microscopic direct laryngoscopy, bronchoscopy and esophagoscopy
are initially performed to verify the location of the stula. An
esophageal bougie is placed. The technique varies depending upon
the surgical approach. Patients undergoing a cervical incision will be
intubated orally, or in the case of an existing tracheostomy, through
the stoma site. Patients requiring a sternal incision and cardiopulmo-
nary bypass will be intubated orally with the stoma sutured shut. In
these patients, cardiopulmonary bypass is established prior to the
beginning of tracheal work. In both approaches, the anterior wall of
the trachea is freed from surrounding tissue as distal as possible. For
patients with a cervical approach, mobilization often continues into
the mediastinum and to the carina. In all patients, care is taken to
preserve lateral tracheal attachments to maintain the blood supply
and avoid damage to the recurrent laryngeal nerves. Retraction
sutures using 20 Prolene (Ethicon, Blue Ash, OH) are placed through
the distal tracheal rings to retract the trachea. Flexible bronchoscopy
through the endotracheal tube or rigid bronchoscopy can be repeated
to conrm the location of the stula. A needle is placed through the
anterior tracheal in the corresponding location of the stula. The
trachea is then divided both superior and inferior to the stula tract,
leaving a small portion of trachea attached to the tract (Fig. 1). The
trachealis of the superior and inferior tracheal segments is then
separated from the esophagus and mobilized. The trachea that
remains attached to the stula is then freed of it mucosa and the
cartilage portion is removed (Fig. 2). The edges of the esophageal side
of the stula are freshened in preparation of closure. The tracheal
mucosa is then inverted and folded into the esophageal portion of the
stula. Closure is performed with a series of interrupted vicryl sutures
(Ethicon). In cases of large stulas, the cartilage can be kept in
continuity with the mucosa and used in the closure for added support.
Periosteum is harvested from the sternum and placed on top of the
esophageal closure (Fig. 3).
Approximately 1 cm of the posterior wall of the inferior tracheal
segment and the anterior wall of the superior segment are then
divided vertically. The corners of the two segments are removed in
order to achieve better approximation during closure. A running,
polydioxanone (PDS) (Ethicon) is then used to close the anastomosis
beginning with the posterior aspect of the trachea. The resulting,
oblique anastomosis is longer than a corresponding end-to-end
anastomosis, thereby distributing the tension across a longer area.
Once all sutures are placed, brin glue is then applied across the
tracheal closure. If occurring through a cervical incision, the
previously placed Prolene retraction sutures can be placed around
the hyoid as internal Grillo sutures. When performed through a
sternotomy, the retraction sutures can be removed as the hyoid is not
exposed. The patient remains intubated overnight in the intensive
care unit and is generally extubated on postoperative day one. The
endotracheal tube lumen should be large enough to accommodate a
exible bronchoscope containing a suction port, thereby allowing for
the removal of secretions or blood. A repeat bronchoscopy can be
performed in one to two weeks. Fig. 4 demonstrates preoperative and
postoperative photos.
Fig. 1. The trachea is divided superior and inferior to the stula site. A small portion of
the trachea remains attached at the stula and is used to reinforce the stula repair.
Fig. 2. The tracheal mucosa is removed from the cartilaginous rings and folded into the
denuded stula to reinforce the closure. In some instances the cartilage can also be used
to reinforce the closure site.
911 M.J. Provenzano et al. / Journal of Pediatric Surgery 49 (2014) 910914
2. Results
Nine patients were identied who had a TE stula repaired by slide
tracheoplasty. The average age at surgery was 48 64 months
(range: 1190 months). A variety of etiologies and associated
anomalies were identied (Table 1). Seven of patients had undergone
previous repairs including open and endoscopic procedures (Table 2).
Two patients had a slide tracheoplasty as their initial procedure given
the complexity of their case. One patient had suffered a foreign body
erosion through a bronchi resulting in a large stula which made
repair via other techniques difcult. This patient had a slide on bypass.
A second patient had a stula in the presence of signicant upper
airway obstruction. In that case, the slide addressed both the stula as
well as some levels of stenosis.
Three patients had additional airway procedures performed to
address subglottic stenosis. Sternal periosteum was used in two
procedures (Table 3). Slides were performed either through a sternal
incision with the patient placed on cardiopulmonary bypass or
through the neck with normal ventilator support. There were no
recurrences after surgical repair. Five patients had a stula greater
than 1 cm in length. A single patient experienced a tracheal
dehiscence that resulted in a second slide procedure. That patient
required a temporary tracheostomy and was eventually decannu-
lated. Five patients had a tracheostomy; four were present preoper-
ative and one was placed postoperative during treatment of subglottic
stenosis. Three patients who did not take oral intake prior to surgery
were able to eat by mouth after stula repair.
Fig. 3. The sternal periosteum is placed between the tracheal and esophageal closure to reinforce the repair. Tracheal closure occurs through an oblique running anastomosis. The
trachea mucosa that had been removed from the tracheal cartilage has been folded into the esophageal side of the stula and incorporated into the repair.
Fig. 4. Preoperative photos of the trachea show the small stula tract with a suction
catheter inserted. The trachea itself shows moderate tracheomalacia withthe stula distal
near the carina. Postoperative photos show the stula tract closed with a small, closed
dimple in the mucosa.
Table 1
Demographic information for 9 patients.
Age at surgery: 48 64 months (range: 1190)
Female: 4 (44%)
Esophageal atresia: 3 (33%)
H-type stulas: 3 (33%)
Congenital 5 (55%)
Battery ingestion 1 (11%)
Iatrogenic 1 (11%)
Tracheostomy tube erosion 1 (11%)
Foreign body erosion 1 (11%)
Associated anomalies
Esophageal stricture 3 (66%)
VACTERL 1 (11%)
DiGeorge 1 (11%)
GERD 4 (44%)
Tracheomalacia 5 (56%)
Cardiac anomalies 2 (22%)
GERD: Gastroesophageal reux disease.
912 M.J. Provenzano et al. / Journal of Pediatric Surgery 49 (2014) 910914
3. Discussion
While other surgical techniques have successfully treated TE
stulas, a subgroup of patients have recurrences, persistence or
complex stulas. Tsai and colleagues reported a 10% recurrence rate
[8], consistent with the experience of other authors [5]. Some patients
experience multiple recurrences, making subsequent repairs increas-
ingly difcult [3]. Certain procedures, such as stula ligation, are
associated with higher rates of recurrence [4]. The technique
presented here was not associated with any recurrences or persistent
stulas. This despite the difculties associated with revision proce-
dures. The difference in recurrence rate between our series and
previously published work likely results from the slide tracheoplasty
technique. Unlike other procedures, this technique offsets the tracheal
and esophageal repairs. By advancing the trachealis the esophageal
and tracheal anastomosis lines are not in continuity. Breakdown of
one closure line should not affect the other closure. In contrast, other
procedures keep the esophageal and tracheal closures juxtaposed. In
that scenario, breakdown of one closure jeopardizes the other.
The use of sternal periosteum in two patients highlights an
additional method to prevent recurrences. The periosteumwas placed
between the tracheal and esophageal walls to support the stula
closures. We employ this technique for laryngeal cleft repair and have
found that even when one side of the stula breaks down, the
periosteum remains intact and the cleft does not recur. Others have
reported the use of pericardium, pleura or vein [5]. We choose to use
periosteumgiven the ease of harvesting it froma cervical incision and
the large amount of available material. To our knowledge, this is the
rst instance of its use in repairing TE stulas. Although not a
vascularized material, its durability likely exceeds that of other free
tissue grafts such as vein or free muscle.
The slide tracheoplasty technique also addresses the difculty
with tension along the anastomosis, a nding noted to effect surgical
outcomes [3,5]. The long, oblique anastomosis line in this technique
distributes the tension across a greater surface area, preventing break
down of the anastomosis. When the slide is done through a cervical
incision, tension along the anastomosis can be decreased through the
hyoid release and use of internal retraction sutures.
While this technique carries signicant benets for TE stula
closure, it also presents challenges and risks. Signicant mobilization
of the trachea can be difcult especially in the setting of previous
surgical repairs. Despite this, previous reports have demonstrated
successful slide tracheoplasty after a previous stula repair [9,10]. A
majority of the patients in our series had undergone a previous
procedure. Despite these past operations, scarring and distorted
anatomy, slide tracheoplasty was performed in all patients. We have
found it difcult to completely free the trachea distally. Mobilization
in this area is facilitated by sternotomy and cardiopulmonary bypass
but can be difcult when performing the slide through a cervical
incision. One patient had previously underwent a tracheal resection
but still had an uneventful slide procedure. Despite this success,
caution should be taken in those patients with a shortened trachea as
mobilization and the anastomosis may be difcult.
Freeing of the trachea also requires attention to recurrent
laryngeal nerve position. The nerves normal location within the
tracheoesophageal groove can be altered from previous surgery,
scarring or aberrant development. We have found that adhering
closely to the tracheal wall protects the nerves. One patient in our
series did have unilateral vocal cord paralysis. This patient had a
postoperative dehiscence requiring reoperation, wound exploration
and a repeat slide. It is unknown if the recurrent laryngeal nerve
injury occurred at the rst or second procedure or whether it was a
preexisting consequence of the original button battery injury.
A single patient (1/9, 11%) had tracheal dehiscence postopera-
tively. This is a major, life threatening complication. Close postoper-
ative monitoring is essential for early detection. Wound crepitus or
respiratory compromise must be promptly and thoroughly invested.
There must be a low tolerance for returning to the operating room.
While our patient was successfully treated with a repeat slide, it has
been our experience that other interventions are occasionally
required to secure the airway in the event of tracheal dehiscence.
These can include placement of a tracheostomy, T-tube, tracheal
stenting or reconstruction with cartilage grafts. Repeat slide tracheo-
plasties in the setting of dehiscence often require additional tracheal
mobilization as the tissue is more friable and tension at the
anastomosis needs to be signicantly reduced.
The single dehiscence reported here is higher than our previously
published work concerning slide tracheoplasty for treatment of
complete tracheal rings [6]. The esophageal component in this series
may be responsible for the higher dehiscence rate. Esophageal
involvement may reduce blood supply to the trachealis while also
exposing the anastomosis to esophageal contents in the event of a
partial breakdown. This patient suffered signicant intimal damage
from the battery ingestion that caused the stula. This likely
contributed to the poor esophageal and tracheal blood supply that
hindered healing and predisposed this patient to dehiscence.
Associated esophageal and tracheal anomalies did not affect
surgical outcome. The two patients with tracheal pouches had
successful closure of their stulas without surgical difculties. Those
patients with tracheomalacia may sometimes benet fromthe altered
conguration of the trachea that results from the slide. However, this
is not the primary purpose of this procedure and we did not assess for
changes in tracheomalacia symptoms after the slide. Any respiratory
improvements were likely secondary to closure of the stula and
prevention of pneumonias. Two patients had continued tracheal
stenosis even after the slides, a nding seen in our slide tracheoplasty
experience [6].
This series demonstrated that slide tracheoplasty can successfully
repair complex, recurrent or persistent TE stulas. It is a procedure
reserved for those instances and should not be employed as initial
treatment for simple stulas that could best be addressed via other
Table 2
Associated procedures.
Previous procedures
No. of patients 6 (67%)
Total no. previous procedures 19
Endoscopic (no. pts) 5 (56%)
Open (no. pts) 2 (22%)
Additional airway procedures performed after slide tracheoplasty
ssLTP ACCG 2 (22%)
CTR 1 (11%)
dsLTP APCCG, arytenoidectomy, petiole repositioning 1 (11%)
ssLTP: single stage laryngotracheoplasty; ACCH: anterior costal cartilage graft; CTR:
cricotracheal resection; dsLTP: double stage laryngotracheoplasty; APCCG: anterior
posterior costal cartilage graft.
Table 3
Surgical procedure and results.
Cardiopulmonary bypass 3 (33%)
Sternal periosteum 2 (22%)
Fistula size
b1 cm 4 (44%)
N1 cm 5 (56%)
Yes 5 (56%)
No 4 (44%)
Surgical outcomes
Recurrence 0 (0%)
Infection 0 (0%)
VC paralysis 1 (11%)
Dehiscence 1 (11%)
Mild tracheal stenosis 2 (22%)
913 M.J. Provenzano et al. / Journal of Pediatric Surgery 49 (2014) 910914
means. In our series no patients had a recurrence. Sternal periosteum
is easily harvested and provides an additional level of repair
reinforcement. Repair in this manner does not prevent future airway
procedures and was associated with relatively fewcomplications. This
technique offers a novel approach to treating these stulas.
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914 M.J. Provenzano et al. / Journal of Pediatric Surgery 49 (2014) 910914