SURGICAL RELIEF OF TRACHEOBRONCHIAL OBSTRUCTION IN INFANTS AND CHILDREN

Objective: Congenital tracheobronchial obstruction (TBO) presents a co mplex problem both in terms of diverse aetiology, presence of associat ed anomalies and the operative strategy to be adopted. We report a sin gle centre experience in managing this difficult problem. Methods: Twe nty-four infants and children with TBO referred to our unit over a 12- year period are reviewed. Aetiology of TBO included vascular rings (n = 9), anomalous innominate artery (n = 6), congenital tracheal stenosi s (n = 5), segmental bronchial stenosis (n = 2) and pulmonary artery c ompression of the main bronchi (n = 2). Seven patients had concurrent cardiac anomalies. Strider was the commonest presenting symptom (67%). Mean delay from onset of symptoms to referral was 19 months. One pati ent died preoperatively due to acute airway obstruction. Mean age at o peration was 33.1 +/- 42 months (range 4 days-156 months) and 11 child ren were under 1 year at the time of surgery. In cases of TBO secondar y to vascular rings, division of the ring resulted in relief of sympto ms in seven cases, with two requiring further surgery for resultant tr acheomalacia. Four of the five patients having tracheal resection were operated on with the use of cardiopulmonary bypass; three of these pa tients had concurrent correction of cardiac lesions, with two survivor s. Tracheobronchial anastomoses were carried out using continuous poly dioxanone (PDS). Patients with anomalous innominate arteries required aortopexy in five and innominate artery suspension in one, while those with pulmonary artery compression of the main bronchi had correction of their intracardiac defects (n = 2). Results: Hospital mortality was 8.7% and there has been one late death due to Eisenmenger syndrome se condary to pulmonary regurgitation, atrial septal defect (ASD) and pat ent ductus arteriosus (PDA). On follow-up (mean 40 +/- 31 months), 19 patients are alive and symptom free. There have been no anastomotic st rictures following tracheobronchial resection. The single most importa nt predictor of mortality was the presence of associated cardiac anoma lies. Conclusions: TBO can be managed effectively by a single operatio n in both infants and children without a detrimental effect on trachea l growth. We advocate consideration of concurrent repair of the trache al and cardiac lesions. Cardiopulmonary bypass (CPB) allows this concu rrent correction of cardiac lesions and also facilitates tracheal rese ction. (C) 1997 Elsevier Science B.V.