Testing the Limits of Neonatal Tracheal Resection By Michael T. Longaker, Michael R. Harrison, and N. Scott Adzick San Francisco, California 9 Obstructive lesions of the trachea in infants can be life-threatening because secretions or mucosal inflamma- tion can easily obstruct the tiny compromised airway, and distal obstruction cannot be relieved by an endotracheal or tracheostomy tube. The principles of tracheal resection in adults are well established. The limits of tracheal resection in neonates are unknown. We present a case in which at least two-thirds of the trachea was resected successfully in a neonate. 9 1990 by W.B. Saunders Company. INDEX WORDS: Neonatal tracheal resection; congenital tracheal stenosis. rl['~HE PRINCIPLES of tracheal resection in adults I 12 1. are well established. ' The management of exten- sive tracheal stenosis in the newborn presents a difficult surgical problem, and the limits of tracheal resection in the neonate are unknown. We present the case of a newborn with critical tracheal stenosis that involved nearly the entire trachea. This lesion was successfully managed by extensive resection and primary anastomo- sis. CASE REPORT A 2,480-g newborn boy underwent repair of a large left congenital diaphragmatic hernia using a Gore-Tex patch (W.L. Gore and Assoc, Flagstaff, AZ). He was gradually weaned from mechanical ventilation over 4 weeks, but it was noted that the tip of the endotracheal tube could never be advanced past the subglottic region. An attempt at extubation failed secondary to stridor. Bronchoscopic examination using the 2.5-mm Storz bronchoscope (Storz Instrument Co, St Louis, MO) showed a pinpoint stenosis 2 cm below the vocal cords and complete tracheal rings. Cine- computed tomography (CT) showed a long, tight stenosis in the midtrachea. Through a cervical collar incision and upper median sternotomy, he underwent surgical exploration at 4 weeks of age. A striking external deformity from 3 cm below the cricoid down to the trifurcation of the trachea was noted (including a "pig" bronchus; the right upper lobe bronchus originated directly off the trachea just above the carina). The tracheal lumen was so severely stenotic that placing a rib graft to augment the luminal diameter was not a surgical alternative. The trachea was transected at multiple levels until the widest available lumen was encountered just above the pig From the Fetal Treatment Program, the Division of Pediatric Surgery, and the Department of Surgery, University of California, San Francisco, CA. Presented at the 22nd Annual Meeting of the Pacific Association of Pediatric Surgeons, Portland and Sun River, Oregon, May 22-26, 1989. Address reprint requests to Michael R. Harrison, MD, Professor of Surgery, 585 HSE, UCSF, San Francisco, CA 94143-0506. 9 1990 by W.B. Saunders Company. 0022-3468/90/2507-002 l $03.00/0 bronchus while the baby was ventilated across the operative field using sterile tubing. It was obvious that the length of the stenotic area had been underestimated by the cine-CT scan. A total of nine complete rings (greater than two thirds of the entire trachea) were resected (Fig 1), and the anastomosis was performed under consider- able tension using interrupted 5-0 polydioxanone (PDS) sutures. Laterally placed stay sutures of 2-0 silk were used to relieve tension on the anastomosis. Complete tracheal rings with severe intralumi- nal stenosis were present in the 6-cm long specimen (Fig 2). He was placed in a cervical flexion brace postoperatively to reduce anasto- motic tension. In addition to his respiratory problems, he had severe gastroesoph- ageal reflux and recurrent aspiration pneumonia along with poor nutrition. We performed a Nissen fundoplication and gastrostomy at 2 months of age, and 3 weeks later small bowel obstruction necessitated repeat exploration and bowel resection for an acquired ileal atresia. Throughout the 12 weeks following tracheal resection, multiple attempts at extubation failed due to stridor and hypercarbia. Multiple balloon dilations were performed, using first a 5-mm and then a 7-ram Grunzig angioplasty catheter (Bard, Inc, Billerica, MA) for recurrent stenosis and granulation tissue at the anastomotic site. Repeated flexible and rigid bronchoscopic examination showed a 40% to 60% anastomotic stenosis that was approximately 5 mm in length and ended 8 mm proximal to the carina. There appeared to be 29 mm of good trachea proximal to the stenosis (Fig 3A). The boy did not show sustained improvement after balloon dilations and remained ventilator-dependent. Accordingly, he was reexplored through the previous cervical incision and upper sternot- omy at 4 months of age. Dense tracheal scarring was encountered, a 5-mm thick stenotic segment at the old anastomotic site was resected, and a tension-free patulous anastomosis was performed using a bronchoplasty onto the right upper lobe pig bronchus (Fig 3B). He was extubated on postoperative day 2 and was discharged in his cervical flexion brace (Fig 4). He has done very well at home and remains asymptomatic at 20 months of age. DISCUSSION Obstructive lesions of the trachea in infants can be life-threatening because secretions or mucosal inflam- mation can easily obstruct the tiny compromised air- way, and distal obstruction cannot be relieved by an endotracheal or tracheostomy tube. Three principle types of congenital tracheal stenosis have been de- scribed: (1) generalized hypoplasia; (2) funnel-like narrowing usually tapering to a tight stenosis just above the carina; and (3) segmental stenosis of various lengths that can occur at any level. 2 This patient had complete tracheal rings and critical stenosis involving nearly the entire trachea. This anatomic arrangement is often associated with bronchial anomalies, 2-6and this patient had a pig bronchus where the right upper lobe bronchus originated directly off the trachea. In evaluating the infant with tracheal stenosis, the diagnostic value of every procedure must be weighed 790 Journal of Pediatric Surgery, Vol 25, No 7 (July), 1990: pp 790-792