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J Thorac Cardiovasc Surg 1998;115:1216-1218
© 1998 Mosby, Inc.
BRIEF COMMUNICATIONS |
Lille, France
From the Clinique Chirurgicale, Hopital Albert Calmette CHRU Lille, 59037 Lille Cedex, France.
Received for publication Nov. 17, 1997. Accepted for publication Dec. 8, 1997. Address for reprints: H. Porte, MD, Clinique Chirurgicale, Hopital Albert Calmette CHRU Lille, 59037 Lille Cedex, France.
A mother fell down a flight of stairs while carrying her 5-year-old sonin her arms. As she fell, she tightened her grip around the child's chest,leading to a blunt chest trauma with reflex closure of the glottis associatedwith trauma to the head. A medical emergency unit found the boy unconscious withsubcutaneous emphysema of the neck and both hemithoraces. He was intubatedwithout sedation with a No. 5 cuffed nasotracheal tube, and positive-pressureventilation was initiated.
On admission to the hospital 1 hour later, the child was conscious andhis respiratory status remained stable. A chest radiograph showed a partialbilateral pneumothorax that was larger on the right side, with extensivesubcutaneous and mediastinal emphysema. A thoracic computed tomographic scanshowed that the esophagus was protruding into the tracheal lumen through itsposterior wall (Fig. 1). Examination with a flexible bronchoscoperevealed a 4 cm posterior longitudinal tear from the trachea to the right mainbronchus. Despite bilateral pleural drainage, the child's respiratory statusdeteriorated rapidly and he was transferred to the operating room with acuterespiratory failure. Selective ventilation of the left lung was not possiblebecause the endotracheal tube could not be advanced far enough beyond thelaceration into the left main-stem bronchus. A right lateral thoracotomy wasquickly performed. As the posterior mediastinal pleura was progressively opened,detailed inspection of the injury revealed an 11 cm burstlike fracture with amajor defect of the membranous pars from the trachea to the right main bronchusand the bronchus intermedius (Fig. 2, A). Gas exchange seriously deterioratedbecause of the extent of the air leak. An attempt to perform high-frequency jetventilation with the tip of the gas inflow catheter advanced distal to therupture failed. The acute condition of the patient and the length of thetracheobronchial rupture necessitated that an esophageal tracheobronchoplasty beperformed to reconstruct the posterior wall of the trachea. The right edge ofthe esophagus was sutured to the right edge of the wound from the trachea to thebronchus intermedius with interrupted 5-0 absorbable monofilament sutures (Fig.2, B
).An immediate air seal was obtained. The tracheal tube was positioned above thesuperior edge of the wound before chest closure. Further recovery requiredbronchoscopic toilets each day to keep the airway clear of secretions.
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Rupture of the tracheobronchial tree is an uncommon complication of bluntchest trauma. In our young patient, the reflex closure of the glottis togetherwith thoracic compression produced a rapid increase in intraluminal pressure.This injury occurred when the child's mother tightened her grip around him,illustrating the fact that extreme violence is not essential for such burstlikelesions. 2 Overinflation ofthe tracheal cuff when the accident occurred may have contributed to the extentof the injury. Moreover, the extensive tearing of the membranous pars can beexplained by further dissection with the aid of positive ventilatory support.
When a major tracheal or bronchial injury is suspected, bronchoscopyshould be performed to establish the precise location of the injury.Nevertheless, this procedure can also lead to an underestimation of the extentof injury. 3 Computedtomographic scans may also provide additional information regarding the severityof the injury, such as in the case described here where the esophagus was foundto be protruding into the tracheal lumen.
Anesthetic management of the ruptured airway can be hazardous inpediatric patients. In the case of rupture of the carina or main bronchus,double-lumen tubes are not available in pediatric sizes, and tubes withbronchial blockers could exacerbate the injury. Consequently, selectiveintubation with the aid of bronchoscopic guidance with a long single-lumentracheal tube is the best technique to achieve appropriate ventilation. 4 Intubation of the left mainbronchus through the operative field is another possibility. None of thesemaneuvers were possible in the case of the small child described here, however,whose condition was extremely unstable. An intraoperative air seal was the soleprocedure available to us to restore proper ventilation. Tracheoplasty with theesophageal wall was initially described to treat patients with congenitaltracheal stenosis. Niwa and associates 5first reported the delayed treatment of an iatrogenic tracheobronchial injurywith this method.
The operative technique we used differed from the one described by Niwa,who sutured the left and right edges of the trachea to the esophagus.
This is, to our knowledge, the first report of such a technique beingsuccessfully used in an emergency to repair a tracheobronchial rupture. We usedthis procedure because it was the most expeditious way to achieve a perfect airseal. In addition, the abundant blood supply to the esophageal wall makes itsuperior to an isolated pericardial graft to repair such a large defect. Theesophageal wall was completely epithelialized 3 months after the procedure wasperformed, and the absence of tracheobronchial stenosis by granulation tissueconfirms that this technique can be used safely in young children.
In conclusion, esophageal tracheobronchoplasty is a simple and efficientmethod to obtain immediate and complete reconstruction of the tracheal wall incases of extended burstlike trauma with further ad integrum recovery of bothairway and esophageal functions.
References
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