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Ann Thorac Surg 1998;65:1830-1831
© 1998 The Society of Thoracic Surgeons

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Update

Experimental Study of a New Porous Tracheal Prosthesis

^a Thoracic Surgery Unit, Hospital General Universitario, Valencia, Spain

Address reprint requests to Dr Guijarro Jorge, Servicio de Cirugía Torácica, Hospital General Universitario, Avda, Tres Cruces s/n, 46014 Valencia, Spain
e-mail: (rguijar{at}separ.es)

Extensive tracheal defects after invasive medical care, trauma, or large resections of tumors remain a major challenge, not solved in general thoracic surgery [1]. When end-to-end anastomosis after extensive mobilization maneuvers is insufficient, a tracheal prosthesis is the solution. Many materials and techniques have been employed to this effect [2]. Such great diversity reflects the ongoing need to develop an ideal solution in this situation.

Research on prosthetic materials for tracheal replacement goes back more than 100 years. Previous studies with nonporous tracheal prosthesis like silicone rubber tubes, stainless steel, and a long list of other materials showed no incorporation of the implant because of developing granulation tissue at the anastomoses [3]. Research soon centered on porous materials, which permitted migration of cellularity and therefore internal growth of fibrous tissue, epithelialization, and bioincorporation of the implant.

Several conditions must be met by an ideal porous tracheal prosthesis. It must be easy to handle and cut to size. It must be also highly biohistocompatible, rigid enough to prevent it from collapsing, and impermeable to air. Several authors [4] have suggested that polytetrafluoroethylene could be an optimum material for such use.

In 1990 we reported an experimental study in rabbits using a new porous reinforced tracheal prosthesis made of expanded polytetrafluoroethylene [5]. In that article, we concluded that a necessary condition for full bioincorporation of the prosthesis was full epithelialization of its inner surface, because if this did not occur, granulation tissue from the surrounding tissues would grow and occlude the graft or cause a fatal tracheal stenosis. Since then, other experimental and clinical studies [2, 6] have concluded that the lack of epithelial lining on the luminal surfaces and inadequate biophysical properties and shapes of the prostheses were the main causes for failure of them.

Several surgical and experimental strategies have been thought of to solve this, like seeding isolated respiratory cells on the luminal surface [1], use of revascularized tracheal grafts [7], and omental wrapping [8]. We designed another experimental study [9] thinking that growth of epithelium in the tracheal prosthesis mainly was from resection edges, although is also possible microemboli from endothelial neoformed vessels surrounding the prosthesis can have a transmural invasion. This vascular invasion was closely dependent on the microporosity of the material (30 µm diameter in the prosthesis we use). This fact is very important in understanding why these implants are so well accepted. Bigger microporosity is not aerostatic, and smaller or no microporosity like in silicone tubes does not allow invasion from the surrounding tissues or allow fibroblasts to pass through the wall.

The epithelial growth from the resection edges is limited (and in most experimental models is never complete), so trying to improve host tissue incorporation we used low-powered laser irradiation (904 nm). Preliminary studies of this have been published [9]. Granulation and epithelialization were found to be far better in the irradiated group than among the nonirradiated controls. Laser irradiation favors microcirculation and gets more speed in growth of epithelium from resection edges.

Results are encouraging from this and other studies that have used polytetrafluoroethylene as a prosthetic material to patch the trachea, although further experimental work must be undertaken before polytetrafluoroethylene can be applied in operations on the human trachea.

Footnotes

As Originally Published in 1990:
Updated in 1998

References

1. Kaschke O., Gerhardt H.J., Bohm K., Wenzel M., Planck H. Experimental in vitro and in vivo studies of epithelium formation on biomaterials seeded with isolated respiratory cells. J Invest Surg 1996;9(2):59-79.[Medline]
2. Petrasch U., Hinrichsen G. The further development of a human, alloplastic tracheal prosthesis. Biomed Tech 1994;39:244-250.
3. Neville W.E., Bolanowsk P.J.P. Prosthetic reconstruction of the trachea and carina. J Thorac Cardiovasc Surg 1976;25:528-538.
4. González Piñera J P., érez-Martínez A., Marco-Macián A., García-Olmo D. An experimental model for the prevention of postanastomotic tracheal stenosis. J Thorac Cardiovasc Surg 1997;114:76-83.[Abstract/Free Full Text]
5. Guijarro Jorge R., Sánchez-Palencia Ramos A., Cueto Ladrón de Guevara A., Martí Huedo F., González de Vega M., París Romeu F. Experimental study of a new porous tracheal prosthesis. Ann Thorac Surg 1990;50:281-287.[Abstract]
6. Kaschke O., Gerhardt H.J., Bohm K., Wenzel M., Planck H. Epithelialization of porous biomaterials with isolated respiratory epithelial cells in vivo. HNO 1995;43(2):80-88.[Medline]
7. Khalil-Manzouk J.F. Allograft replacement of the trachea. Experimental synchronous revascularization of composite thyrotracheal transplant. J Thorac Cardiovasc Surg 1993;105:242-246.[Abstract]
8. Satoh S., Elstrodt J., Hinrichs W.L., Feijen J., Wildevuur C.R. Prevention of infection in a porous tracheal prosthesis by omental wrapping. ASAIO Trans 1990;36:438-440.
9. Guijarro Jorge R., Cantó Armengod A., Arnau Obrer A., Fernández-Centeno A. An experimental study of the effects of infrared 904 nm laser irradiation on the tissue incorporation of a new porous tracheal prosthesis. Res Surg 1992;4(3):171-177.

This article has been cited by other articles:

				B. R. Beldholm, M. K. Wilson, R. M. Gallagher, D. Caminer, M. J. King, and A. Glanville Reconstruction of the trachea with a tubed radial forearm free flap J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 545 - 550. [Abstract] [Full Text] [PDF]

				S. Ercan, M. Yuksel, H. F. Batirel, and B. Yildizeli Tracheal prostheses. Ann. Thorac. Surg., April 1, 1999; 67(4): 1215 - 1216. [Full Text] [PDF]

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