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Ann Thorac Surg 2002;74:306-307
© 2002 The Society of Thoracic Surgeons
a Division of Pediatric Surgery, Department of Surgery, Hasbro Children’s Hospital, and Brown Medical School, Providence, Rhode Island, USA
* Address reprint requests to Dr Tracy, Pediatric Surgeon in Chief, Hasbro Children’s Hospital, Room 147, 593 Eddy St, Providence, RI 02903 USA
Pediatric surgeons, thoracic surgeons, and pediatric otolaryngology (head and neck) surgeons uniformly find the greatest challenges in and often form the closest relationships with patients who have tracheal anomalies. Knowing everyone from the registration staff to the critical care personnel, these patients and their families become part of the fabric of children’s surgical centers. The routine, sometimes daily, endoscopy that is part of diagnosis and follow-up becomes an elegant exercise practiced by all airway surgeons and their staff that blends technique, technology, experience, and judgment. The truth remains that for all operative airway maneuvers, other important elements include tricks, wishful thinking, hope, and luck. Any organ that can respond to the exact same operative intervention in totally disparate ways leading to malacia or restenosis, and anything in between, does not present a level playing field. Surgeons and families should never feel comfortable with success or resignation after failure. Even with that uncertainty and uneasiness, committed, focused airway surgeons and investigators must analyze every one of these individual patients for common successful threads of technical management and operative judgment.
The retrospective review of outcomes for pediatric tracheal surgery from a single institution reported by Wright and colleagues [1] demonstrates a very special commitment by expert airway surgeons over a 23-year period. Through the moving targets of technology and evolving techniques, they have sought to document the complications and outcomes of tracheal procedures that included 80 major tracheal resections. Since the early 1970s in the laboratories of Hermes Grillo and the late Arnold Salzberg, surgeons have questioned the response of the young trachea to resection and reanastomosis. Techniques developed in the laboratory to reduce anastomotic tension, restenosis, malacia, and intraluminal granulation have not easily translated to children’s operating rooms. In this review, four different techniques are presented that resulted in a 21% failure or death rate, an honest reality. Only 65% of outcomes achieved the designation of a good or stable airway, which improved to 72% when the results of tracheal or laryngotracheal resection and anastomosis were isolated.
It is beyond the scope of these comments to pick apart this report to compare it with other excellent groups and series. Those with even the slightest experience of pediatric tracheal reconstruction will find these results outstanding. Only 50% of patients with 30% to 50% of the trachea resected and reanastomosed had complications. Is the cup half full or half empty? It depends on what we do from this point on.
Surgeons trying to understand these results are faced with fundamental questions about how they were achieved. Are the complications related to pediatric tracheal reconstruction due to tracheal biology, surgical practice, etiology of the malformations, or countless other factors. Until now, but perhaps not into the future, the overriding presentation of outcomes in tracheal surgery has revolved around center-specific and even surgeon-specific results. The opening sentence to this report by Wright and associates clearly highlights the uncommon presentation of pediatric airway obstruction requiring operative intervention. The comments throughout the study underscore the flexibility and the variability of technical innovations required to manage these patients. The discussion presents well-thought-out, but not scientifically proven differences between groups and between adult and pediatric patients.
Is it not time we put our heads together? Throughout the world there are clearly enough leaders in this area who have achieved success through sometimes very different, but often common techniques and management algorithms. There are definite intergroup differences with respect to age, technique, and postoperative ancillary maneuvers for patients who undergo operation. The answers to many of our questions will not come from time-consuming meta-analysis of currently published reports. They may, however, come from well-designed and well-managed registries and from intergroup collaborative studies applied to patients seen at centers of excellence in airway management. The interinstitutional blending of otolaryngology and thoracic surgery as alluded to by Wright and associates is found in many airway centers with a nearly seamless fusion between pediatric surgery, otolaryngology, and adult thoracic surgery. The richness of that kind of clinical environment could be transferred to prospective multiinstitutional trials. These are the next steps to provide insight for a better understanding of the successes and the failures. Prospective studies involving this small category of patients should have the goal of a more uniform application of both the best practices in the surgical field itself and the best decisions in regard to operability and operative timing.
In this report, the outstanding honesty in terms of the complications and the outcomes is extremely welcome to us as readers. However, as practitioners, we must come away with a frustrating sense that this is yet another single institution’s experience with a very complex problem. It seems well worth the prospective effort to attempt to meld the experience of all of our surgical subspecialties and to collect our experience with airway reconstruction to finally do something to fill the cup further for those infants and children who deserve our very best.
References
This article has been cited by other articles:
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  W. Schroder, D. Stippel, M. Lacher, C. A. Gutschow, K.T. E. Beckurts, and A. H. Holscher Does continuous mucosal partial carbon dioxide pressure measurement predict leakage of intrathoracic esophagogastrostomy? Ann. Thorac. Surg., December 1, 2002; 74(6): 1917 - 1922. [Abstract] [Full Text] [PDF]
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