Ann Thorac Surg 2003;75:1578
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Invited commentary
Douglas J. Mathisen, MDa
a General Thoracic Surgical Unit, Massachusetts General Hospital, Boston, MA 02114, USA
e-mail: dmathisen{at}partners.org
The search for the ideal tracheal substitute has followed many paths. Most of these paths have led to dead ends because of granulation tissue, stenosis, arterial erosion, migration, or infection. The need for such a replacement is of limited necessity because of the small number of patients requiring extensive replacement of the trachea, which cannot be managed by the surgical techniques allowing resection and reconstruction of up to 50% of the adult trachea. However, for the individual patient unable to undergo primary reconstruction of the trachea, a reliable tracheal substitute could be lifesaving or avoid the need for a lifelong tracheal appliance.
Martinod and colleagues present an interesting hypothesis for solution of the problem of a reliable tracheal substitute. The use of an autologous segment of the thoracic aorta supported by a tracheal stent achieved moderate success in sheep. Trading one set of problems to solve another set is often fraught with unexpected pitfalls (graft infection, fistula, false aneurysm, and bleeding) and is certainly possible in clinical application of the proposed solution for tracheal replacement. Many other examples of tracheal substitute have enjoyed modest success with limited replacement of the trachea. Indeed in their sheep model, 10 to 11 rings of a possible 50 (only 20%) were resected and replaced. This percentage is certainly within the range of primary resection and reconstruction. Would the same success be realized if 50% of the sheep trachea were resected and replaced by autologous aortic graft?
How can we explain the development of cartilaginous tracheal rings along with a membranous wall? This remains the most puzzling yet intriguing aspect of their experience. Will dystrophic calcifications continue to develop with longer follow-up?
The authors have shed some light on the possible solution for a reliable tracheal substitute, but questions remain and greater experience is needed.
