Outcomes of Slide Tracheoplasty in Children: A Single-center Experience

ABSTRACT

Background:

Long-segment tracheal stenosis in children is a rare, life-threatening condition. Slide tracheoplasty has emerged as the preferred surgical technique, but outcome data from resource-limited settings remain limited.

Materials and Methods:

A retrospective review was performed on children who underwent slide tracheoplasty at our institution between 2012 and 2025. Demographic details, etiology, associated anomalies, and outcomes were analyzed.

Results:

Twenty-eight children underwent slide tracheoplasty, including 15 boys and 13 girls. The median age was 1 year (range: 3 months–13 years). Congenital tracheal stenosis was present in 18 children. Complete trachea was involved in 7 children and segmental trachea in 11 (upper in 1 and lower in 10). Ten children had acquired stenosis, all with prior intubation. Seven children had pure tracheal stenosis, while three children had associated large tracheoesophageal fistulae. Children with acquired stenosis were older (median age: 8.5 years) compared to those with congenital pathology. Associated comorbidities were common, particularly congenital heart disease, seen in 19 children. Eleven children had a tracheostomy at presentation. There were two postoperative deaths, both in the congenital group, related to persistent low cardiac output following associated cardiac surgery. No deaths were directly attributable to tracheal reconstruction. Adequate airway was achieved in all surviving children. Late airway interventions (laryngoplasty in two children and balloon dilatation in one) were required in three children, with all eventually achieving a stable airway.

Conclusion:

Slide tracheoplasty provides effective and durable airway reconstruction in children with long-segment tracheal stenosis. Despite associated cardiac anomalies, morbidity and mortality are low, and excellent airway outcomes can be achieved.

INTRODUCTION

Long-segment tracheal stenosis in children poses significant challenges in airway reconstruction. Historically, various techniques such as resection with end-to-end anastomosis, patch tracheoplasty, and autologous grafts were employed, but the outcomes were inconsistent. Slide tracheoplasty, introduced by Tsang et al.,[1] has become the standard of care due to its ability to maintain tracheal vascularity, increase luminal diameter, and promote growth of the reconstructed segment. This study reviews our institutional experience with slide tracheoplasty in a heterogeneous cohort of congenital and acquired tracheal stenosis in children.

MATERIALS AND METHODS

This retrospective study included all children under 18 years of age who underwent slide tracheoplasty at our center between 2012 and 2025. Data were collected from medical records. The parameters studied were age, sex, weight, etiology (congenital or acquired), site and length of stenosis, associated anomalies, need for cardiopulmonary bypass (CPB), postoperative duration of mechanical ventilation, and postoperative complications and mortality. Preoperative workup included airway endoscopic assessment, i.e., microlaryngobronchoscopy (MLB), computed tomography (CT) scans, and echocardiography. The extent/length of the stenotic segment of the trachea is measured preoperatively with CT scan (whenever done). In other cases, preoperatively, MLB is done to identify the proximal extent of the stenosis. The bronchoscope is not negotiated across the narrow segment, as it may cause edema and complete occlusion of the airway. The distal end is assessed intraoperatively under CPB by negotiating the scope across the stenosed segment. Children with tracheal stenosis/fistula involving more than 4–5 tracheal rings or more than 30% of the tracheal length were treated with slide tracheoplasty.

Surgical technique

A standard slide tracheoplasty was performed via median sternotomy in most cases. CPB was used when stenosis involved the distal trachea and carina, for complex lesions, or when concomitant cardiac repair was required. A cervical approach was used when the stenotic segment was in the neck.

Follow-up

Patients were followed clinically and at 6 weeks and then 3 months postoperatively. Formal airway evaluations, i.e., MLB, were done. The data were collated and analyzed.

Surgical technique

Operations were performed under general anesthesia. A preoperative airway assessment was performed before induction. Intubation was performed either by threading a small-bore endotracheal tube, usually uncuffed, through the stenosis. If the stenosis was too small to allow passage of even the smallest endotracheal tube, an age-appropriate tube was wedged into the upper end of the stenosis. As the first tracheal ring is not usually affected in congenital tracheal stenosis, this latter approach is feasible in most cases. An alternative is to use laryngeal mask ventilation until the airway can be secured and CPB is established.

A transverse cervical or median sternotomy approach was used as necessary. After sternotomy, CPB was established if necessary. The anterior surface of the trachea from the cricoid cartilage to the proximal main-stem bronchi was exposed by splitting the thymus and looping the innominate vessels. The true extent of the stenosis is measured intraoperatively. Fiberoptic bronchoscopy was done during the surgery, and the proximal extent of the stenosis was visualized and confirmed on the trachea by passing a fine needle through the anterior tracheal wall. Stay sutures are taken on the trachea at this point. Then, the scope is negotiated across the narrow segment, and the distal extent is marked. In this way, the actual length of the narrow segment is measured.

The trachea was dissected circumferentially and divided at the middle of the stenotic length [Figure 1a]. The trachea–esophageal space was entered, and both the tracheal ends were mobilized. Dissection of lateral attachments to the tracheal segments (both proximal and distal ends) was avoided to preserve blood supply and prevent injury to the recurrent laryngeal nerves. Opposite sides of each tracheal segment were opened longitudinally (distal segment opened posteriorly in midline and the proximal segment opened anteriorly) to points just beyond the extent of the stenosis, typically down to the carina distally [Figure 1b]. The distal incision was carried onto the proximal bronchus if ostial stenosis was present. Oblique, side-to-side anastomosis was performed using a running polydioxanone suture (from distal end to proximal end) [Figure 2]. Interrupted sutures are placed at regular intervals to avoid inversion of the tracheal edges and prevent subsequent “figure of 8” deformity. Age appropriate endotracheal tube was repositioned in the center of the reconstruction just before the completion of the anastomosis. The repair was leak-tested under saline to an airway pressure of 30 cm water. The CPB was then reversed, and the chest closed. The airway distal to the stenosis was accessed to allow ventilation. Whenever a cardiac procedure was required, the tracheal repair was performed after the cardiac repair and reversal of cardioplegia.

Figure 1.

(a) Intraoperative image showing the trachea transected in the middle and depicting narrowing due to complete tracheal rings. (b) Intraoperative image showing the opening of the trachea longitudinally

Figure 2.

Schematic diagram showing the steps of slide tracheoplasty. (a) The tracheal narrowing. (b) The transection of stenosis in the center of the stenosed segment and longitudinal opening of the tracheal segments (proximal anteriorly and distal segment posteriorly). (c) The orientation for suturing. (d) The final image of the enlarged, shortened trachea

For cervical lesions, a transverse skin incision was made, and subplatysmal flaps were raised. The trachea was approached in the midline by splitting the straps and thyroid isthmus. The rest of the procedure was similar (as described above).

RESULTS

Twenty-eight children underwent slide tracheoplasty during the study period, 15 of whom were boys and the remaining 13 girls. Their age ranged from 3 months to 13 years (median: 1 year).

Stridor was the most common symptom present in 17 children. Babies with associated cardiac disease (15 babies) were diagnosed at the time of cardiac surgery due to the inability to intubate with an age-appropriate endotracheal tube. In these children, the respiratory distress was attributed to cardiac disease. Eleven children had prior tracheostomies and presented with the primary complaint of inability to decannulate. These were then evaluated with CT scan and MLB [Figure 3], and the tracheal stenosis was diagnosed.

Figure 3.

(a) Preoperative microlaryngobronchoscopy showing complete tracheal rings. (b) Preoperative computed tomography showing tracheal narrowing

Of the 28 children, congenital causes of tracheal stenosis were seen in 18 children. Of these, 17 children had complete tracheal rings, and one boy had absent distal tracheal rings. The median age and weight of this group of congenital tracheal stenosis were 13 months and 13.3 kg, respectively. The anomaly involved the complete trachea in 7 children and the segmental trachea in 11 (upper 1 and lower 10) children. Associated cardiac anomalies were noted in 15 children (left pulmonary artery sling in 2, tetralogy of Fallot in 4, and others like VSD/ASD in 9). These children underwent concomitant cardiac surgery at the time of the slide tracheoplasty.

The remaining 10 children of the cohort presented with acquired tracheal stenosis, all having had previous intubations. These children were older, with a median age of 8.5 years (vs. 1 year in the congenital group) [Table 1]. Of the 10 children, 7 had purely tracheal stenosis and 3 had tracheal stenosis associated with large tracheoesophageal fistulae (2 had esophageal atresia with recurrence of tracheoesophageal fistula and 1 had a large fistula develop after prolonged intubation following encephalomyelitis). The stenosis involved the cervical trachea in one and the thoracic trachea in nine children [Figure 4]. The tracheal stenosis in all involved multiple tracheal rings, and the fistulae were large in size (involving more than 5 tracheal rings), making simple resection and anastomosis not amenable. Hence, a slide was done in these cases. Comorbidities were noted in 6 children (CHD in 4, lobar emphysema in 1, and neuromyopathy in 1). Of the entire cohort of 28 children, 11 had a tracheostomy in place at the time of referral (4 in the congenital and 7 in the acquired group).

Table 1.

Comparative table for congenital and acquired tracheal stenosis cases

	Congenital	Acquired
Mean age	13 months	8.5 years
Mean weight (kg)	13.3	22
Comorbidity
Yes	16	6
No	2	4
Tracheal involvement
Upper	1	1
Lower	10	8
Complete	7	1
CPB
Yes	15	4
No	3	6
Death	2	0

CPB: Cardiopulmonary bypass

Figure 4.

Tracheal stenosis distribution

CPB was used in a total of 19 children (15 in the congenital group and 4 in the acquired group). The CPB was mainly for the concomitant cardiac surgery, except in lower tracheal or complete tracheal involvement. After the cardiac surgery, the slide tracheoplasty was performed. Most of the cases were ventilated postoperatively in view of associated cardiac disease and poor cardiac output. From the slide tracheoplasty point of view, early extubation was preferred.

There were two deaths in the postoperative period, both in the congenital group and related to persistent low cardiac output states postcardiac surgery. There were no deaths directly attributed to the tracheal reconstruction.

The average follow-up period was 6 years (range: 6 months to 13 years). On follow-up, initially, MLBs were done, which showed adequate airway (airway was calibrated with age appropriate endotracheal tube). Adequate airway was achieved in 24 out of 26 children [Figure 5]. Two children in the congenital group developed subglottic stenosis, perhaps due to traumatic attempts at intubation before the tracheal stenosis was identified. They required additional surgery, which was laryngoplasty for the same. Both have achieved a normal airway. One boy in the acquired group, who had significant neurological deficits after meningoencephalitis, required placement of a T tube for 4 months; he too is now tube-free and has a normal airway. None of the children required balloon dilatation.

Figure 5.

Postoperative microlaryngobronchoscopy showing adequate airway

DISCUSSION

Slide tracheoplasty was first described by Tsang et al.[1] in 1989. This was initially designed for long-segment tracheal stenosis. Techniques for surgical reconstruction of long-segment tracheal stenosis include simple resection, pericardial patch, rib cartilage grafting, or tracheal autograft patching.[2,3,4,5] Tracheoplasty using a costal cartilage insert was reported initially by Kimura and associates in 1982 and later by many surgeons.[6] Idriss et al. in 1984 described the use of pericardial patch tracheoplasty for these lesions. However, the outcomes remained unsatisfactory. Slide tracheoplasty has shown superior results and is increasingly the preferred surgical technique.

Preoperative evaluation for slide tracheoplasty always includes endoscopic airway assessment (MLB) to document the degree and length of the tracheal stenosis. Echocardiograms are performed to assess for associated cardiac anomalies. Contrast chest CT with three-dimensional reconstruction is often performed to assist with documentation of vascular anomalies and to identify the distal limit and the length of tracheal stenosis. However, frequently, the diagnosis of tracheal stenosis is missed on imaging, and the diagnosis is made due to difficulty in intubation for cardiac surgery. Respiratory symptoms are usually attributed to associated cardiac disease, and the airway anomaly is missed. The diagnosis in these cases is done by immediate endoscopic airway assessment.

The advantages of slide tracheoplasty are that reconstruction is performed with the patient’s native tracheal tissues.[1] Although there is shortening of the trachea, the fourfold increase in cross-sectional area obtained is adequate to provide marked and nearly complete symptomatic relief. Despite this shortening of the trachea, long-term outcomes are favorable, with evidence showing that “slide tracheoplasty does not inhibit tracheal growth” and that the mid-tracheal and distal tracheal cross-sectional areas significantly increased with time (P < 0.0001).[7] Clinical series further confirm that satisfactory growth of the repaired segment occurs, indicating that shortening does not impair development. Furthermore, there is no evidence that the reduction in tracheal length leads to long-term growth restriction or functional limitation.[8]

Other advantages of this method are less extensive surgical dissection, minimal requirement for postoperative intubation and ventilation, lessened likelihood of mediastinal complications, and, where the technique is carefully executed, a near absence of granulation tissue, as there is no raw mesenchymal surface in the reconstructed trachea.

The appeal of the slide tracheoplasty technique lies mainly in its versatility: it can be successfully employed in both short-segment and full-length tracheal reconstructions, in patients who have undergone prior reconstructions using other techniques, and in cases where the orientation of the slide must be modified to deal with proximal bronchial stenosis or the presence of a tracheal origin of the right upper lobe bronchus. The inherent stability of a repair that uses only cartilage-supported tissue allows early extubation. The use of only local, autologous, vascularized tissue in the reconstruction should result in the best prospect for tracheal growth in this young population. Slide tracheoplasty does not inhibit tracheal growth. After operations, the trachea grows, and the tracheal diameter significantly increased with time.[7,8,9]

In patients with associated cardiac disease requiring surgery, simultaneous repair of tracheal stenosis and cardiac anomalies is preferable to a staged approach. Achieving as normal a cardiopulmonary physiologic state as surgically feasible maximizes the chance for the most rapid, complication-free recovery. Although prolonged CPB time correlates with a higher failure rate for early extubation, this likely reflects the presence of associated cardiac anomalies. Prolonged CPB time did not, however, correlate with poorer survival or the need for further surgery.[10,11]

The mortality of slide tracheoplasty ranges from 5% to 30%. The outcome has gradually improved with time, and the incidence of mortality has come down to 5%–10% in high-volume centers.[12,13,14,15] We had only two death on our cohort, both of which were due to poor cardiac output in view of cardiac disease. There were no deaths attributed to the slide tracheoplasty.

CONCLUSION

Slide tracheoplasty provides excellent airway reconstruction in pediatric long-segment tracheal stenosis. Despite a high prevalence of comorbidities (particularly cardiac anomalies), outcomes are favorable, with low morbidity and mortality rates. The possibility of continued tracheal growth ensures excellent outcomes even in small infants.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.