Esophageal and Airway Treatment Center | Airway management/tracheomalacia

Koo DC, Scalise PN, Izadi SN, Kamran A, Mohammed S, Zendejas B, Demehri FR. Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns with Esophageal Atresia: Intubate Above or Below the Fistula? J Pediatr Surg. 2023 Oct 25:S0022-3468(23)00654-1. doi: 10.1016/j.jpedsurg.2023.10.044. Epub ahead of print. PMID: 37957098.

This study describes the location of tracheoesophageal fistulas (TEF) in infants born with esophageal atresia and TEF to determine the best approach for intubation. 

Mohammed S, Kamran A, Izadi S, Visner G, Frain L, Demehri FR, Shieh HF, Jennings RW, Smithers CJ, Zendejas B. Primary Posterior Tracheopexy at Time of Esophageal Atresia Repair Significantly Reduces Respiratory Morbidity. J Pediatr Surg. 2024 Jan;59(1):10-17. doi: 10.1016/j.jpedsurg.2023.09.028. Epub 2023 Sep 22. PMID: 37903674.

Trachebronchomalacia (TBM) is highly prevalent in children with EA/TEF. After having to re-operate on hundreds of children with TBM after their EA/TEF repair to surgically address their TBM, we sought to evaluate the effect of surgically addressing TBM primarily at the time of their initial or index EA/TEF repair. 

Izadi S, Zendejas B, Meisner J, Kamran A, Mohammed S, Demehri F, Staffa S, Zurakowski D, Hseu A, Cunningham M, Choi S, Barnewolt C. Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children. J Pediatr Surg. 2024 Jan;59(1):109-116. doi: 10.1016/j.jpedsurg.2023.09.017. Epub 2023 Sep 22. PMID: 37845124.

Screening for vocal fold movement impairment (VFMI) is essential for children undergoing esophageal, airway, and cardiovascular procedures. The gold standard screening modality involves the use of a flexible nasolaryngoscope that enters the child’s nose while awake. We evaluated the accuracy of an alternative non-invasive modality such as laryngeal ultrasound and compared it to flexible nasolaryngoscopy in the evaluation of VFMI. We found that laryngeal ultrasound is equally accurate and represents a viable alternative screening modality for select patients. 

Meisner JW, Izadi S, Kamran A, Shieh HF, Smithers CJ, Bennett J, Demehri FR, Mohammed S, Lawlor C, Choi SS, Zendejas B. Screening for Vocal Fold Movement Impairment in Children Undergoing Esophageal and Airway Surgery. Laryngoscope. 2023 Mar 9. doi: 10.1002/lary.30646. Epub ahead of print. PMID: 36892035.

This study shows that VFMI is more common than we previously thought and suggests that VFMI can be present in roughly 1 to every 4 to 5 children who have undergone complex esophageal, airway, or cardiovascular surgery.

Lawlor CM, Meisner J, Jennings RW, Zendejas B, Choi SS. Comparative Effectiveness of Recurrent Laryngeal Nerve Monitoring Techniques in Pediatric Surgery. Laryngoscope. 2022 Apr;132(4):889-894. doi: 10.1002/lary.29837. Epub 2021 Aug 25. PMID: 34432299.

Different techniques exist to monitor recurrent laryngeal nerves intraoperatively in order to decrease the risk of VFMI. This study compared the different modalities (endotracheal tubes [ETT] with integrated electrodes or with adhesive electrodes added to them, direct needle electrodes into the larynx either transorally, percutaneously or via a neck incision).

Izadi S, Demehri F, Mohammed S, Choi S, Zendejas B. An invaginating congenital tracheal diverticulum: The importance of routine airway evaluation. Videoscopy. Vol. 33. Issue 1. Oct 2023, http://doi.org/10.1089/vor.2023.0011 

Case report of an invaginating tracheal diverticulum creating a ball-valve effect and airway obstruction in an infant with long-gap esophageal atresia (LGEA). This case highlights the importance of a proper dynamic 3-phase rigid tracheobronchoscopy in the evaluation and management of children with LGEA. 

Kamran A, Zendejas B, Jennings RW. Current concepts in tracheobronchomalacia: diagnosis and treatment. Semin Pediatr Surg. 2021 Jun;30(3):151062. doi: 10.1016/j.sempedsurg.2021.151062. Epub 2021 May 23. PMID: 34172207.
tracheomalacia. Videoscopy. http://doi.org/10.1089/vor.2018.0543

Review of the diagnosis and management of tracheobronchomalacia in children. 

Kamran A, Smithers CJ, Baird CW, Jennings RW. Experience with bioresorbable splints for treatment of airway collapse in a pediatric population. JTCVS Tech. 2021 Apr 19;8:160-169. doi: 10.1016/j.xjtc.2021.04.010. PMID: 34401841; PMCID: PMC8350796

Description of our experience with custom-made bioresorbable splints for the treatment of airway compression/collapse or tracheobronchomalacia. As opposed to others who have reported 3D printing of these splints, we are able to custom make them in the OR in a matter of minutes by molding existing bioresorbable material into an airway splint. 

Lawlor CM, Zendejas B, Julian CM, Meisner J, Jennings RW, Choi SS. Recurrent Laryngeal Nerve Monitoring in Pediatric Surgery Using a Modified Dragonfly Electrode. Laryngoscope. 2021 Nov;131(11):2586-2589. doi: 10.1002/lary.29505. Epub 2021 Mar 15. PMID: 33720399.

Commercially available technology to monitor the recurrent laryngeal nerve does not yet exist for the pediatric population, particularly those aged 5 years or less. In this report, we describe how we have adapted existing technology for adults to be successfully used in young children (of any age) so we can adequately monitor the recurrent laryngeal nerve function during complex cervical and thoracic procedures where the nerve is at risk. 

Lawlor CM, Zendejas B, Baird C, Munoz-San Julian C, Jennings RW, Choi SS. Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review. Front Pediatr. 2020 Nov 27;8:587177. doi: 10.3389/fped.2020.587177. PMID: 33330282; PMCID: PMC7728690.

This study reviews the importance of intraoperative recurrent laryngeal nerve monitoring in children undergoing complex cervical or thoracic procedures. It overviews the available modalities that exist and the elements that need to be in place to make this effort successful.

 Svetanoff WJ, Zendejas B, Frain L, Visner G, Smithers CJ, Baird CW, Prabhu SP, Jennings RW, Hamilton TE. When to consider a posterolateral descending aortopexy in addition to a posterior tracheopexy for the surgical treatment of symptomatic tracheobronchomalacia. J Pediatr Surg. 2020 Dec;55(12):2682-2689. doi: 10.1016/j.jpedsurg.2020.04.018. Epub 2020 May 3. PMID: 32444171.

This manuscript highlights our experience posterior tracheopexy and the unique considerations involved. 

Svetanoff WJ, Zendejas B, Smithers CJ, Prabhu SP, Baird CW, Jennings RW, Hamilton TE. Great vessel anomalies and their impact on the surgical treatment of tracheobronchomalacia. J Pediatr Surg. 2020 Jul;55(7):1302-1308. doi: 10.1016/j.jpedsurg.2019.08.001. Epub 2019 Aug 6. PMID: 31422856.

This work highlights the significant proportion and variation of great vessel anomalies that are associated with children with symptomatic tracheobronchomalacia. This study exemplifies why it is important to obtain a CT scan of the chest with IV contrast in patients who are being considered for surgical management of their TBM. 

Kamran A, Friedman KG, Jennings RW, Baird CW. Aortic uncrossing and tracheobronchopexy corrects tracheal compression and tracheobronchomalacia associated with circumflex aortic arch. J Thorac Cardiovasc Surg. 2020 Sep;160(3):796-804. doi: 10.1016/j.jtcvs.2020.03.158. Epub 2020 May 6. PMID: 32616349.

This study highlights an innovative technique in which the circumflex aortic arch is “uncrossed” or changed to align with the side of the descending aorta, in order to create space behind the airway/esophagus so that supportive sutures or pexies can be applied to the airway and be able to successfully treat the airway compression/malacia. 

Labuz DF, Kamran A, Jennings RW, Baird CW. Reoperation to correct unsuccessful vascular ring and vascular decompression surgery. J Thorac Cardiovasc Surg. 2022 Jul;164(1):199-207. doi: 10.1016/j.jtcvs.2021.08.089. Epub 2021 Nov 11. PMID: 34922756.

This study evaluates the common causes for reoperation after a prior vascular ring repair. It demonstrates that a large proportion of reoperations are driven by not having addressed the underlying trachebronchomalacia that can be present in these patients, or not adequately decompressing the vascular ring such that residual vascular compression remains. 

Lawlor C, Smithers CJ, Hamilton T, Baird C, Rahbar R, Choi S, Jennings R. Innovative management of severe tracheobronchomalacia using anterior and posterior tracheobronchopexy. Laryngoscope. 2020 Feb;130(2):E65-E74. doi: 10.1002/lary.27938. Epub 2019 Mar 25. PMID: 30908672.

This study showcases the use of anterior and posterior tracheobronchopexies for patients with severe TBM who need support from an anterior and posterior approach. 

Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Jennings RW, Baird CW. Descending Aortopexy and Posterior Tracheopexy for Severe Tracheomalacia and Left Mainstem Bronchomalacia. Semin Thorac Cardiovasc Surg. 2019 Autumn;31(3):479-485. doi: 10.1053/j.semtcvs.2018.02.031. Epub 2018 Mar 7. PMID: 29524603.

This study highlights the technique of descending aortopexy for the treatment of left mainstem compression for a descending aorta. 

Kamran A, Hamilton TE, Zendejas B, Nath B, Jennings RW, Smithers CJ. Minimally Invasive Surgical Approach for Posterior Tracheopexy to Treat Severe Tracheomalacia: Lessons Learned from Initial Case Series. J Laparoendosc Adv Surg Tech A. 2018 Dec;28(12):1525-1530. doi: 10.1089/lap.2018.0198. Epub 2018 Jul 5. PMID: 29975595.

Description of our minimally invasive posterior tracheopexy technique

Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi MA, Baird CW, Jennings RW. Posterior Tracheopexy for Severe Tracheomalacia Associated with Esophageal Atresia (EA): Primary Treatment at the Time of Initial EA Repair versus Secondary Treatment. Front Surg. 2018 Jan 15;4:80. doi: 10.3389/fsurg.2017.00080. PMID: 29379786; PMCID: PMC5775263.

Report of outcomes of children with a history of esophageal atresia treated with a posterior tracheopexy for severe tracheomalacia, and comparison of those who are treated upfront at the time of their initial EA repair versus those who undergo TBM repair as secondary treatment after EA repair. 

Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Rhein LM, Manfredi MA, Baird CW, Jennings RW. Posterior tracheopexy for severe tracheomalacia. J Pediatr Surg. 2017 Jun;52(6):951-955. doi: 10.1016/j.jpedsurg.2017.03.018. Epub 2017 Mar 18. PMID: 28385426.

Description of symptom improvement after posterior tracheopexy for severe TBM. This shows improvements across a wide range of respiratory symptoms after posterior tracheopexy.

Bairdain S, Smithers CJ, Hamilton TE, Zurakowski D, Rhein L, Foker JE, Baird C, Jennings RW. Direct tracheobronchopexy to correct airway collapse due to severe tracheobronchomalacia: Short-term outcomes in a series of 20 patients. J Pediatr Surg. 2015 Jun;50(6):972-7. doi: 10.1016/j.jpedsurg.2015.03.016. Epub 2015 Mar 14. PMID: 25824437.

First report of direct tracheopexy sutures (anterior and/or posterior) and the favorable outcomes associated with this strategy. 

Jennings RW, Hamilton TE, Smithers CJ, Ngerncham M, Feins N, Foker JE. Surgical approaches to aortopexy for severe tracheomalacia. J Pediatr Surg. 2014 Jan;49(1):66-70; discussion 70-1. doi: 10.1016/j.jpedsurg.2013.09.036. Epub 2013 Oct 16. PMID: 24439583.

Overview and outcomes of different approaches to anterior aortopexy, showcasing improved outcomes with our preferred approach of a partial anterior mini-sternotomy.