Tracheal Replacement with Aortic Allografts
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《新英格兰医药杂志》
To the Editor: We report tracheal replacement with fresh aortic allografts in two patients with large chemotherapy-resistant and radiotherapy-resistant tumors (mucoepidermoid and adenoid cystic carcinomas). These interventions were made on the basis of the extent of the lesions (making them unresectable), the severity of each patient's clinical condition, the lack of alternative treatment options, and the success of this intervention in sheep and pig models.1,2,3,4 The transplantation was approved for each patient by the French National Bioethics Advisory Commission. Both procedures were performed through a median cervicosternotomy. In the first patient, tumor dissection was followed by sectioning of the trachea proximally just below the second ring and distally until the cross-section margins were negative for tumor on frozen section (subtotal resection of the main carina). Carinal restitution was achieved by suturing the right and left main bronchi together. An aortic allograft that was harvested from a brain-dead donor and splinted by means of a bifurcated silicone stent was interposed with end-to-end proximal and distal anastomoses (Figure 1). To protect the large vessels from the stent-splinted graft and to promote revascularization, the graft was wrapped with a pectoral muscle flap.
Figure 1. CT Scans of the Chest Showing Tracheal Tumors in Patient 1 (Panel A) and Patient 2 (Panel B) and Diagrams Showing Tracheal Reconstruction with the Stent and Graft in Place in Patient 1 (Panel C) and Patient 2 (Panel D).
The arrows in Panels A and B show the upper and lower limits of the tumors.
The procedure was performed in a similar way in the second patient. However, since the tumor extension was wider, the trachea was sectioned just below the first cartilage. Distally, after a right upper lobectomy, the entire right main bronchus and the first two cartilages of the left main bronchus were resected. Restitution of the carina was achieved by suturing the bronchus intermedius and the left main bronchus together. With the use of end-to-end anastomosis, this new carina was then approximated to the distal segment of the aortic allograft.
The first patient had a fairly uneventful postoperative course. Because of the ineffectiveness of coughing, bronchoscopy was performed every other day during the first 2 weeks. Acute anterior spinal cord ischemia developed in the second patient on postoperative day 1. The definitive explanation for this severe complication is not known, but several factors may have played a role. These factors include microemboli as a result of a concussion injury to the ascending aorta, the anomalous origin of the left vertebral artery, and tumor-related thrombophilia. Fortunately, there was partial recovery (respiratory autonomy and strength and function in both arms).
Biopsy specimens of the aortic allografts in both patients 1 year after surgery showed the development of respiratory epithelium, as observed in animal models. It is unclear whether host mesenchymal stem cells engraft the aortic allograft and undergo cartilaginous differentiation, as in animal models. So far (with 18 months of follow-up), graft ischemia, problematic suture dehiscence, infection, and graft rejection have not been observed, despite the absence of immunosuppressive therapy. Since the stents are well tolerated, as a precautionary measure we have decided not to withdraw them before 2 years, or at least not before computed tomography or bronchoscopy shows that newly formed cartilaginous rings can stiffen the new trachea.
Alain Wurtz, M.D.
Henri Porte, M.D., Ph.D.
Massimo Conti, M.D.
Jacques Desbordes, M.D.
Marie Christine Copin, M.D., Ph.D.
Centre Hospitalier Régional Universitaire
59000 Lille, France
Jacques Azorin, M.D.
H?pital Avicenne
93000 Bobigny, France
Emmanuel Martinod, M.D., Ph.D.
Laboratoire d'Etude des Greffes et Prothèses Cardiaques
75014 Paris, France
Charles-Hugo Marquette, M.D., Ph.D.
Université de Lille II
59000 Lille, France
c-marquette@chru-lille.fr
References
Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572-1578.
Martinod E, Seguin A, Holder-Espinasse M, et al. Tracheal regeneration following tracheal replacement with an allogenic aorta. Ann Thorac Surg 2005;79:942-949.
Seguin A, Martinod E, Kambouchner M, et al. Carinal replacement with an aortic allograft. Ann Thorac Surg 2006;81:1068-1074.
Jaillard S, Holder-Espinasse M, Hubert T, et al. Tracheal replacement by allogenic aorta in the pig. Chest 2006;130:1397-1404.
Figure 1. CT Scans of the Chest Showing Tracheal Tumors in Patient 1 (Panel A) and Patient 2 (Panel B) and Diagrams Showing Tracheal Reconstruction with the Stent and Graft in Place in Patient 1 (Panel C) and Patient 2 (Panel D).
The arrows in Panels A and B show the upper and lower limits of the tumors.
The procedure was performed in a similar way in the second patient. However, since the tumor extension was wider, the trachea was sectioned just below the first cartilage. Distally, after a right upper lobectomy, the entire right main bronchus and the first two cartilages of the left main bronchus were resected. Restitution of the carina was achieved by suturing the bronchus intermedius and the left main bronchus together. With the use of end-to-end anastomosis, this new carina was then approximated to the distal segment of the aortic allograft.
The first patient had a fairly uneventful postoperative course. Because of the ineffectiveness of coughing, bronchoscopy was performed every other day during the first 2 weeks. Acute anterior spinal cord ischemia developed in the second patient on postoperative day 1. The definitive explanation for this severe complication is not known, but several factors may have played a role. These factors include microemboli as a result of a concussion injury to the ascending aorta, the anomalous origin of the left vertebral artery, and tumor-related thrombophilia. Fortunately, there was partial recovery (respiratory autonomy and strength and function in both arms).
Biopsy specimens of the aortic allografts in both patients 1 year after surgery showed the development of respiratory epithelium, as observed in animal models. It is unclear whether host mesenchymal stem cells engraft the aortic allograft and undergo cartilaginous differentiation, as in animal models. So far (with 18 months of follow-up), graft ischemia, problematic suture dehiscence, infection, and graft rejection have not been observed, despite the absence of immunosuppressive therapy. Since the stents are well tolerated, as a precautionary measure we have decided not to withdraw them before 2 years, or at least not before computed tomography or bronchoscopy shows that newly formed cartilaginous rings can stiffen the new trachea.
Alain Wurtz, M.D.
Henri Porte, M.D., Ph.D.
Massimo Conti, M.D.
Jacques Desbordes, M.D.
Marie Christine Copin, M.D., Ph.D.
Centre Hospitalier Régional Universitaire
59000 Lille, France
Jacques Azorin, M.D.
H?pital Avicenne
93000 Bobigny, France
Emmanuel Martinod, M.D., Ph.D.
Laboratoire d'Etude des Greffes et Prothèses Cardiaques
75014 Paris, France
Charles-Hugo Marquette, M.D., Ph.D.
Université de Lille II
59000 Lille, France
c-marquette@chru-lille.fr
References
Martinod E, Seguin A, Pfeuty K, et al. Long-term evaluation of the replacement of the trachea with an autologous aortic graft. Ann Thorac Surg 2003;75:1572-1578.
Martinod E, Seguin A, Holder-Espinasse M, et al. Tracheal regeneration following tracheal replacement with an allogenic aorta. Ann Thorac Surg 2005;79:942-949.
Seguin A, Martinod E, Kambouchner M, et al. Carinal replacement with an aortic allograft. Ann Thorac Surg 2006;81:1068-1074.
Jaillard S, Holder-Espinasse M, Hubert T, et al. Tracheal replacement by allogenic aorta in the pig. Chest 2006;130:1397-1404.