title: Removal of cartilage rings prevents graft stenosis in extended tracheal allotransplantation with omentopexy and immunosuppression: an experimental study.
abstract: BACKGROUND
  One of the serious problems in longer size tracheal transplantation is severe stenosis of the graft, probably caused by an inadequate blood supply. We have previously reported that removal of some cartilage rings of the graft and omentopexy helps to provide sufficient blood flow to the graft mucosal tissue and results in satisfactory survival and non-significant graft stenosis in extended tracheal autotransplantation. However, it is unclear whether this method can be applied to extended tracheal allotransplantation that requires immunosuppression. In this report, we describe midterm results of extended tracheal allotransplantation with the technique.
  
  
  METHODS
  Twenty-four adult mongrel dogs were used. In 18 dogs, a nine-cartilage-ring length of the trachea was allotransplanted when five cartilage rings of the graft were removed, leaving two rings intact at both ends of the graft for simple fixing to the recipient. Two artificial tracheal rings outside the graft and a stent inside the graft were used for maintaining the lumen width. Omentopexy was done for sufficient blood supply to the graft. FK 506 (0.1 mg/kg) was given on each day after the operation in Group A (n = 10), but was not given at all in Group B (n = 8). In Group C (n = 6), a nine-cartilage-ring length of the trachea, without removal of any cartilage ring, was transplanted into the recipient dog and covered with an omental pedicle flap. The same dose of FK 506 as that used in Group A dogs was given to Group C dogs.
  
  
  RESULTS
  In Group A, 2 dogs died of graft stenosis within 9 weeks after surgery and 1 died of emaciation without tracheal stenosis. Seven dogs (70%) survived until time of killing. Among the 8 dogs in Group B, 6 died of graft stenosis within 9 weeks after surgery, with 1 dying of pneumonia and only 1 (13%) surviving for >1 year until killing. In Group C, all 6 dogs died of graft stenosis within 6 weeks after surgery. Survival at 16 weeks after surgery was 70% in Group A, 13% in Group B and 0% in Group C (p < 0.01, A vs B and C). No significant graft stenosis was found in 6 dogs and mild stenosis was found in 2 dogs at the time of death or killing in Group A (80%), whereas mild stenosis was found in only 2 dogs in Group B (25%) (p < 0.05). Mucosal blood flow of the graft in Group A was higher than that in Group C and was the same as that in Group B within 4 weeks after surgery; however, it remained unchanged to ultimately be higher than in Group B at 6 and 8 weeks after surgery.
  
  
  CONCLUSIONS
  Removal of some cartilage rings, omentopexy and immunosuppression improved blood supply to the graft and resulted in good survival and non-significant tracheal stenosis in extended tracheal allotransplantation.
authors.affiliation: Second Department of Surgery, Yamagata University School of Medicine, Yamagata, Japan.
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Masaoka
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Oizumi
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Fujishima
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Naruke
authors.forename: Satoshi
authors.initials: S
authors.lastname: Shiono
authors.forename: Yasuhisa
authors.initials: Y
authors.lastname: Shimazaki
mesh_terms: D000818:Animals; D020878:Device Removal; D004195:Disease Models, Animal; D004285:Dogs; D004724:Endoscopy; D006083:Graft Occlusion, Vascular / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control*; D007108:Immune Tolerance; D007817:Laryngeal Cartilages / Q000637:transplantation*; D007820:Laryngeal Mucosa / Q000098:blood supply; D009852:Omentum / Q000601:surgery*; D019919:Prosthesis Implantation; D012039:Regional Blood Flow / Q000502:physiology; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D014132:Trachea / Q000637:transplantation*; D014135:Tracheal Stenosis / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome