title: Pediatric tracheal reconstruction using cadaveric homograft.
abstract: OBJECTIVE
  To examine the indications, risks, and surgical outcomes after tracheal reconstruction using cadaveric homograft in children.
  
  
  METHODS
  Retrospective medical record review.
  
  
  METHODS
  Tertiary referral center.
  
  
  METHODS
  Ten children (4 boys and 6 girls).
  
  
  METHODS
  Tracheal reconstruction using cadaveric homograft.
  
  
  METHODS
  Cause of stenosis, number and type of procedures before homograft reconstruction, severity of preoperative stenosis, surgical approach, homograft length, duration of stenting, number and type of procedures after reconstruction, and rates of decannulation and survival.
  
  
  RESULTS
  Ten children (mean [SD] age, 8.4 [5.5] years) underwent 14 tracheal reconstructions using cadaveric homograft. Patients had an average of 7.0 (range, 1-16) procedures before homograft reconstruction, including an average of 2.8 (range, 0-6) major open airway reconstructions. Mean (SD) pretracheoplasty Myer-Cotton grade of stenosis was 3.80 (0.42) (range, 3-4), and all patients were tracheotomy dependent. A cervical approach was used in 12 reconstructions (86%), and 2 (14%) required median sternotomy. Mean (SD) homograft length was 3.9 (1.7) cm (range, 2-8 cm), which was approximately 0.60 times the length of the total recipient trachea. Mean (SD) duration of stenting for all homografts was 0.67 (0.46) years (range, 0.24-1.98 years). The survival rate was 90% after a mean follow-up of 5.47 (1.52) years (range, 3.32-7.55 years). Surviving patients required an average of 7.38 (5.52) procedures (range, 1-19) after homograft transplant, including an average of 1 major open airway reconstruction (range, 0-4). The mean (SD) grade of stenosis after the final homograft placement was 1.89 (1.27) (range, 1-4). Although the operation-specific decannulation rate was only 7% (1 of 14), the overall decannulation rate eventually reached 60%. Statistical bootstrapping methods and a multivariate regression model determined that increasing patient age (odds ratio, 1.21; 95% confidence interval, 1.07-1.36), increasing number of prior procedures (1.26; 1.02-1.57), and increasing homograft length (2.42; 1.60-3.40 [P < .001]) were associated with an increased risk of no decannulation after tracheal homograft reconstruction.
  
  
  CONCLUSIONS
  Tracheal reconstruction using cadaveric homograft is an option in children who have undergone multiple airway surgical procedures and present with long-segment stenoses that cannot be bridged using conventional methods. These patients must receive close postoperative follow-up. Subsequent procedures are almost always required before decannulation, and eventual decannulation rates are only 60%. Decannulation rates are lower in older patients who have previously undergone many procedures and require a long tracheal homograft.
authors.affiliation: Department of Pediatric Otolaryngology, The Hospital for Sick Children, Toronto, ON, Canada. evan.propst@utoronto.ca
authors.forename: Evan J
authors.initials: EJ
authors.lastname: Propst
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Prager
authors.forename: Jareen
authors.initials: J
authors.lastname: Meinzen-Derr
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Clark
authors.forename: Robin T
authors.initials: RT
authors.lastname: Cotton
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Rutter
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002102:Cadaver; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015607:Stents; D014132:Trachea / Q000601:surgery* / Q000637:transplantation*; D014135:Tracheal Stenosis / Q000601:surgery*; D014140:Tracheotomy; D014184:Transplantation, Homologous