title: Autologous tracheal replacement: from research to clinical practice.
abstract: BACKGROUND
  Despite numerous attempts, synthetic materials and heterologous tissues failed to replace durably the trachea. Autologous tracheal substitution (ATS) without synthetic material or immunosuppression was investigated to replace extended tracheal defect. We present our experience regards to this innovative challenge.
  
  
  METHODS
  After a previous research study, we developed a novel reconstruction technique for extended tracheal defects on animals. Through a single stage operation, a tube from a forearm free fascio-cutaneous flap vascularized by radial vessels is re-anastomosed to cervical vessels. This flap is reinforced by rib cartilages interposed transversally in the subcutaneous tissue. It provides also a reliable ATS. Twelve patients benefits from an extended tracheal resections, 7-12 centimeter (mean 11 cm) long. Indications were eight Primary tracheal Neoplasms (including 5 adenoid cystic carcinoma [ACC] and 3 squamous cell carcinoma [SCC]), three secondary tracheal neoplasms (including 1 thyroid carcinoma and 2 lymphoma) and one post-intubation tracheal destruction after long history of stenting. Daily bronchoscopy and transitory tracheotomy was associated due to absence of mucociliary clearance.
  
  
  RESULTS
  The research work leads to present the first described animal model for tracheal resection and replacement with an autologous conduit. It was constructed from costal cartilages and a pediculed cervical skin flap. From 2004 to 2012, 12 patients have had ATS with associated resections in four cases. All patients were extubated on the first postoperative days; eight patients are alive at 2 to 94 months (mean=36) postoperatively, with no respiratory distress. The two patients with ATS after resection extended to the carina died due to pulmonary infection. No airway collapse has been detectable, either by endoscopy, dynamic CT scan or spirometry. Two patients still have a tracheotomy because performed too low at the level of the proximal anastomosis. One patient with a chronic severe respiratory insufficiency required recently a distal and short stent.
  
  
  CONCLUSIONS
  ATS is actually a good, durable tracheal substitute that can resist respiratory pressure variations because of their transverse rigidity without any immunosuppression. The limits of this technique are probably, chronic respiratory insufficiency and cartilage calcifications. Research to develop a method for lining the neo-trachea with ciliated respiratory epithelium is needed.
authors.affiliation: Marie Lannelongue Hospital, Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Le Plessis Robinson, France. Electronic address: d.fabre@ccml.fr.
authors.forename: Dominique
authors.initials: D
authors.lastname: Fabre
authors.forename: Frédéric
authors.initials: F
authors.lastname: Kolb
authors.forename: Elie
authors.initials: E
authors.lastname: Fadel
authors.forename: Nicolas
authors.initials: N
authors.lastname: Leymarie
authors.forename: Sacha
authors.initials: S
authors.lastname: Mussot
authors.forename: Thierry
authors.initials: T
authors.lastname: Le Chevalier
authors.forename: Philippe
authors.initials: P
authors.lastname: Dartevelle
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D000818:Animals; D003528:Carcinoma, Adenoid Cystic / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D002356:Cartilage / Q000637:transplantation*; D005205:Fascia / Q000637:transplantation*; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply / Q000637:transplantation*; D006801:Humans; D008223:Lymphoma / Q000601:surgery; D008297:Male; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D023421:Models, Animal; D016609:Neoplasms, Second Primary / Q000601:surgery; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016038:Skin Transplantation / Q000379:methods*; D015996:Survival Rate; D013552:Swine; D013964:Thyroid Neoplasms / Q000601:surgery; D014132:Trachea / Q000601:surgery*; D014134:Tracheal Neoplasms / Q000601:surgery; D014182:Transplantation, Autologous; D016896:Treatment Outcome