The next steps for pediatric tracheal reconstruction.

Pediatric surgeons, thoracic surgeons, and pediatric otolaryngology (head and neck) surgeons uniformly find the greatest challenges in and often form the closest relationships with patients who have tracheal anomalies. Knowing everyone from the registration staff to the critical care personnel, these patients and their families become part of the fabric of children’s surgical centers. The routine, sometimes daily, endoscopy that is part of diagnosis and follow-up becomes an elegant exercise practiced by all airway surgeons and their staff that blends technique, technology, experience, and judgment. The truth remains that for all operative airway maneuvers, other important elements include tricks, wishful thinking, hope, and luck. Any organ that can respond to the exact same operative intervention in totally disparate ways leading to malacia or restenosis, and anything in between, does not present a level playing field. Surgeons and families should never feel comfortable with success or resignation after failure. Even with that uncertainty and uneasiness, committed, focused airway surgeons and investigators must analyze every one of these individual patients for common successful threads of technical management and operative judgment. The retrospective review of outcomes for pediatric tracheal surgery from a single institution reported by See page 308 Wright and colleagues [1] demonstrates a very special commitment by expert airway surgeons over a 23-year period. Through the moving targets of technology and evolving techniques, they have sought to document the complications and outcomes of tracheal procedures that included 80 major tracheal resections. Since the early 1970s in the laboratories of Hermes Grillo and the late Arnold Salzberg, surgeons have questioned the response of the young trachea to resection and reanastomosis. Techniques developed in the laboratory to reduce anastomotic tension, restenosis, malacia, and intraluminal granulation have not easily translated to children’s operating rooms. In this review, four different techniques are presented that resulted in a 21% failure or death rate, an honest reality. Only 65% of outcomes achieved the designation of a good or stable airway, which improved to 72% when the results of tracheal or laryngotracheal resection and anastomosis were isolated. It is beyond the scope of these comments to pick apart this report to compare it with other excellent groups and series. Those with even the slightest experience of pediatric tracheal reconstruction will find these results outstanding. Only 50% of patients with 30% to 50% of the trachea resected and reanastomosed had complications. Is the cup half full or half empty? It depends on what we do from this point on. Surgeons trying to understand these results are faced with fundamental questions about how they were achieved. Are the complications related to pediatric tracheal reconstruction due to tracheal biology, surgical practice, etiology of the malformations, or countless other factors. Until now, but perhaps not into the future, the overriding presentation of outcomes in tracheal surgery has revolved around center-specific and even surgeonspecific results. The opening sentence to this report by Wright and associates clearly highlights the uncommon presentation of pediatric airway obstruction requiring operative intervention. The comments throughout the study underscore the flexibility and the variability of technical innovations required to manage these patients. The discussion presents well-thought-out, but not scientifically proven differences between groups and between