Thoracoscopic resection of esophageal duplication causing tracheobronchomalacia in a 5-year-old patient

Abstract

Central MessageThoracoscopy is a safe, effective, and superior alternative to open surgical approach for complex mediastinal masses. Extensive preoperative evaluation and a precise surgical plan is always mandatory.See Commentaries on pages 386 and 387. Thoracoscopy is a safe, effective, and superior alternative to open surgical approach for complex mediastinal masses. Extensive preoperative evaluation and a precise surgical plan is always mandatory. See Commentaries on pages 386 and 387. Tracheobronchomalacia is the most common congenital anomaly of the upper airways in children.1Wallis C. Alexopoulou E. Antón-Pacheco J.L. Bhatt J.M. Bush A. Chang A.B. et al.ERS statement on tracheomalacia and bronchomalacia in children.Eur Respir J. 2019; 54: 1-19Google Scholar It is defined as a dynamic expiratory collapse of the posterior tracheal wall, which can be partial or total. Tracheomalacia is most often of congenital origin, explained by weakness of the cartilage ring or caused by extrinsic compression.1Wallis C. Alexopoulou E. Antón-Pacheco J.L. Bhatt J.M. Bush A. Chang A.B. et al.ERS statement on tracheomalacia and bronchomalacia in children.Eur Respir J. 2019; 54: 1-19Google Scholar We present a child with a delayed diagnosis of tracheobronchial compression by a mediastinal mass, which in terms of diagnosis and surgical strategy has been challenging and educational. A 5-year-old girl had a 2-year history of recurrent respiratory tract infections and reactive airway disease when she was referred with suspicion of foreign body aspiration. Clinical examination revealed no dyspnea but significant wheezing and a barking cough highly suggestive of tracheomalacia (Video 1). Flexible bronchoscopy showed a malacia of the distal part of the trachea with severe extension to the left bronchus, secondary to nonpulsating posterior compression (Video 2).Video 2Preoperative flexible tracheobronchoscopy. The video shows the compression of the distal part of the trachea and its extension to the left bronchus, which appears completely inflammatory beyond the compression. The caliber of the right bronchus remains normal. Video available at: https://www.jtcvs.org/article/S2666-2507(20)30397-7/fulltext.View Large Image Figure ViewerDownload (PPT) Thoracic computed tomography scan showed a prevertebral mediastinal mass in front of the thoracic vertebrae 3-6 measuring 4.5 × 3.5 × 2 cm (Figure 1, A-D). The upper airways were compressed and the esophagus appeared displaced to the right and only partially visualized. Magnetic resonance imaging of the chest revealed the liquid content of the mass (Figure 1, E and F). A barium-swallow confirmed that esophagus was displaced but did not show any narrowing of its lumen (Figure 2). These results suggested a congenital cystic mass: bronchogenic cyst or esophageal duplication.Figure 2Barium swallow examination for a mediastinal mass (5 year-old child). A, Barium examination shows a narrowing of the upper part of the esophagus (arrows) due to the compression by the mediastinal mass (esophageal duplication) from the left side. B, With active swallow, the esophageal lumen widens to its normal size (arrow), but it stays displaced to the right. C, Final images show the persistence of a clear compression of the esophagus from the left at the level of thoracic vertebrae 3-6 (arrows).View Large Image Figure ViewerDownload (PPT) Despite the impossibility of single-lung ventilation and the proximity of major vascular structures, a right thoracoscopic approach was decided. The azygos vein was sealed and cut and the esophagus dissected just above the cyst and looped. The cyst had inflammatory adhesions to the posterior wall of trachea and left bronchus (Video 3). To avoid tracheal or esophageal burns, blunt dissection was preferred. After cyst perforation and suction of its mucous content, it was completely detached from the posterior wall of the upper airways and esophagus. No common wall was noted. The esophageal muscular