Tracheal replacement

Abstract

Tracheal reconstruction is one of the greatest challenges in thoracic surgery when direct end-to-end anastomosis is impossible or after this procedure has failed. The main indications for tracheal reconstruction include malignant tumours (squamous cell carcinoma, adenoid cystic carcinoma), tracheoesophageal fistula, trauma, unsuccessful surgical results for benign diseases and congenital stenosis. Tracheal substitutes can be classified into five types: 1) synthetic prosthesis; 2) allografts; 3) tracheal transplantation; 4) tissue engineering; and 5) autologous tissue composite. The ideal tracheal substitute is still unclear, but some techniques have shown promising clinical results. This article reviews the advantages and limitations of each technique used over the past few decades in clinical practice. The main limitation seems to be the capacity for tracheal tissue regeneration. The physiopathology behind this has yet to be fully understood. Research on stem cells sparked much interest and was thought to be a revolutionary technique; however, the poor long-term results of this approach highlight that there is a long way to go in this research field. Currently, an autologous tissue composite, with or without a tracheal allograft, is the only long-term working solution for every aetiology, despite its technical complexity and setbacks.

Biomedical grafts for tracheal tissue repairing and regeneration “Tracheal tissue engineering: an overview”

“…Butler et al () also reported that the vacuum‐assisted decellularization of tracheal graft results better graft for clinical application. Clinical study of acellular graft was done for the tracheal tissue reconstruction (Elliott et al, ; Etienne et al, ; Li et al, ; Martinod et al, ).…”

“…The common therapy used for the treatment of damaged tracheal tissue is “direct anastomosis,” “suboptimal laser treatment,” and “stenting.” There are many other treatments, such as autografting and allografting: Use of prosthetic materials or a combination (e.g., silk‐coated titanium mesh) has also been attempted (Graziano, Spinazzola, & Neville, ; Okumura, Nakamura, Shimizu, Natsume, & Ikada, ). Available prosthetics often have some limitations, such as incomplete host tissue integration and inflammation; they do not mimic native tissue properties and shows extrusion (Etienne et al, ; Kojima & Vacanti, ). However, in case of grafting, surgical outcomes are excellent without any rejection or inflammation when autograft is used.…”

Kartogenin preconditioning commits mesenchymal stem cells to a precartilaginous stage with enhanced chondrogenic potential by modulating JNK and β‐catenin–related pathways

“…Tracheal stenosis is usually caused by trauma, malignant neoplasms with airway involvement, and inherent factors (1). Most patients with long‐segment tracheal stenosis are often confronted with a poor prognosis because of a limitation in the materials available for tracheal reconstruction (2, 3).…”

Combination of vascularization and cilia formation for three‐dimensional airway tissue engineering

“…Tracheal resection can become necessary for malign or benign stenosis or fistulas (Etienne et al, 2018). When more than half of the length of the trachea (up to 5 cm) of adults or more than a third in children have to be resected, end-to-end-anastomosis is not possible due to increased strain on the tissue (Kucera, Doss, Dunn, Clemson, & Zwischenberger, 2007).…”

“…When more than half of the length of the trachea (up to 5 cm) of adults or more than a third in children have to be resected, end-to-end-anastomosis is not possible due to increased strain on the tissue (Kucera, Doss, Dunn, Clemson, & Zwischenberger, 2007). As airway transplantation still has major shortcomings such as restenosis, immunological rejection, lack of blood supply, or infections, longer defects can only be treated palliatively (Delaere, 2012;Etienne et al, 2018) Thus, the development of an adequate tissue-engineered tracheal substitute is of high clinical interest. Three major shortcomings are described for current tissue engineered airway substitutes: a lack of mechanical stability, a missing long-term stable sealed connection to the patient's trachea, and an insufficient blood supply with nutrition of the engineered tissue in vivo (Law et al, 2016).…”