Find an ideal substitute for the trachea

Cancer of the trachea or its extensive destruction are short-term lethal diseases by asphyxia because it can not replace the duct connecting the larynx to the lungs. But after 50 years of unsuccessful search, two French teams now propose a new solution!

The marriage of plastic and thoracic surgery

Two surgeons have developed an artificial autologous trachea (elaborated from the patient's cells), which makes it possible to take care of patients until then in failure of treatment. Revealed six years after the first surgery, this world premiere is the result of close collaboration between the surgical teams of Prof. Philippe Dartevelle (Marie Lannelongue - Plessis Robinson surgical center) and Dr. Frédéric Kolb (Institut Gustave Roussy) Code>

Patients saved, a promising technique

The tumors that invade the trachea (thyroid, trachea, esophagus ...) or its extensive destruction expose to fatal outcomes in more or less short term, especially asphyxia. For 50 years, management has been faced with the impossibility of having a reliable replacement solution when more than half of the trachea has to be replaced (if the part to be removed is less important, a suture between the two extremities is Carried out).

Autologous artificial trachea: the evacuation of the mucus remains a point to improve

Despite the progress of prostheses or grafts, replacement of a trachea is a puzzle. Prof. Dartevelle of the Marie Lannelongue Surgical Center tells us the reasons

Despite the hopes of the artificial organs, no solution emerges today of bio-engineering. But the "free flap technique" developed by two French teams made it possible to manufacture almost ideal substitutes for the trachea.

In order to propose an ideal alternative, Professor Dartevelle of the Marie Lannelongue Surgical Center and Dr. Kolb of the Gustave Roussy Institute used a piece of the patient's skin, which they "armed" with pieces of cartilage taken from The ribs of the patient - technique commonly used in restorative surgery to remake pieces of nose.

A rectangle of skin (12 x 9 cm) vascularized by the radial artery and vein was then taken from the forearm. The cartilage fragments were recovered on the 9th and 10th ribs, at the level where the rib joined the sternum. In total, 6 or 7 ring cartilages were collected (5 mm wide, 2 mm thick and 9 cm long).

This piece of skin with its frame was then curved and sutured to make a perfectly vascularized replacement tube (12 cm long and 3 cm in diameter) and presenting on its inner surface an "epithelium" (the skin of the patient) To protect it, as it naturally does from the external aggression of microbes present in the air.

"The pathological trachea is removed and the tube is sutured at the ends, that is to say on the tracheobronchial bifurcation at the bottom and on the larynx at the top.Gasic exchanges of the patient are ensured during this phase by ventilation at The revascularization of the flap is done via a subclavian or external carotid artery and a vein of the neck or mediastinum, "says Professor Dartevelle.

The first patient was operated when he was virtually condemned by a fistula between the trachea and the esophagus. Today, he lives, breathes and eats normally 6 years after the operation. The second patient presented with thyroid cancer revealed by respiratory distress and invasion of the trachea. Four years after the operation, he is cured of his cancer, speaks and breathes normally ... A total of 8 patients have benefited from this technique which has been refined as the practice. The 5 patients treated for tumor complications are currently in complete remission of their cancer

Two failures were reported, patients developed pneumonia and acute respiratory distress syndrome (ARDS) and a fatal infection. These deaths were not directly related to the technique because the flaps remained viable and functional until the death of the patients by respiratory infection. But it is rather the accumulation of bronchial secretions that is guilty. Indeed, the absence of muco-ciliary purification is the main defect of this artificial trachea.

Unlike the natural organ, the artificial autologous trachea does not benefit from a mucociliary purification: it has no eyelashes at the level of the epithelium which makes it possible to evacuate the mucus towards the outside. "This absence of mucociliary treatment (as in patients with cystic fibrosis) should lead to a particular attention during the immediate postoperative period, to aspirate the bronchial secretions by possibly a transient tracheotomy and to teach the patient the drainage of posture. For the same reasons, this intervention is not indicated when the patient does not have a perfect respiratory and diaphragmatic mechanism which allows him an effective cough, "says Professor Dartevelle, who specifies that work is underway to solve this problem . "Studies carried out in the laboratory of experimental surgery by Dr. Dominique Fabre should make it possible to resolve this imperfection by substituting for the cutaneous epithelium a ciliated epithelium from a culture of nasopharyngeal epithelium.Work on the animal are promising and We can expect the first experiments in humans within a year. "

"We decided to communicate around this technique because our team now has enough knowledge to offer it to patients who were previously in short-term therapeutic failure and whose last patient is a woman Addressed by his attending physician to our institution after the latter has read in the media the existence of our know-how "declared enthusiastic Professor Dartevelle

Will this technique be widely disseminated? "The urgency is not today to disseminate all this technology at the risk of seeing it overused. For the time being, it is especially useful to rely on teams that master the technicality of this method. , We will then publish in scientific journals the details of this technique and we will present it to our international colleagues, "concludes Prof. Dartevelle.

Interview with Prof. Philippe Dartevelle of Marie Lannelongue Surgical Center (Plessis Robinson) - 26 January 2011

Press Kit "World Premiere - Autologous Artificial Tracheal Transplant - The Real Solution to Tracheal Replacement by Meeting Plastic Surgery and Thoracic Surgery: The First 7 World Cases" - November 29, 2010

A duct rigid and flexible at the same time: The duct must be sufficiently rigid to resist the negative pressure generated by the inspiration and positive during exhalation. Autologous tissues such as the intestine, the esophagus, the skin or the aorta have encountered this problem, they collapse (collapse due to pressure) invariably and expose the patient to a risk of " asphyxia. Though rigid, the duct must have a minimum of flexibility to follow the movements of the neck Avoid the risks of infection and rejection: The inner duct in contact with the air must play a role of barrier against the infection, As are all the surfaces of the organism in contact with an external environment aerial or liquid. But silicone or metallic prostheses have so far systematically failed in this area. Another requirement: these prostheses must not erode the surrounding organs. In addition, the "classical" graft of the revascularized trachea is very complex and requires a lifetime immunosuppressive treatment: Allow the expectoration of the bronchial secretions: These secretions must be able to go back towards the pharyngo-laryngeal intersection to be eliminated by expectoration or ingestion. For this, the trachea is equipped with a ciliated epithelium which allows this evacuation.