Reports have described direct suturing of a tracheobronchial injury in children [3,4,5]. In those cases, the injured areas were narrower than those in our case. In our case, the membranous area defect was so extensive that direct suturing was not possible. In another report, the pericardium was used to repair a tracheobronchial injury in a child . However, in that case, suture failure occurred after surgery, requiring reinforcement of the sutures with the latissimus dorsi muscle. Insufficient blood flow and bacterial contamination of the injured area may have caused suture failure. The injured area, in that case, was similar to that in our case. Pericardial closure may have been an option in our case; however, there was a risk of suture failure owing to the reasons described above. Therefore, we did not choose that method.
Recently, it has been reported that covered self-expanding metallic stent (SEMS) implantation can be used to treat tracheobronchial injuries with high surgical risk . Treatment of such injuries with a covered SEMS involves two processes. First, the SEMS covers the defect and serves to clear the airway. Second, prolonged implantation allows inflammatory cells to infiltrate the defect, causing granulation and healing. It is necessary to adjust the size and shape of the SEMS to fit the injured area. In our case, the patient’s circulation was unstable, the airway needed urgent reconstruction, and there was little time to prepare a SEMS that would fit. Even if a suitable SEMS had been available, the extent of the membranous defect was so large that stenting would not have resulted in granulation.
If direct suturing, pericardial patch, and covered SEMS are not suitable treatments for a tracheobronchial injury, reconstruction of the injured area is necessary. Before performing reconstruction, resection of the injured area is necessary, as reconstruction without resection may lead to postoperative suture failure and anastomotic stenosis owing to insufficient blood flow and bacterial contamination. Given these risks, we resected the injured area, though the injury was extensive. Reconstruction methods for tracheal bifurcation include the double-barreled, Barclay’s, inverted Barclay’s, and Grillo’s methods [7,8,9,10]. Tension-free anastomosis should be selected because excessive tension on the anastomosis can cause suture failure. In our case, the right main bronchus had a limited range of motion that may have been caused by pulmonary congestion. Double-barreled, Barclay’s, and Grillo’s methods might have led to excessive tension on the anastomosis, resulting in suture failure. Therefore, we chose an inverted Barclay’s method, in which the anastomosis of the right main bronchus was formed caudally. As a result, suture failure did not occur. Although stenosis due to defective granulation of the right main bronchus occurred once, we performed bronchoscopic curettage of the granulation followed by balloon dilation, and no restenosis was observed afterward.