Nagpur's Meditrina hospital docs do tracheal reconstruction, probably first in India

                               Dr Sameer Paltewar, Dr Parikshit Janai, Dr Gaurav Agrawal with the patient.

By Vikas Vaidya

IN A record of sorts, a team of doctors in city’s Meditrina Hospital has successfuly restored speech of a patient by implanting trachea reconstructed from the body part of the patient himself.
This is probably the first of its kind surgery performed in India.
The surgery was performed in four parts. The most difficult job was to implant the reconstructed trachea. It took 13 long hours but in the end the patient went home fit, fine and happy.
Girish, a city resident, had met with a road accident in May 2015. He was in a critical condition after sustaining polytrauma. He required long term intubation, tracheostomy and ventilatory support. After recovering from the injuries he developed tracheal stenosis, which is a known complication of long term intubation. As a result, he was not able to respire, not able to talk.
Girist visited a number of centers in India seeking treatment but returned disappointed. Two of the biggest problems he faced were inability to speak and constant possibility of blocking the tracheostomy tube.
Finally, Girish came to Meditrina Institute of Medical Sciences where he met Dr. Sameer Paltewar, a well-known Neurosurgeon.
Dr Paltewar discussed the case with Dr Parikshit Janai, Consultant Plastic Surgery, Microvascular and Cosmetic Surgery and Dr Gaurav Agarwal, Consultant ENT from Meditrina. It was decided to reconstruct his trachea by performing staged surgeries.
“Such extensive reconstructive surgeries of trachea are one of its kind and probably one of the first in India,” Dr Paltewar told ‘The Hitavada’.
First two stages involved opening the neck and knowing the size of wind pipe needed to be reconstructed. The 4.5 cm gap in the wind pipe was bridged with a temporary silicon T tube so that the patient could speak.
“It was successful but it was still a temporary solution. Accordingly a radial artery forearm flap was prepared by adding cartilages from both the ears (Prefabricated Radial artery flap). It was implanted in forearm to make it alive. After four weeks it matured. The cartilages were added to bring some rigidity to the tube made from his forearm skin,” he added.
In the third stage, two months after the first two, Girish’s neck was reopened. The surgery was difficult as doctors had to search proper blood vessels. His neck had been operated a number of times at other hospitals so it was in bad shape. Blood vessels were identified in the neck to receive the flap from the forearm. Skin from the forearm was harvested with the blood supplying vessels and a tube of 4.5 cm was created out of it.
“The tube was used to fill the gap between tracheal ends. The blood vessels of this ‘skin island’ were joined to the blood vessels in the neck to make this skin survive. This procedure was of critical nature and demanded exceptional clinical acumen coupled with unmatched operation theatre infrastructure. It took more than 12 hrs to complete this procedure,” explained Dr Janai and Dr Agarwal.
“Once we were sure that the tube we created is surviving and stable, a silicon stent was placed by Rigid Endoscopy and intervention. This made the tube more rigid and stable for the obstruction free breathing,” Dr Janai and Dr Agarwal told about the fourth stage.
Key elements in the entire procedure were the tertiary level readiness of OT, clinical acumen, and team effort.
According to Dr Janai, the contribution of team of anaesthesiologists was very important.
Team anaesthesia led by Chief Anaesthetist Dr Deepak Madankar, Dr Sheetal Samel, Dr Neelesh Mathankar, Dr Ritesh Borkar and Dr Latika Panpaliya had a unique challenge in managing this case as the wind pipe, which is the gateway for anaesthesia, was itself being repaired.
The team effort and one of its kind surgery bore fruits and Girish got his speech back. He responded well to the treatment and has since been discharged.

What is trachea

The trachea, commonly known as the windpipe, is a tube about 4 inches long and less than an inch in diameter in most people. The trachea begins just under the larynx (voice box) and runs down behind the breastbone (sternum).
The trachea then divides into two smaller tubes called bronchi: one bronchus for each lung. Tracheal stenosis: Inflammation in the trachea can lead to scarring and narrowing of the windpipe. Surgery or endoscopy may be needed to correct the narrowing (stenosis), if severe.