Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.     

A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea

Anterior mediastinal tracheostomy (AMT) is a rare but challenging operation associated with a high morbidity and mortality rate mainly related to the invasiveness of the procedure. In order to provide a more conservative technique with a lower risk of major postoperative complications, we proposed: (1) to reduce the extent of chest wall resection to only a trapezoidal segment of the manubrium; (2) to use a simple pedicle pectoralis major flap instead of myocutaneous or omental flaps; and (3) to perform a simple relocation of the residual trachea (RT) below the brachiocephalic artery instead of artery ligation, percutaneous stent placement or replacement by cadaveric allograft. This technique was used in a patient with cancer recurrence at the cervical stoma after total laryngectomy. Despite a short 2.5-cm RT, it was possible to perform AMT without any tension at the mediastinal stoma. Postoperative course showed only regressive minor complications. There was no late complication related to the procedure with a one-year follow-up. This more conservative technique for AMT could be used as an alternative to previously described procedures in order to reduce postoperative complications and mortality rate after sub-total resection of the trachea.     

Anterior mediastinal tracheostomy for tracheostomal recurrence of laryngeal carcinoma

The patient was a 58-year-old male with tracheostomal recurrence after surgery for laryngeal carcinoma. After median sternotomy, half of the bilateral clavicula, the anterior portion of the bilateral 1st ribs, and the upper portion of the sternum were resected. The tumor was resected with the muscle layer of the esophagus and the left internal jugular vein. A left internal jugular vein was reconstructed from the major saphenous vein. The trachea was resected at a position of 5 rings from the carina, and then a tracheostoma was made. At an early stage after surgery, there was no problem associated with the tracheostoma. Three months after surgery, stenosis of stoma occurred, but temporary intubation of the trachea released the stenosis completely. From this result, we concluded that when anterior mediastinal tracheostomy is performed for tracheostomal recurrence with invasion to the major vessels, addition of a median sternotomy is a safe and beneficial procedure.     

Treatment of mediastinal infection after coronary artery bypass surgery by transposition of the greater omentum]

From January, 1986 to May, 1990 twenty one adult patients (men 16, women 5, age 64 +/- 7 years old) underwent transposition of the greater omentum to control mediastinal infection after coronary artery bypass surgery. Upon diagnosing mediastinitis, the mediastinum was drained open and irrigated with 0.5% povidone iodine-saline solution until the omental transposition. The interval between the diagnosis of mediastinitis and the omental transposition ranged from 0 to 171 (mean 19) days. Three quarters of the patients had the omentum transposed within 14 days. In nineteen of 21 patients (90%) the mediastinitis was effectively controlled. In the remaining two patients the infection could not be controlled and proceeded to succumb from multiple organ failure. There was no complication related to the omental transposition in itself. We conclude that transposition of the greater omentum is a safe and effective method for treating mediastinal infection after coronary artery bypass surgery.     

Anterior mediastinal tracheostomy with and without cervical exenteration.

Anterior mediastinal tracheostomy (AMT) facilitates resection of stomal recurrences after laryngectomy for carcinoma and tumors involving the cervicothoracic trachea and esophagus. Erosion of the innominate artery has been reported as a frequent major complication of AMT, and routine prophylactic division of the innominate artery with AMT has even been advised. Forty-four patients underwent AMT, 10 as an isolated procedure (for stomal recurrence [5], laryngeal carcinoma [1], or benign stenosis after laryngectomy [4]) and 34 with concomitant cervical exenteration (laryngopharyngoesophagectomy) for laryngeal, thyroid, or cervicothoracic esophageal malignancies. Transposition of the remaining tracheal stump beneath and to the right of the innominate artery to eliminate tension on the vessel was carried out in 14 patients (32%). Postoperatively, anastomotic leaks complicated nine of 31 pharyngogastric anastomoses. Iatrogenic hypoparathyroidism occurred in 10 patients. All six hospital deaths (14%) occurred in patients undergoing AMT with cervical exenteration, not isolated AMT. There was only one instance of innominate artery erosion. Survival was related to the pathology for which AMT was performed. Anterior mediastinal tracheostomy is a valuable adjunct in the treatment of select patients with malignancies of the cervicothoracic trachea and esophagus, and with attention to operative detail, innominate artery erosion should rarely, if ever, complicate the operation. Prophylactic division of the innominate artery with AMT is unnecessary.     

Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap.

We describe the reconstruction of an anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap. This procedure is safer, more easily carried out, a more reliable means of creating an anterior mediastinal tracheostomy and is better suited for chest wound healing than previous methods. In addition, the appearance of the patient's chest after operation is cosmetically excellent.     

Use of computed tomography to assess mediastinal complications after median sternotomy

Thirty computed tomographic (CT) scans from 27 patients who had undergone median sternotomy were reviewed. A control group of 15 asymptomatic patients was studied either early (within 21 days) or late (46 days to 22 years) after sternotomy. Twelve patients with symptoms ranging from sternal click to obvious mediastinitis also were studied within 30 days of sternotomy. The CT findings were correlated with the patient's clinical course. Imperfect sternal closure (sternal step-offs and gaps) was found in 10 of the 15 asymptomatic patients. Focal retrosternal fluid collections, air, and hematomas were seen in more than 75% of the asymptomatic patients. Retrosternal abscess, presternal abscess, and sternal disruption were noted in 3 symptomatic patients. Computed tomography correctly diagnosed the extent of mediastinal abscess in all patients. In the 3 patients in whom there was a discrepancy between the CT scan and the clinical findings, the scan ultimately was shown to be correct. These results indicate that computed tomography is a valuable tool in diagnosing wound problems after sternotomy because it accurately depicts the extent and depth of the wound infection.     

Use of the omentum in chest-wall reconstruction

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on both sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.