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.     

Cervical exenteration

Cervical exenteration is a radical operation to remove the larynx, portion of the trachea, and the esophagus, and frequently requires a mediastinal tracheostomy. Highly selected patients with obstructing neoplasms of the esophagus and airway can be palliated and sometimes cured by this aggressive surgical approach. Fatal hemorrhage from pressure or exposure of the innominate artery is avoided by elective division of the artery (preoperative angiograms and intraoperative electroencephalographic control are essential), using the omentum to separate the trachea and great vessels, and removal of a bony plaque of chest wall to allow a well-vascularized bipedicled skin flap to drop into the mediastinum for the tracheocutaneous anastomosis. Eighteen exenterations were performed. Mediastinal tracheostomy was performed in 14 patients and division of the innominate artery was performed in 7. Esophageal replacement was predominantly with the left colon. Complications include esophageal leak (2 patients), stomal separation (2), transient hemiplegia (1), colonic obstruction by substernal tunnel (1), and need for prolonged mechanical ventilation (4). There was a single operative death. Postoperative survival was disease dependent. All patients achieved an excellent airway and relief from dysphagia.     

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.     

A case of carcinoma of the esophagus involving the trachea undergoing anterior mediastinal tracheostomy with pedicled omental wrapping

A 62-year-old male who complained of dysphagia, body weight loss and hoarseness was admitted to our hospital. Chest x-ray film disclosed right superior mediastinal mass compressing membranous portion of trachea. Esophageal fiberscope revealed carcinoma of cervical esophagus. Bronchofiberscope revealed the paralysis of right recurrent laryngeal nerve and the invasion of esophageal cancer to tracheal membranous portion from the 5th tracheal ring to the 12th. The cancer also invaded the right lobe of thyroid which was shown by echogram. Operation was performed. On dissecting the cervical region, it was found that the tumor invaded both sides of the trachea so that tracheal reconstruction could not be done without injuring left recurrent laryngeal nerve. Sternotomy was added. Anterior mediastinal tracheostomy was done after laryngeal resection with total thoracic esophagectomy and tracheal resection leaving 5 rings long cartilage from carina. The trachea was wrapped with pedicled omentum. Post-operative course was uneventful. This procedure helps to increase blood supply to the tracheal anastomosis and turns to advantage in preventing infectious extension around trachea to mediastinum as well as tracheal compression to major vessels.     

A case of pulmonary metastasis from adenoid cystic carcinoma of the trachea

A 33-year-old woman with adenoid cystic carcinoma of the trachea was treated by resection of the upper and mid-trachea, plus total laryngectomy, subtotal thyroidectomy, partial resection of the cervical esophageal muscle layer and mediastinal tracheostomy. This tumor invaded directly into the thyroid gland, the larynx, the recurrent laryngeal nerve and the cervical esophagus. Three years after the operation, metastases developed in the right lung (S10, S2) and partial resection of the lung was performed. This patient is now free from disease. Aggressive surgical resection is important for the improvement of survival in this condition, although this tumor shows low grade malignancy and is slowly growing.     

Upper esophagectomy with pharyngolaryngectomy for esophageal carcinoma at the cervicothoracic junction.

The choice remains controversial as to which surgical procedure should be selected for carcinomas situated in the esophagus at the cervicothoracic junction involving the trachea. After mediastinal tracheostomy associated with pharyngolaryngoesophagectomy and thoracic esophagectomy, numerous reports have previously described severe postoperative complications, such as tracheal necrosis and rupture of the great vessels in the neck. To prevent such complications, we have developed the procedure called "upper esophagectomy" followed by a free jejunal graft and mediastinal tracheostomy through either manuburectomy or upper median sternotomy. We have established that this procedure maintains the vascular networks between the trachea and the esophagus, avoids an occurrence of tracheal necrosis or great vessel bleeding postoperatively, and obtains an improved prognosis in the surgical treatment of esophageal carcinoma at the cervicothoracic junction.     

Use of omentum for mediastinal tracheostomy after total laryngoesophagectomy

BACKGROUND: Carcinomas of the cervicothoracic esophagus frequently invade the trachea and complete removal of the tumor often requires mediastinal tracheostomy. Traditionally, this surgical management was associated with high morbidity and mortality. Several types of myoctaneous flaps have been used for mediastinal tracheostomy to reduce the complication. We present our experience with a new technique for construction of mediastinal tracheotomy after total laryngoesophagectomy and reconstruction with the stomach. METHODS: The anterior chest wall was amply resected and the distal end of the trachea was placed low between the superior vena cava and aortic arch. We mobilized the entire omentum with the stomach and brought them up to the neck through the posterior mediastinum. The omentum was put around the trachea, main arteries, and the anastomosis. RESULTS: Seven mediastinal tracheostomies were performed using this method. There was no hospital death. Complications included respiratory failure (2 patients) and pyothorax (1 patient). Anastomotic leakage and inominate artery rupture were not experienced. Postoperative survival was disease dependent. All patients were discharged with satisfactory oral food intake, good airway condition, and excellent cosmetic appearance. CONCLUSIONS: We suggest the use of the omentum as a simple and reliable technique in constructing mediastinal tracheostomy following total laryngoesophagectomy for cervicothoracic esophageal cancer.     

Technique to avoid innominate artery ligation and perform an anterior mediastinal tracheostomy for residual trachea of less than 5 cm

A 47-year-old man was admitted with recurrent autolimited bleeding arising from a cervical tracheostoma made 2 years earlier during a total laryngectomy. Stomal recurrence of the past laryngeal cancer invading the neighboring innominate artery was diagnosed by angiographic computer tomography and bronchoscopic biopsies. The malignant tracheostoma-innominate fistula was approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, and manubriectomy. It was treated with an anterior mediastinal tracheostomy with omental major transposition, right latissimus dorsi myocutaneous flap for tissue coverage, and brachiocephalic artery rerouting with cadaveric homograft. The patient was discharged on postoperative day 14 after an uneventful postoperative course.     

Upper esophagectomy with pharyngolaryngectomy for esophageal carcinoma at the cervicothoracic junction

The choice remains controversial as to which surgical procedure should be selected for carcinomas situated in the esophagus at the cervicothoracic junction involving the trachea. After mediastinal tracheostomy associated with pharyngolaryngoesophagectomy and thoracic esophagectomy, numerous reports have previously described severe post-operative complications, such as tracheal necrosis and rupture of the great vessels in the neck. To prevent such complications, we have developed the procedure called “upper esophagectomy” followed by a free jejunal graft and mediastinal tracheostomy through either manuburectomy or upper median sternotomy. We have established that this procedure maintains the vascular networks between the trachea and the esophagus, avoids an occurence of tracheal necrosis or great vessel bleeding postoperatively, and obtains an improved prognosis in the surgical treatment of esophageal carcinoma at the cervicothoracic junction.     

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.     

Experience with primary neoplasms of the trachea and carina

From 1963 to 1983, 44 patients presented with a primary tracheal neoplasm that was amenable to surgical treatment. Forty-two of the 44 tumors were malignant. Thirty-three patients were managed by resection and primary anastomosis. The following resections were done: trachea only, 12; trachea plus carina, 13; trachea plus cricoid cartilage, four; and trachea plus larynx, four. There were two operative deaths in these 33 patients. Prosthetic reconstruction with heavy-duty Marlex mesh was done in six patients. Three of the six died of erosion of the innominate artery during the postoperative period. In three patients with nonresectable tumors, a silicone-coated Montgomery T-tube provided transient but worthwhile palliation. In two patients with nonobstructive adenoid cystic carcinoma involving the subglottis, irradiation was chosen as the initial treatment, since resection would necessitate laryngectomy. Resection, including laryngectomy, may be required in the future. The following points are emphasized: (1) A majority of operable neoplasms can be resected through a cervical collar incision and median sternotomy. Median sternotomy is the optimal operative exposure in most neoplasms necessitating resection of the carina. (2) Partial resection of the cricoid with sparing of the recurrent laryngeal nerves and larynx is possible in some patients with primary malignant tumors involving the proximal trachea and subglottic region. (3) In patients with adenoid cystic carcinoma, resection may afford excellent, long-term palliation even when the resection is incomplete. Pulmonary metastases are common in patients with adenoid cystic tumors. However, they usually progress slowly, may remain asymptomatic for many years, and are not necessarily a contraindication to resection of the primary tumor even when they are synchronous. Our experience suggests that adjunctive radiotherapy is beneficial in patients with adenoid cystic carcinoma.     

Adenoid cystic carcinoma of the trachea. Experience with 16 patients managed by tracheal resection

Sixteen patients with adenoid cystic carcinoma of the trachea were treated by resection, on occasion combined with radiotherapy. In 14 patients in whom circumferential resection was done, the defect was reconstructed by primary anastomosis (5 patients, up to 8.5 cm. resected), prosthetic replacement (6 patients, up to 11 cm. resected), or laryngectomy with end tracheostomy (3 patients). In 3 remaining patients a partial tracheal resection was closed with a patch of autologous tissue.There were no operative deaths in 11 patients (12 resections) managed by primary anastomosis, autologous graft, or end tracheostomy; and 8 of these 11 patients are alive and clinically free of local tumor 2 to 18 years following resection. Prosthetic replacement in 6 patients resulted in 4 postoperative deaths (3 due to innominate artery erosion); good palliation was obtained in the 2 survivors. In 6 patients receiving preoperative radiotherapy, no local recurrence of tumor has been observed, and tracheal healing was not impaired.Extensive sleeve resection of the trachea with primary anastomosis is now possible and is the treatment of choice for this tumor. Preoperative radiotherapy may delay or obviate local recurrence.     

A new method of anterior mediastinal tracheostomy following resection of cervical esophagus and the larynx: Report of a case

We report herein the case of a 52-year-old man for whom a split pectoralis major myocutaneous flap was applied at the time of extended radical surgery for esophageal carcinoma with tracheal involvement, to avoid the postoperative complications of anterior trachcostomy such as tracheal necrosis and rupture of the major vessels. Laryngopharyngectomy and extended resection of the proximal trachea was performed through a manubrectomy, leaving the tracheal remnant only 4 cm above the carina. A pectoralis major myocutaneous flap was split into two with one piece being wrapped around the trachea at the anterior mediastinal tracheostomy site, and the other being placed between the trachea and brachiocephafic artery. The postoperative course was uneventful and the patient was discharged from hospital on the 34th postoperative day. A split pectoralis major myocutaneous flap may be effective not only for filling the dead space between the trachea and brachiocephalic artery, but also for reducing tension at the tracheocutaneous anastomosis and protecting against circulatory damage at the mediastinal tracheostomy site to minimize stomal retraction.     

Cervical mediastinoscopy after total laryngectomy and radiotherapy: its feasibility.

OBJECTIVE: The feasibility of cervical mediastinoscopy after total laryngectomy and radiotherapy has not been documented. METHODS: We describe our experience with cervical mediastinoscopy in two patients with total laryngectomy and radiotherapy for squamous cell carcinoma and had a Blom-Singer speaking tracheostomy valve in situ. Both patients presented with mediastinal lymphadenopathy and radiographic features suggesting a new pulmonary malignancy. RESULTS: Rigid bronchoscopy and cervical mediastinoscopy were undertaken and paratracheal and subcarinal lymph nodes were biopsied. Both patients made uneventful post operative recovery. Mediastinal lymph node biopsy was definitive in deciding their further care. CONCLUSION: Cervical mediastinoscopy is feasible in patients with total laryngectomy, tracheostomy and radiotherapy.     

Tracheobronchoplasty for functional restoration

We have experienced 10 cases of terminal mediastinal tracheostomy (TMT), 7 cases of laryngotracheal anastomosis with subtotal resection of cricoid cartilage (LTT), 5 cases of sleeve or wedge segmentectomy (SS, WS) for lung cancer with low pulmonary function, and 5 cases of carinal reconstructions (CR) with one stomal anastomosis between left lobar bronchus and trachea after partial resection of carina for tuberculous stenosis of left main bronchus. Modified TMT which stomaplasty was constructed with cervical and anterior chest skin flap different from primary procedure by Grillo was performed in 3 cases without innominate artery rupture nor cicatricial stomal stenosis. LTT by Pearson's procedure caused telescoped anastomosis. Pulmonary function was reserved in all 5 cases of SS and WS. Salvaged left lung by single stomal CR in the cases of tuberculous stenosis functioned well. Two different approaches for subaortic arch anastomosis, namely Pull-down and Pull-up, were proposed in single stomal CR. Pull-down provided excellent exposure of the carina without sacrifice of intercostal arteries. Indication of plasty was extended by TMT and LTT for upper limits of airway resection, SS and WS for limited operation against lung cancer, and single stomal CR for tuberculous stenosis of left main bronchus.     

Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx.

OBJECTIVE: Stomal recurrence after total laryngectomy is one of the most serious issues in the management of laryngeal carcinoma. The management of stomal recurrence, including chemotherapy, radiotherapy, and surgery, has been reported as unsatisfactory. STUDY DESIGN AND SETTING: From 1985 to 1995, 69 patients underwent total laryngectomy for the treatment of laryngeal cancer at the University of Tokyo Hospital. To identify the risk factors for stomal recurrence, we analyzed these patients according to various clinicopathological factors. RESULTS: Stomal recurrence developed in 6 of 69 patients who underwent total laryngectomy for laryngeal carcinoma. Statistical analysis reveals that primary site, preoperative tracheotomy, and paratracheal lymph node metastasis are significant risk factors for stomal recurrence. CONCLUSION: Intensive follow-up should be performed for patients with glottic carcinoma who had preoperative tracheotomy, paratracheal lymph node metastasis, or both to detect stomal recurrence at an early stage.     

Tracheoinnominate fistula: diagnosis and management

TIF is a rare and often fatal complication of tracheostomy. Bleeding from the trachea after tracheostomy demands urgent investigation. Bronchoscopy is the diagnostic procedure of choice. Bedside control of hemorrhage by cuff overinflation or by digital arterial compression can be lifesaving. Prompt operation with division of the innominate artery and subsequent separation of the trachea from the divided artery by viable tissue is indicated. Neurologic complications are rare.     

Management of trachea--innominate artery fistula.

The case histories of three patients with trachea-innominate artery fistula are presented. Low tracheostomy was the etiologic factor producing the fistula in two patients. In both cases, the neck was hyperextended by placing a large roll behind the patient's shoulders and thereby elevating the trachea out of the mediastinum. In one patient a balloon cuff eroded the innominate artery. Management of these patients includes control of hemorrhage by cuff overinflation and/or by endotracheal intubation and packing of the tracheostomy site. The best surgical approach is via a right anterior thoracotomy and a separate neck incision to isolate the blood vessels involved. Median sternotomy should be avoided to prevent mediastinal infection and sternal dehiscence. Carotid stump pressures are a useful guide to determine the efficacy of innominate artery ligation. One patient was saved and is a long-term survivor.     

A new technique to preserve the larynx in surgery for cervical esophageal carcinoma and the limit of its practical application]

A new technique to preserve the larynx in esophagectomy for cervical esophageal carcinoma is described. The trachea, which prevents exposure of the cervical esophagus, is dissected while maintaining the continuity of the recurrent laryngeal nerve. The tracheal stumps were turned over like a double door, and the esophageal tumor is excised with sufficient margins for suturing. The cervical esophagus is safely replaced with a free jejunum or the stomach followed by tracheal reconnection. The technique of tracheal reconnection in the neck is not difficult and is a safe procedure. Anastomotic insufficiency of the trachea may be compensated for with a temporary tracheostomy. This method is applicable in esophagectomy not only with curative but also with palliative intent to offer the patient a better quality of life. Theoretically, this method can be applied even for tumors minimally invading the trachea in which the invaded tracheal segment can be excised in combination with the esophagus, followed by tracheal anastomosis. Because this technique is a safe and easy procedure, it is recommended in cases in which proximal anastomosis appears difficult.     

Surgical treatment of carcinoma of the hypopharynx and cervical esophagus]

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arose after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.9%) and palliative in 23 (14.1%). In 33 cases of laryngo-pharyngo-cervical segmentary esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent laryngo-pharyngo-total esophagectomy and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)