As originally published in 1992: Anterior mediastinal tracheostomy with and without cervical exenteration. Updated in 1998

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, laryngeal carcinoma, or benign stenosis after laryngectomy) 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 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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Radiological assessment of the structural relationship between the trachea and the innominate artery in physically disabled and scoliotic children

Studies were made on the physically disabled and scoliotic children who underwent tracheostomy. The purpose was to clarify factors that might lead to the tracheo-innominate artery fistula, by use of three-dimensional helical CT (3 DCT). In a case of right scoliosis, the tracheo-innominate artery fistula may be caused by the left-ward displacement of the trachea from the vertebra, having the innominate artery ride over the trachea and compressing it. In a case of the physically disabled and scoliotic children, there may be more compression on the trachea by the innominate artery along with the worsening scoliosis. Therefore, we consider it necessary to examine the structural relationship between the trachea, the vertebra, and the innominate artery periodically by 3 DCT.     

Vascular rings and slings. Diagnosis and surgical treatment of 49 patients

Forty-nine infants with symptomatic vascular rings and slings, ranging in age from 20 days to 12 months, required surgical intervention between 1973 and 1984. The following anomalies were present in our patients: double aortic arch with left descending aorta (14), double aortic arch with right descending aorta (6), anomalous innominate artery (13), right aortic arch with aberrant left subclavian artery (4), left aortic arch with aberrant right subclavian artery (10), aberrant left pulmonary artery (pulmonary sling) (2). All the babies had symptoms related to compression of the trachea and/or esophagus. Four patients required temporary tracheostomy in the early postoperative period; 1 patient, affected by a pulmonary sling, required tracheal resection and anastomosis, for severe tracheomalacia. There was one hospital death in a patient with severe tracheal compression from an anomalous innominate artery and brain damage as a result of metabolic problems. Forty-eight patients survived and follow-up ranged from 3 months to 11 years. For each type of vascular anomaly encountered, and based on personal experience, we have outlined a diagnostic scheme allowing an accurate morphological definition and a subsequent surgical procedure.     

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.     

FATAL HAEMORRHAGE FROM THE INNOMINATE ARTERY AFTER TRACHEOSTOMY

A case of fatal haemorrhage from the innominate artery occurreda week after tracheostomy was performed. Control of the bleedingwas tried unsuccessfully by hyperinflation of the cuff of thetracheostomy tube. The mechanism is erosion of the artery bythe inferior border of the tracheostomy tube. Since the treatmentof massive haemorrhage from the innominate artery is extremelydifficult, the avoidance of low tracheostomies and the use ofshort and properly curved tracheostomy tubes may be effectivein prevention of this fatal complication.     

Healing of Lesions Caused by Cuffed Tracheostomy Tubes and their Late Sequelae A Follow-Up Study

The healing of tracheostomy and cuff-induced tracheal injury was followed up in 48 tracheostomized patients (44 men and 4 women). The patients were studied by means of tracheoscopy, fluoroscopy and tracheography, with a positive contrast medium. At extubation, tracheoscopy revealed 12 mild, 23 moderate and 13 severe injuries at the cuff level. Three months after extubation, the stoma had closed in 89% of the patients studied. In 85% of the patients, the side wall of the stoma was found to have collapsed inwards and in 71% scars were observed at the cuff level. No significant changes took place after the follow-up study at 3 months. At tracheography it was found that narrowing of the tracheal diameter at the stomal level was of only mild or moderate degree (i.e. 0–33 %). There was not a single instance of severe stenosis. At the cuff level, a slight inward collapse of the side wall was observed in one patient, and in all the other patients the lumen was normal. Fluoroscopy did not reveal severe tracheomalacia in any patient. Increased mobility of the stomal scar, especially in connection with coughing was seen in some patients. One tracheo-innominate artery erosion and one bleeding granulation tissue at the stoma were confirmed during follow-up. Surgical trauma to the trachea at the stoma seems to be a more potent cause of subsequent narrowing of the trachea than the cuff. Even though severe injuries may also heal with few sequelae, the use of tracheostomy tubes with large, low-pressure cuffs, which have been shown to cause less damage to the trachea, is indicated.     

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.