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 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.     

Pectoralis major musculocutaneous flap with nipple-areola complex in head and neck reconstruction: preliminary results of a new modified method

Pectoralis major musculocutaneous flap remains the workhorse tool for head and neck reconstruction. Flap failure in head and neck reconstruction is a devastating complication with a high morbidity and mortality. Inclusion of nipple-areola complex on the skin paddle stabilizes the blood circulation in the skin island of the pectoralis major musculocutaneous flap. A modified use of pectoralis major musculocutaneous flap with nipple-areola complex on the skin island was performed in 11 male patients in head and neck reconstructions with success without partial or total skin island necrosis.We recommend the inclusion of nipple-areola complex on the skin island of the pectoralis major musculocutaneous flap in head and neck reconstructions to increase the blood supply of the skin paddle. We concluded that the skin island of the pectoralis major musculocutaneous flap might include the areola and nipple complex in patients with large defects of the head and neck, which stabilize the blood circulation in the skin island.     

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.     

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.     

Mediastinal tracheostomy

Upper airway obstruction in primary or recurrent carcinomas of the head and neck extending into the mediastinum may demand surgical intervention despite severe technical difficulties in patients with tumors previously considered inoperable. In fact, many of these tumors may be operable and some perhaps curable. A technique has been developed based in part on our experience with previously described procedures. A preliminary sternal split is used to demonstrate the extent of the mediastinal involvement as well as to provide enhanced exposure and proximal control of the great vessels. The pectoralis major muscle is used with a generous flap of overlying skin comprising nearly half of the anterior portion of the chest. A tracheostomy is then created in a fashion similar to the placement of a cardiac valvular prosthesis by creating a circular defect in the pectoralis major flap and suturing it to the tracheal remnant. This technique offers a reasonably safe and reliable means of creating a low anterior mediastinal tracheostomy for tumors previously considered inoperable. The preliminary sternal split makes the procedure safer and easier to perform, and the use of a very large pectoralis major island flap allows for reliable closure of the resulting mediastinal and sternal defects.     

Simple and reliable way in sternum wound coverage--tripedicle pectoralis major musculocutaneous flap

Objective: Sternotomy wound infection requires radically debridements and need secondary reconstruction of the resulting defect. Pectoralis major muscular or musculocutaneous flap is quite common in sternal wound closure. We modified the pectoralis major musculocutaneous flap design: bipedicle advancement cutaneous flap combined with thoracoacromial myocutaneous perforators, as a “tripedicle” fashion. We tried to utilize the cutaneous pedicle to provide a reliable skin coverage and decrease the wound dehiscence rate in lower one third sternal wound. Methods: Four patients undergoing median sternotomy surgery between 2004 and 2007 suffered from sternal wound infection and received tri‐pedicle pectoralis major musculocutaneous flaps transfer. Results: No skin paddle necrosis or wound dehiscence occurred in the postoperative course. Cosmetically and chest stability were satisfactory without complains about the daily activity. Conclusions: Tripedicle pectoralis major musculocutaneous flap is a simple and reliable technique to cover sternal wound defect necessitating resurfacing surgery. The blood supply to the skin paddle can be enriched by the superior and inferior cutaneous pedicle and the wound dehiscence rate is decreased with this technique. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

A surgical procedure to prevent tracheo-innominate artery erosion.

The innominate artery of a patient requiring prolonged mechanical ventilation was palpated in the inferior portion of his tracheostomy wound. Life-threatening hemorrhage was prevented by rotation of a local muscle flap the protect the artery and rotation of pedicled skin flaps to create a permanent tracheostomy.     

Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy

Salvage total pharyngolaryngectomy after failed organ‐preserving therapy often results in composite defects involving the alimentary tract, trachea, and neck skin. This retrospective study examined combined use of the free jejunum flap and the pectoralis major muscle flap with skin graft for such a complex reconstruction. We reviewed 11 patients who underwent free jejunum transfer for alimentary reconstruction and pedicled pectoralis major muscle flap transfer with a skin graft on the muscle for simultaneous neck skin resurfacing after salvage total pharyngolaryngectomy from 2005 through 2010. The operative morbidity rate was 27.3%. No pharyngocutaneous fistula developed in this series. Oral intake could be resumed within 3 weeks after surgery in all patients. Seven of 11 patients had a functional tracheostoma with adequate stomal patency. Combined use of free jejunum and pectoralis major muscle flap with skin graft provided secure wound closure even for complicated cases. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Continuous intraarterial infusion of prostaglandin E1 and heparin to extend and improve the survival of pedicled musculocutaneous flaps through unusual routes: a clinical preliminary report.

Sixteen pedicled musculocutaneous flaps (pectoralis major, 3; latissimus dorsi, 4; and transverse rectus abdominis musculocutaneous [TRAM], 9) received continuous intraarterial infusion of prostaglandin E1 (5 micrograms/k of flap per day) and heparin (100 to 200 U/cannula per day) for 14 days postoperatively to extend the flap or improve survival in a high-risk patient. Therapy was successful in 15 patients. To preserve the main arterial inflow to the flap, the infusion was administered via the lateral thoracic artery in the pectoralis major and a branch to the serratus anterior muscle in latissimus dorsi flaps in retrograde fashion, respectively, and was via both the ipsilateral deep epigastric artery and the contralateral superficial epigastric artery in TRAM flaps. This technique permits the use of a pedicled flap in some patients who would otherwise require a free flap.     

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.     

Successful repair using innominate vein flap, pericardial flap and thymus pedicle flap for tracheo-innominate artery fistula.

Tracheo-innominate artery fistula (TIF) is a rare but frequently fatal complication after tracheostomy. Without operation, the mortality is nearly 100% because of acute massive tracheal hemorrhage. Although the survival rate is extremely low, survival is possible only when an immediate operation is performed. Many surgeons have chosen ligation or resection of the innominate artery because repair with blood flow maintained in the innominate artery carries a high risk of postoperative fatal recurrent bleeding. We report on a successful surgical management of one case by patch closure with an innominate vein flap, wrapping of the innominate artery with a pericardial flap, and interposition of a thymus pedicle flap between the innominate artery and the trachea. Our surgical procedure is effective in maintaining the patency of the innominate artery preventing neurological deficits, and in preventing postoperative recurrent bleeding.     

Pectoralis Major Musculocutaneous Flap in Head and Neck Cancer Reconstruction

Described initially by Ariyan in the 1970s, the pectoralis major flap has broad acceptance for its versatility in head and neck cancer reconstructions. It is supplied by the thoracoacromial artery, with an additional circulation provided by the lateral thoracic artery. It can be safely used even in patients who have undergone postoperative radiation. The objective of this work is to analyze retrospectively the indications and results of this reconstruction technique in 17 patients with head and neck cancer. We have selected the pectoralis major flap for reconstruction of floor of the mouth and tongue (7 patients); pharyngoesophageal transit after pharyngolaryngectomy (7 patients); facial tissue repair after parotid cancer excision and reconstruction of the soft part of cervical area after skin excision during cervical dissection. Total necrosis of the flap for pharyngoesophageal reconstruction was observed in one patient. Partial loss of the skin flap with partial dehiscence occurred in four patients underwent tongue and floor of the mouth repair, but without fistulae and infection. There was donor site seroma in one patient. The flap was functionally adequate both in the reconstruction of the neopharynx and for repair of great surgical defects. So it is a versatile method with good functional results.     

胸大肌岛状皮瓣修复高龄患者头颈肿瘤术后局部缺损的体会

目的探讨胸大肌岛状皮瓣在修复高龄患者头颈肿瘤术后缺损的应用体会。方法回顾性分析1996年10月至2007年10月我科收治的60岁以上头颈部肿瘤患者术后缺损，以胸大肌岛状皮瓣转移修复缺损18例，术后予颈部制动、抗炎、抗凝、抗痉挛治疗。结果：手术时间在30分钟至150分钟之间，无手术死亡，无并发症加重，皮瓣均成活，达到较好的修复效果。结论：以胸大肌岛状皮瓣修复高龄头颈部肿瘤术后所致的缺损，效果好，方法简单、可靠、快速，能有效减少围手术期风险。     

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.     

胸大肌肌皮瓣脂肪液化的相关危险因素探讨

目的探讨胸大肌肌皮瓣术后发生脂肪液化的相关危险因素。方法对1998年5月至2005年12月采用胸大肌肌皮瓣修复口腔癌术后组织缺损的82例中10例术后发生不同程度脂肪液化的病例,进行Logistic回归分析。结果Logistic单因素回归分析结果表明：肥胖、电刀切开皮下组织、皮岛设计低于第7肋、吸烟等因素与胸大肌肌皮瓣术后发生脂肪液化有关;Logistic多因素回归分析结果表明：胸大肌肌皮瓣术后发生脂肪液化与肥胖、电刀切开皮下组织、皮岛设计低于第7肋等因素有关,而与吸烟无关。结论肥胖、电刀切开皮下组织、皮岛设计低于第7肋等因素是胸大肌肌皮瓣术后发生脂肪液化的危险因素。     

Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Limitations and refinements in 56 cases

The transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Fifty-six transaxillary latissimus dorsi musculocutaneous flap reconstructions were performed in 55 patients. There were two cases of complete flap necrosis and eight cases of partial flap necrosis. The latissimus dorsi vascular pedicle is separate from the irradiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicled latissimus dorsi flap does not reach far enough cephalad, the nutrient vessels may be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, mandibulofacial region, and neck may be reconstructed with a single large latissimus dorsi flap. Hairless skin particularly suitable for oral cavity reconstruction is usually available. Aesthetic and functional deficits are minimal after latissimus dorsi reconstruction. Disadvantages of this technique include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury may occur. The latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed by simpler methods.     

Vascular compromise of the pectoralis major musculocutaneous flap in head and neck reconstruction

In head and neck reconstructive surgery, the pectoralis major musculocutaneous flap is a major reconstructive tool, both in primary as well as secondary reconstructions. In a few cases the authors have been able to demonstrate that when the pectoralis major musculocutaneous flap is translocated to the mouth through a noncompromised neck tunnel, as is done for head and neck reconstructions, the taut lateral pectoral nerve is seen to compress the vascular pedicle of the flap, adversely affecting its vascularity, which can lead to partial or total necrosis of the flap. The authors explain this feature, very specific to this flap, with the help of a prospective series of patients.     

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.