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.     

Bronchial flap closure of the lower membranous trachea

A novel method for closure of the lower membranous trachea after right pneumonectomy using a flap derived from the cartilaginous portion of the right main bronchus is described in this study. This technique was used successfully in patients with tracheal stenosis due to a giant posterior mediastinal tumor known as schwannoma. Because of the severe tracheobronchial stenosis and destroyed right lung, tumor resection combined with resection of the lower membranous trachea and right pneumonectomy was carried out. We closed the defect in the membranous lower trachea with the flap derived from the right main bronchus. The clinical course was uneventful.     

Thoracoscopic resection of esophageal cancer with a tracheal diverticulum

Tracheal diverticulum, a benign entity characterized by single or multiple invaginations of the tracheal wall, is commonly asymptomatic and detected incidentally. We report the case of a 76-year-old man with a tracheal diverticulum who underwent thoracoscopic esophagectomy with a three-field lymphadenectomy for middle thoracic esophageal cancer. The tracheal diverticulum was located at the right posterolateral region of the trachea, which overlapped the region of dissection of the right recurrent laryngeal nerve lymph nodes. Paratracheal lymph node dissection is an important surgical procedure for thoracic esophageal cancer. In such cases, there is a risk of misidentifying a tracheal diverticulum as an enlarged lymph node and injuring it. Injury of a tracheal diverticulum causes serious complications such as mediastinal emphysema, mediastinitis, and pulmonary fistula. It is important to recognize its existence preoperatively and perform accurate lymph node dissection by taking full advantage of the magnified visual effect provided by thoracoscopic surgery.     

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.     

An experimental study on viability of the devascularized trachea

This experiment was designed to evaluate the effect of varying extents of devascularization to the viability of the trachea, and the influence of preservation of the right bronchial artery on the ischemia of the widely devascularized trachea. In experiment 1, the canine trachea was devascularized in a stepwise manner, and the regional blood flow was measured in each situation. This experiment revealed that the regional blood flow decreased to one-third of the non-treated trachea when the bilateral bronchial arteries were transected, and to nil when the cervical and mediastinal trachea was devascularized. In experiment 2, in which dogs were divided into 2 groups depending on preservation of the right bronchial artery, the trachea was stepwisely devascularized and the regional blood flow measured. This experiment indicated that the regional blood flow in the trachea when the right bronchial artery was preserved did not so remarkably diminish, though the cervical and mediastinal trachea was devascularized. In experiment 3, dogs were divided into 3 groups according to the extent of devascularization of the trachea and to the presence or absence of the preserved right bronchial artery, and were followed for 2 months postoperatively. This experiment demonstrated that the preservation of the right bronchial artery prevented tracheal necrosis caused by devascularization of the cervical and mediastinal trachea. We concluded that the regional tracheal blood flow markedly decreased and that tracheal necrosis occurred following devascularization of the cervical and mediastinal trachea when the bilateral bronchial arteries were transected. The preservation of the right bronchial artery however, prevented a decrease in the regional blood flow and necrosis of the widely devascularized trachea.     

An experimental study on viability of the devascularized trachea

This experiment was designed to evaluate the effect of varying extents of devascularization to the viability of the trachea, and the influence of preservation of the right bronchial artery on the ischemia of the widely devascularized trachea. In experiment 1, the canine trachea was devascularized in a stepwise manner, and the regional blood flow was measured in each situation. This experiment revealed that the regional blood flow decreased to one-third of the non-treated trachea when the bilateral bronchial arteries were transected, and to nil when the cervical and mediastinal trachea was devascularized. In experiment 2, in which dogs were divided into 2 groups depending on preservation of the right bronchial artery, the trachea was stepwisely devascularized and the regional blood flow measured. This experiment indicated that the regional blood flow in the trachea when the right bronchial artery was preserved did not so remarkably diminish, though the cervical and mediastinal trachea was devascularized. In experiment 3, dogs were divided into 3 groups according to the extent of devascularization of the trachea and to the presence or absence of the preserved right bronchial artery, and were followed for 2 months postoperatively. This experiment demonstrated that the preservation of the right bronchial artery prevented tracheal necrosis caused by devascularization of the cervical and mediastinal trachea. We concluded that the regional tracheal blood flow markedly decreased and that tracheal necrosis occurred following devascularization of the cervical and mediastinal trachea when the bilateral arteries were transected. The preservation of the right bronchial artery however, prevented a decrease in the regional blood flow and necrosis of the widely devascularized trachea.     

分化型甲状腺癌侵入气管内的外科治疗及气道重建

目的探讨分化型甲状腺癌侵入气管内的外科治疗方法及效果。方法回顾性分析分化型甲状腺癌侵入气管内的患者行气管袖状切除术后的治疗结果。16例分化型甲状腺癌（均为乳头状癌）侵入气管内的患者进行了颈部淋巴结清扫术＋肿瘤整块切除术及气管袖状切除术,并一期行气管端端吻合术重建气道。结果16例患者手术均成功进行,术后并发症发生率为12．5％（2／16）,其中气管吻合口狭窄1例,CO：激光加浅层放疗治愈;双侧声带麻痹1例,CO2激光切除一侧声带后分治愈。平均随访时间23个月,1例患者术后3个月出现局部淋巴结复发,再次术后带瘤生存;1例局部复发死亡。结论气管袖状切除一拉拢缝合术能有效治疗分化型甲状腺癌侵犯气管内,而CO2激光与浅层放疗对术后双侧声带麻痹及吻合口瘢痕增生是有效的。     

Stair‐step tracheal repair: Surgical technique

Typical surgical treatment for invasive thyroid carcinoma at the level of the cricoid substantially reduces surrounding cartilaginous support and risks damage to the recurrent laryngeal nerve (RLN). We present a novel tracheal reconstructive technique that minimizes this injury risk. A 72‐year‐old man with recurrent invasive thyroid carcinoma underwent cricotracheal resection and reconstruction using a stair‐step approach. Diseased cartilage was removed by a left hemitracheal and hemicricoid resection. A portion of normal trachea was also resected on the contralateral right side, removing the third and fourth hemitracheal rings, to close the defect with a sliding tracheoplasty and avoid dissection near the right cricothyroid joint on the side of the functioning RLN. The trachea was elevated superiorly and reanastomosed to the cut margin of the cricoid. This novel stair‐step approach to tracheal reconstruction offers reduced risk of injury to the contralateral RLN while still establishing a patent airway.     

Salvage Lymphadenectomy of the Right Recurrent Nerve Node with Tracheal Involvement After Definitive Chemoradiation Therapy for Esophageal Squamous Cell Carcinoma: Report of Two Cases

Thoracic esophageal cancers frequently metastasize to the right recurrent nerve nodes (RRNNs). In fact, huge RRNNs invading the trachea sometimes remain after definitive chemoradiation therapy (CRT), despite complete remission of the primary lesion. We performed salvage lymphadenectomy of a large RRNN combined with partial resection of the trachea in two patients. Using an anterior approach, we removed part of the sternum, clavicle, and the first and second costal cartilage; then, we removed the RRNNs with combined resection of the lateral quarter circumference of the trachea, the esophageal wall, and the recurrent nerve. Reconstruction was done with a musculocutaneous patch of major pectoral muscle to cover the tracheal defect. The only minor complication was venous thrombosis in one patient. Thus, combined removal of the RRNN and trachea was performed safely as a salvage operation after definitive CRT for esophageal squamous cell carcinoma.     

Cervico-mediastinal schwannoma of the vagus nerve: resection with intraoperative nerve monitoring

Schwannomas are usually benign, single, encapsulated, slow-growing tumours originating from cranial or spinal nerve sheaths. The vagus nerve involvement at the mediastinal inlet is very uncommon. For anatomical reasons, the resection of cervical and mediastinal schwannoma of the vagus nerve has a high risk of vocal fold paralysis. We describe the case of a 67-year-old female with a cervico-mediastinal schwannoma of the vagus nerve that we removed using the intraoperative neuromonitoring technique. The patient presented with mild hoarseness and complained of discomfort behind the jugular notch. Neck and chest computerized tomography described a 35 × 30 mm solid lesion behind the left clavi-sternal junction; preoperative fine needle aspiration cytology revealed schwannoma. Resection of the mass was performed with a cervical approach and the vagus nerve tumour was completely removed under continuous neuromonitoring (NIM-3^® System), preserving the vagus and the recurrent laryngeal nerve function. Pathology on the resected mass documented A-type schwannoma with “ancient schwannoma” areas. The intraoperative neurostimulation and neuromonitoring approach for the resection of vagus schwannoma are recommended because it may reduce the risk of injury to the vagus and to the recurrent laryngeal nerve.     

Resection of thyroid carcinoma infiltrating the trachea.

We have treated surgically 11 patients with thyroid carcinoma that had infiltrated into the trachea. Three patients had primary tumours, and eight had recurrent tumours after previous operations. Sleeve resection of trachea was performed where thyroid carcinoma had proliferated; the trachea was reconstructed by end-to-end anastomosis. In two patients 10 rings of the trachea were resected. In three patients the anterior half of the cricoid cartilage was resected along with the cervical trachea. In one patient tracheoplasty was performed using partial extracorporeal circulation because severe tracheal stenosis prevented endotracheal intubation. Two of the 11 patients died from the surgery and one from disseminated metastases. One patient who had undergone tracheal resection for thyroid carcinoma three years and five months previously had a recurrence of the tumour in the trachea adjacent to the anastomosis, and a second tracheal resection was performed. In three patients postoperative laryngeal stenosis occurred. Five patients are alive and well two years and one month to four years and seven months after their operations. The histological pattern of the tumour was papillary adenocarcinoma in all 11 patients.     

Tracheomalacia after reoperation for an adenomatous goiter located in a unique position

Tracheomalacia after thyroidectomy is a life-threatening situation. However, it is difficult to predict postoperative tracheal obstruction with certainty. A case of a 74-year-old woman with a long-standing adenomatous goiter (98 g) is reported. She had undergone partial right lobe thyroidectomy 54 years earlier. After total thyroidectomy, she was reintubated and required a tracheostomy because of tracheomalacia. The right residual thyroid tumor weighed only 5 g, but it extended to the retrotracheal space. Because the right lobe had stretched the membranous wall of the trachea over a long period of time, the tracheal lumen was thought to have collapsed because of loss of the foundation of the tracheal cartilage (the residual right lobe) along with the supportive surrounding tissue (the left lobe) after surgery. The present case suggests that the occurrence of tracheomalacia could be attributed to reoperation and retrotracheal extension. Thus far, six preoperative predictive factors for the development of severe postoperative respiratory obstruction have been reported: goiter for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and/or deviation, retrosternal extension, difficult endotracheal intubation, and thyroid cancer. Two more factors, reoperation and retrotracheal extension of tumor, may also be risks for airway obstruction after thyroidectomy.     

Resectional management of airway invasion by thyroid carcinoma

Invasion of the trachea by thyroid carcinoma is best managed by resection with airway reconstruction. Localized extension of tumor may also require esophageal resection or radical resection including laryngectomy with mediastinal tracheostomy. Twenty-two patients (12 with papillary, 3 with follicular, 4 with mixed papillary and follicular, and 3 with undifferentiated carcinoma) underwent resection--16 with airway reconstruction and 6 with cervicomediastinal en bloc resection with mediastinal tracheostomy. Eleven had prior thyroidectomy. Ten of those having airway restitution required cylindrical tracheal resection, 5 had resection of trachea with a portion of the larynx, and 1 had wedge resection. Three undergoing laryngotracheal resection also needed esophagectomy. Colon reconstruction was used. Fifteen of the 16 having airway reconstruction had good surgical results with speech preservation. One died of complications due to prior irradiation. One of 6 undergoing radical resection died postoperatively. Six of the 20 survivors died of recurrence in 1 2/3 to 9 years, and 2 others died of other diseases. Three who had known pulmonary metastases at the time of palliative operation are alive between 2 and 3 2/3 years postoperatively, and a fourth who has pulmonary metastases is alive 6 1/6 years later. Eight patients are alive without disease from 1/12 to 8 3/4 years. Only two patients had airway recurrence. Resection and primary reconstruction of the trachea invaded by carcinoma of the thyroid should be done in the absence of extensive metastases when technically feasible. It offers prolonged palliation, avoidance of suffocation due to bleeding or obstruction, and an opportunity for cure. In carefully selected patients with massive regional involvement, radical excision with laryngectomy and esophagectomy is also appropriate.     

Merits and Demerits of Operative Procedure to the Trachea in Patients with Differentiated Thyroid Cancer

Local radical thyroidectomy, including cervical lymph node dissection and combined circumferential resection of the trachea, has been performed over the past 20 years in 31 patients with differentiated cancer invading the trachea. The 5- and 10-year survival rates for these patients were 77.4% and 66.7%, respectively. In 19 of the 31 (61%) cases the recurrent nerve was resected because of direct cancer invasion. Bilateral recurrent nerve palsy occurred in 12 patients, 3 of whom were managed postoperatively using a T-shaped tube for preservation of the larynx. Hoarseness remained in 21 patients. In two patients with recurrent cancer invasion of the larynx, partial laryngectomy and hemilaryngectomy were performed, and reconstruction was done using ear cartilage without postoperative dyspnea or dysphagia. Parathyroid function is an important factor in regard to the quality of life of patients. In 22 patients at least one of the parathyroids was preserved. Postoperative calcium administration was necessary in 14 patients. Our long-term observations indicate that local radical thyroidectomy with combined resection of the trachea can serve as a useful treatment for advanced differentiated cancer invading the airway.     

Lateral Mobilization of the Recurrent Laryngeal Nerve to Facilitate Tracheal Surgery in Patients with Thyroid Cancer Invading the Trachea Near Berry’s Ligament

Background Thyroid cancer often invades the trachea and the recurrent laryngeal nerve (RLN) at or near Berry’s ligament, which fixes the thyroid gland to the trachea. In patients with thyroid cancer invading the trachea near the ligament, preservation of the RLN is very difficult. Regardless of whether the nerve is preserved or is resected and reconstructed, the presence of the nerve interferes with tracheal resection and repair. We proposed a new technique to solve this problem. Methods Before tracheal surgery, the inferior pharyngeal constrictor muscle was divided along the lateral edge of the thyroid cartilage, and the RLN was mobilized and retracted laterally. We applied this technique in 11 patients with papillary thyroid carcinoma invading the trachea. Two patients demonstrated vocal cord paralysis preoperatively. The procedures used for tracheal surgery in this series were partial resection of the trachea with creation of a tracheocutaneostomy, that with direct suture, and shaving off the tumor in 7, 2, and 2 patients, respectively. Results The RLN could be preserved and mobilized laterally in eight patients. While three patients demonstrated transient vocal cord paralysis, the remaining five had functioning cords postoperatively. In three patients the RLN was resected, and the remaining distal stump was mobilized and anastomosed with the ansa cervicalis. These patients recovered their voices and maximum phonation time increased to the normal level. The tracheocutaneous stoma was closed with local skin flap about four months later in all patients. Conclusion Lateral mobilization of the RLN facilitates the preservation of the nerve and the performance of tracheal surgery in patients with thyroid cancer invading the trachea at or near Berry’s ligament.     

Video-assisted thoracic surgery lobectomy for right lung cancer in a patient with right aortic arch: report of a case

A 57-year-old man with an anomalous right aortic arch presented with cancer of the right lung. The right recurrent laryngeal nerve was found to be hooked around the right aortic arch. Right lower lobectomy with systematic mediastinal lymph node dissection was successfully performed using video-assisted thoracic surgery to provide close intraoperative attention to the branching of recurrent laryngeal nerve.     

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.     

Primary Reconstruction of Airway after Resection of Subglottic Laryngeal and Upper Tracheal Stenosis

Eighteen patients with low subglottic laryngeal stenosis and upper tracheal stenosis underwent resection of the anterior and lateral cricoid cartilage and upper trachea with reconstruction by primary laryngotracheal anastomosis. The posterior cricoid plate and recurrent laryngeal nerves were preserved. The distal trachea was tailored obliquely with an anterior prow and was anastomosed to the thyroid cartilage anteriorly and to the residual cricoid posteriorly. Where the stenosis was circumferential, scarred mucosa was resected from the anterior surface of the posterior cricoid lamina and the defect covered with a tailored flap of membranous tracheal wall.In 14 patients the lesions followed intubation injury. In 2 the stenosis was idiopathic. One stenosis resulted from inhalation burn and one from localized amyloidosis. Many patients had undergone previous surgical repairs.Sixteen patients had good to excellent results from six months to five and one-half years later. Reconstruction of the burned airway failed. One additional patient is still under treatment with a T tube.     

Anterior approach to the cervical vertebrae and the location of the recurrent laryngeal nerve

It is well known that the recurrent laryngeal nerve is often damaged during or following an anterior approach to the cervical vertebral column. Reports in the literature suggest that the right-sided approach gives rise to more complications of the recurrent nerve than the left-sided approach and that the right recurrent nerve is in a less protected position. There are also studies addressing the risks involved in the right-sided and the left-sided approach and suggesting the opposite conclusion. In our study, the position of the recurrent nerve was found to be variable and even to be different on the right and left sides in the same person. In 44.6% of cases (45 of 101) the recurrent nerve was found to be have an intermediate course (at the dorsal edge of the trachea or in the sulcus between trachea and esophagus) on both sides. The recurrent nerve was in an anterior position (lateral of the ventral two-thirds or the dorsal one-third of the trachea) in 50.5% (51 cases) on the left and in 49.5% (50 cases) on the right. A posterior position (lateral to the esophagus) of the recurrent nerve was found in 4.9% (5 cases) on the left and in 5.9% (6 cases) on the right. All combinations are possible. The position of the recurrent nerve cannot be inferred from its position on the opposite side. The right-sided or the left-sided approach cannot be preferred on the basis of the position of the recurrent nerve.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.