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Ann Thorac Surg 1997;63:1479-1480
© 1997 The Society of Thoracic Surgeons

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Case Report

Successful Surgical Treatment of a Complete Traumatic Tracheal Disruption

Department of Thoracic and Cardiovascular Surgery, Jichi Medical School Hospital, Tochigi, Japan

Accepted for publication January 3, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report a case of a survivor who suffered a complete traumatic disruption of the cervical trachea associated with multiple organ injuries. She underwent an emergent operation including end-to-end anastomosis of the disrupted trachea with pedicled omental coverage to prevent dehiscence and mediastinitis. The postoperative course was uneventful, with hospital discharge on day 36. She returned to her previous lifestyle.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
A 12-year-old girl was injured in a pedestrian versus motor vehicle accident. She was struck on the left anterior portion of the neck by a side-view mirror. When she was brought by ambulance to the emergency room, she coughed up bloody sputum from the laceration on her neck. The horizontal laceration was 5 cm long, located 3 cm above the sternal notch. She complained of dyspnea and was tachypneic. No pulse was palpable in the left radial artery. Multiple abrasions were present on the extremities.

The distal end of the trachea was emergently grasped with forceps. It was retrieved from the mediastinum, and an endotracheal tube was inserted. She was brought to the operating room. Plain radiographs revealed a left pneumothorax, and an infiltrate in the right lung field due to the aspiration of blood.

Under general anesthesia, a collar incision and a median sternotomy were performed. The cervical trachea was completely disrupted at the level of the lower pole of the thyroid gland (Fig 1). The esophagus had two longitudinal lacerations each 5 cm in length in the anterior and posterior walls. The left subclavian artery had intimal damage and was obstructed by thrombi. The thoracic duct was disrupted. Leakage of lymph fluid was evident.

View larger version (145K): [in this window] [in a new window]   Fig 1. . Photograph during the operation demonstrating the complete disruption of the cervical trachea with the inserted tracheal tube. (Right is cranial side and left is caudal.) (Lt. = left.)

An upper midline laparotomy was performed. A pedicled omentum flap based on the right gastroepiploic artery was created and delivered into the mediastinum through the substernal space. The anastomoses in the trachea and esophagus were completely wrapped with omentum. A jejunostomy was placed for postoperative enteral nutrition.

She was sedated for 4 days after the operation. Thereafter she was weaned from the respirator, and extubated on the 8th postoperative day. The patient was discharged on day 36. Fiberoptic bronchoscopy 5 months after the operation showed no stenosis of the tracheal anastomosis. Except for hoarseness and left-sided ptosis, she returned to her previous lifestyle. No anastomotic stenoses have been seen at 1 year.

	Comment

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Traumatic injuries of the cervical trachea are relatively rare because of its anatomic features. Causes of complete disruption of the cervical trachea are quite rare. Some authors have reported that these injuries are fatal because of respiratory distress, difficulties in establishing an airway, and the high frequency of associated multiple organ injuries (head injuries, vascular injuries or spinal injuries) [1–4].

Unlike previously reported cases [5–7], we diagnosed the disruption of the trachea with ease because of the open wound. This was an advantage in our case because it enabled early diagnosis and treatment.

The treatment for disruption of the trachea is reconstruction by an end-to-end anastomosis, if possible. In our case, complete transection of the trachea was repaired by careful approximation of the mucosa with absorbable sutures, after debridement of the damaged area. Concerning associated injuries, Sheely and associates [2] have reported that esophageal injuries, pneumothorax, and damage to the central nervous system were frequent. In this case, esophageal injuries, pneumothorax, thoracic duct injuries, and a rupture of the left subclavian artery were present. There was no injury of the carotid arteries or the spinal cord. This is why survival was a possibility.

The primary repairs were covered with a pedicled omental flap to prevent dehiscence. There are some methods for reinforcing the trachea and separating the trachea and esophageal suture lines, eg, omental flap, muscular flap, pericardial flap, and pleural flap [4]. We chose the omental flap because of the contaminated open wound in our case. Muehrcke and colleagues [8] have reported the usefulness of the omentum in similar situations. The omentum appears to elaborate an angiogenic factor that stimulates the development of a new blood supply in avascular areas. In addition, it provides new fibroblasts to enhance healing. The omentum can reach any part of the airway with ease. The omentum also appears to function well in the presence of infection. We believed that the use of the omentum to prevent esophageal or tracheal dehiscence was critical in this case.

	Footnotes

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Address reprint requests to Dr Hasegawa, Department of Thoracic and Cardiovascular Surgery, Jichi Medical School Hospital, 3311-1 Yakushiji, Minami-kawachimachi, Kawachi-gun, Tochigi 329-04, Japan.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Ecker RR, Libertini RV, Rea WJ, Sugg WL, Webb WR. Injuries of the trachea and bronchi. Ann Thorac Surg 1971;11:289–98.[Medline]
2. Sheely CH, Mattox KL, Beall AC. Management of acute cervical tracheal trauma. Am J Surg 1974;128:805–8.[Medline]
3. Chen FH, Fetzer JD. Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma. J Trauma 1993;35:140–2.[Medline]
4. Kelly JP, Webb WR, Moulder PV, Moustouakas NM, Lirtzman M. Management of airway trauma II: combined injuries of the trachea and esophagus. Ann Thorac Surg 1987;43:160–3.[Abstract]
5. Kirsh MM, Orringer MB, Behrendt DM, Sloan H. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:93–101.[Abstract]
6. Sofferman RA. Management of laryngotracheal trauma. Am J Surg 1981;141:412–7.[Medline]
7. Hermon A, Segal K, Har-El G, Abraham A, Sidi J. Complete cricotracheal separation following blunt trauma to the neck. J Trauma 1987;27:1365–7.[Medline]
8. Muehrcke DD, Grillo HC, Mathisen DJ. Reconstructive airway operation after irradiation. Ann Thorac Surg 1995;59:14–8.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Osamu Kamisawa Katsuo Fuse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hasegawa, T. Articles by Fuse, K. Search for Related Content PubMed PubMed Citation Articles by Hasegawa, T. Articles by Fuse, K.