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Ann Thorac Surg 1999;67:1159-1160
© 1999 The Society of Thoracic Surgeons

Case Reports

Membranous tracheobronchial injury repaired with gastric serosal patch

Richard Gitter, MDa, Thomas M. Daniel, MDa, Bradley W. Kesser, MDb, James F. Reibel, MDb, Curtis G. Tribble, MDa

a Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health Science Center, Charlottesville, Virginia, USA
b Department of Otolaryngology, University of Virginia Health Science Center, Charlottesville, Virginia, USA

Accepted for publication October 7, 1998.

Address reprint requests to Dr Tribble, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Science Center, Box 310, Charlottesville, VA 22908


   Abstract
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 Abstract
Introduction
 Comment
 References
 
This unusual case involves pharyngolaryngoesophagectomy complicated by injury to the membranous trachea and right bronchus. Repair was possible after partial sternal split and elevation of the tracheostoma through the anterior mediastinum, pulling the stomach to the neck, and using the stomach as a patch to repair the injury to the membranous portion of the airway.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Membranous tracheal and bronchial injuries are potentially lethal complications of blunt transhiatal esophagectomy [1–4]. In this case we repaired this injury by using the anterior wall of the stomach as a vascularized pedicle providing a serosal patch.

A 55-year-old male smoker presented with odynophagia and dysphagia. Results of endoscopic evaluation and biopsies included squamous cell carcinoma of the supraglottis and a second squamous cell carcinoma of the cervical esophagus. He had a total laryngectomy, transhiatal esophagectomy, bilateral neck dissections, and total thyroidectomy. These procedures were complicated by a linear laceration of the membranous portion of the trachea and right main stem bronchus from the level of the suprasternal tracheostoma to the right upper lobe takeoff of the main stem bronchus, which occurred during the dissection of the upper esophagus from the neck incision.

Because the patient could not tolerate single, left main stem lung ventilation, each bronchus was independently reintubated with 4F pediatric endotracheal tubes to reestablish secure ventilation and oxygenation.

After ventilation was assured, the cervical esophagus was divided and passed through to the abdomen. Removal of the esophagus improved exposure of the injury. The abdominal portion of the procedure was completed with excision of the esophagus and gastroesophageal junction while tailoring the gastric pull through with gastrointestinal anastomosis (GIA) staplers.

Attempted primary repair of the membranous laceration from the neck, however, was unsuccessful because of the amount of tissue loss and injury to the remaining posterior tracheal wall. Partial sternal split to the third intercostal space, with manubrial retraction, afforded additional tracheal mobility anteriorly. The lateral tracheal blood supply was preserved.

A single, double-armed, monofilament, absorbable suture was placed into the membranocartilaginous junction of the right bronchus at the apex of the distal portion of the laceration. The needles were tagged while the gastric pouch was tunneled through the mediastinum. The stomach was anchored at the appropriate level to the prevertebral fascia. After retracting the trachea anteriorly, a running suture was used to sew the anterior gastric wall to the injured trachea. Each arm of the suture was then run proximally to include partial thickness bites of the stomach and lateral tracheal membrane (Fig 1). As the proximal apex was reached, the suture arms were tied together with the knot between the anterior stomach wall and the intact membranous trachea.



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  		Fig 1. Repair of tracheal injury with gastric pedicle.

 
Daily postoperative bronchoscopic surveillance showed viability of the patch and the tracheal wall. On postoperative day 3, however, the most proximal portion of the repair, at the suprasternal tracheostoma, became necrotic. A 1 x 1 cm segment of the stomach (neomembranous trachea) required operative debridement and was covered by ipsilateral pectoralis muscle. Endoscopic gastric evaluation confirmed viability of the remaining stomach and patch. The patient’s trachea and gastric substitute healed without further problem.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Membranous tracheal injuries represent potentially lethal complications during transhiatal esophagectomy. Immediate airway control is essential. The trachea or bronchus must be reintubated distal to the laceration to ensure effective ventilation and oxygenation. In the event of extensive lacerations, such as described above, separate endotracheal tubes may be necessary when single lung ventilation proves inadequate [1, 3].

Although right and proximal left bronchial injuries, as well as some tracheal injuries, are usually approached through a right thoracotomy, the present case represents a unique predicament [5]. The membranous trachea was too severely injured to secure endotracheal tubes for repositioning. Additionally, the concurrent laryngectomy provided further mobilization of the trachea anteriorly making visualization and repair of the posterior trachea possible.

The primary usefulness of this report is to show that the stomach can be used as a viable flap to repair the trachea when airway injuries occur during transhiatal esophagectomy. By using the gastric pouch as a serosal patch to the injured trachea and bronchus, both repair of the complication and completion of the intended operation could be done. Postoperative endoscopic vigilance is mandatory to assess gastric viability and prevent spontaneous breakdown with potential gastric aspiration. We believe that the proximal area of postoperative necrosis occurred from a triple point of vascular compromise where our gastric pouch staple line intersected the hypopharyngeal anastomosis and the tethering suture to the prevertebral fascia.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Fynn A., Nicholson G., Jacobson I. Management of low tracheal tear. Anaesth Intensive Care 1997;25:426-428.[Medline]
  2. Gorenstein L.A., Abel J.G., Patterson G.A. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg 1992;54:784-786.[Abstract/Free Full Text]
  3. Mitchell J.B., Ward P.M. The management of tracheal rupture using bilateral bronchial intubation. Anaesthesia 1993;48:223-225.[Medline]
  4. Kron I.L., Johnson A.M., Morgan R.F. Gastrotracheal fistula: a late complication after transhiatal esophagectomy. Ann Thorac Surg 1989;47:767-768.[Abstract/Free Full Text]
  5. Pearson F.G., Deslauriers J., Ginsberg R.J., et al. Esophageal surgery. New York: Churchill Livingstone, 1995:696.



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This Article
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Right arrow Author home page(s):
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Thomas M. Daniel
Curtis G. Tribble
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Right arrow Articles by Tribble, C. G.

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