Ann Thorac Surg 2002;74:2200-2201
© 2002 The Society of Thoracic Surgeons
How to do it
Tracheal reconstruction with autogenous composite nasal septal graft
A. Kür
at Bozkurt, MD*a,
Harun Cansiz, MDb
a Department of Thoracic and Cardiovascular Surgery, University of Istanbul, Cerrahpa
a Medical Faculty, Istanbul, Turkey
b Department of Otolaryngology, University of Istanbul, Cerrahpaa Medical Faculty, Istanbul, Turkey
Accepted for publication May 19, 2002.
* Address reprint requests to Dr Bozkurt, Ataköy 5. kisim A7/40, 34750 Istanbul, Turkey
e-mail: akbozkurt{at}yahoo.com
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Abstract
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We describe lateral resection of tracheal tumors and repair of the defect with a composite graft of nasal septal mucosa and cartilage. The preliminary experience with this technique in 3 patients was satisfactory. The procedure can be used for patients who are not candidates for standard resection and end-to-end anastomosis.
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Introduction
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Resection and direct end-to-end anastomosis is the standard method of repair for tracheal tumors [1]. Lateral resection was abandoned because of inadequate tumor removal and lack of satisfactory patches. Fascia, skin, pericardium, and several foreign materials were tried but did not prove to have adequate healing characteristics. Composite grafts consisting of nasal septal mucosa and cartilage have been used for laryngotracheal stenosis and laryngeal tumors by otolaryngologists for more than 2 decades [2–5]. However, their utilization for the treatment of tracheal tumors has not been addressed. Occasionally, conditions such as extensive scar tissue, radiation fibrosis, ankylosing spondylitis, and advanced age restrict the longitudinal flexibility of the trachea and impede resection and end-to-end anastomosis. In these circumstances, lateral excision and patching might be a surgical alternative for select tumors of the trachea. One of us (H.C.) has a wide experience in using composite nasal septal cartilage grafts for laryngeal lesions [5]. We adapted this technique for patients with low-grade tracheal tumors and present the preliminary results here.
The series comprises 3 patients with tracheal tumors that were treatable through the standard surgical approach. The patients were told that the procedure is new for tracheal reconstruction, although it is used routinely by otolaryngologists for benign and malignant laryngotracheal lesions. They were fully informed about the details of the planned procedure and the standard surgical approach. Written consent was obtained. The longitudinal extension of the tumors along the tracheal wall was 2.7, 2, and 3.2 cm in patients 1, 2, and 3, respectively, and the pathological diagnosis was adenoid cystic carcinoma, glandular-type squamous papilloma, and well-differentiated adenocarcinoma, respectively.
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Technique
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A collar incision was used in 2 patients and a collar incision plus a ministernotomy, in the other patient. The tumors were excised laterally with a satisfactory margin and immediately sent to the pathology department for examination for tumor-free surgical margins. The defect in the trachea was measured, and a composite nasal septal cartilage graft was obtained using general septoplasty instruments. A graft as large as 3 x 5 cm can be obtained from the nasal septum [2]. The graft includes mucosa, perichondrium, and cartilage protecting the opposite perichondrium and mucosa. The anterior border of the graft was marked with a surgical pen for proper orientation of the mucosal cilia.
After the presence of tumor-free surgical margins was confirmed, the composite graft was fashioned and placed in the tracheal defect. The anterior portion of the graft is placed inferiorly for normal ciliary activity. The anastomosis was performed with 3-0 interrupted absorbable sutures. A few well-placed, full-thickness sutures are preferable for better graft viability. Superficial cuts made in the cartilage with a No. 15 blade can give the graft a reasonably concave shape (Fig 1).
In the case of involvement of the membranous part of the trachea, the cartilaginous layer of the graft can be trimmed with a scalpel so that the remaining mucosa and perichondrium can better accommodate the membranous defect. The anastomosis was checked broncoscopically at the end of the operation. Neither intraluminal stents nor tracheostomies were used in this series.
All patients were extubated in the operating room but kept in the intensive care unit for 24 hours. Chin flexion was not necessary, and after 48 hours, the patients were ambulant and eating orally. Length of hospitalization was 5, 5, and 6 days for patients 1, 2, and 3, respectively. We did not observe any complications such as sputum retention during the early postoperative period. Fiberoptic bronchoscopy was not carried out routinely. Harvesting the composite nasal septal cartilage graft did not cause any problems. Only a nasal pack was placed, and it was removed after 2 days.
The patients have been followed up for 18, 20, and 22 months. The grafted area was checked for granulation tissue, integrity, and recurrence at 1, 3, 6, 12, and 18 postoperative months with fiberoptic bronchoscopy and computer tomography (Fig 2).
Satisfactory healing of the graft has been observed in each patient, and there has been no recurrence, stenosis, or complications to date.
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Comment
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Adequate rigid circular support with normal mucosal lining is crucial for the treatment of laryngotracheal stenosis and laryngeal tumors, and autogenous cartilage grafts have a well-established role in this challenging problem [2–5]. Recently, Rhee and colleagues [3] reported single-stage laryngotracheal reconstruction using composite nasal septal cartilage or costal cartilage grafts without stenting in 15 adult patients. Temporary use of an endotracheal tube was the only airway support in their series, and the overall results were excellent. Zohar and coworkers [4] used composite nasal septal cartilage grafts in 29 patients after extended partial laryngectomy for carcinoma invading the anterior commissure of the glottis. Good functional results with reliable, rigid cartilaginous wall lined by respiratory mucosa were reported for all patients.
We agree that resection and direct end-to-end anastomosis should be the standard approach for the treatment of tracheal neoplasms [1]. The efficacy of this method with low morbidity and mortality has been documented in many series. However, this preliminary study in 3 patients demonstrates the feasibility of lateral resection and patching of the defect with composite nasal septal cartilage grafts. No fistula, mediastinal infection, or stenosis was observed. We do not think ischemia of the free graft is a major concern for this type of graft. In an experimental model, Duncavage and colleagues [6] showed the stability and the good healing characteristics of the composite nasal septal cartilage graft. However, we start to harvest the graft after tracheal resection to minimize the ischemic time. The anastomosis usually takes only 30 minutes, and minimal dissection in the vicinity of the trachea protects the vascular network around it. We suggest gentle handling of the graft to avoid tissue damage.
We conclude that in select patients who are not considered candidates for the standard approach, tracheal neoplasms up to 4 cm long and 2 cm wide can be resected and repaired with a composite nasal septal cartilage graft.
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References
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- Grillo H.C. Surgical anatomy of the trachea and techniques of resection. In: Shields T.W., LoCicero J., III, Ponn R.B., eds. General thoracic surgery, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 1999:873-883.
- Toohill R.J. Composite nasal septal graft in the management of advanced laryngotracheal stenosis. Laryngoscope 1981;91:233-237.[Medline]
- Rhee J.S., Toohill R.J. Single-stage adult laryngotracheal reconstruction without stenting. Laryngoscope 2001;111:765-768.[Medline]
- Zohar Y., Shvilli I., Laurian N. Laryngeal reconstruction by composite nasoseptal graft after extended partial laryngectomy. Twelve-year follow-up. Arch Otolaryngol Head Neck Surg 1988;114:868-871.[Abstract/Free Full Text]
- Sekercioglu N., Cansiz H., Gunes M. Reconstruction with composite nasal septal cartilage and auricular cartilage in extended partial laryngectomy. J Laryngol Otol 1996;110:739-741.[Medline]
- Duncavage J.A., Toohill R.J., Isert D.R. Composite nasal septal graft reconstruction of the partial laryngectomized canine. Otolaryngology 1978;86:285-290.
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Abstract
Introduction
