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Ann Thorac Surg 2004;77:397-404
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Closure of large intrathoracic airway defects using extrathoracic muscle flaps

Antoine J. H. Meyer, MDa, Thorsten Krueger, MDa, Domenico Lepori, MDb, Michael Dusmet, MDa, John-David Aubert, MDc, Philippe Pasche, MDd, Hans-Beat Ris, MD*a

a Thoracic Surgery Unit, Lausanne, Switzerland
b Department of Radiology, Lausanne, Switzerland
c Division of Pulmonary Medicine, Lausanne, Switzerland
d Department of Head and Neck Surgery, CHUV, University of Lausanne, Lausanne, Switzerland

Accepted for publication July 21, 2003.

* Address reprint requests to Dr Ris, Thoracic Surgery Unit, CHUV, CH-1011 Lausanne, Switzerland
e-mail: hans-beat.ris{at}chuv.hospvd.ch


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: Prospective assessment of pedicled extrathoracic muscle flaps for the closure of large intrathoracic airway defects after noncircumferential resection in situations where an end-to-end reconstruction seemed risky (defects of > 4-cm length, desmoplastic reactions after previous infection or radiochemotherapy).

METHODS: From 1996 to 2001, 13 intrathoracic muscle transpositions (6 latissimus dorsi and 7 serratus anterior muscle flaps) were performed to close defects of the intrathoracic airways after noncircumferential resection for tumor (n = 5), large tracheoesophageal fistula (n = 2), delayed tracheal injury (n = 1) and bronchopleural fistula (n = 5). In 2 patients, the extent of the tracheal defect required reinforcement of the reconstruction by use of a rib segment embedded into the muscle flap followed by temporary tracheal stenting. Patient follow-up was by clinical examination bronchoscopy and biopsy, pulmonary function tests, and dynamic virtual bronchoscopy by computed tomographic (CT) scan during inspiration and expiration.

RESULTS: The airway defects ranged from 2x1 cm to 8x4 cm and involved up to 50% of the airway circumference. They were all successfully closed using muscle flaps with no mortality and all patients were extubated within 24 hours. Bronchoscopy revealed epithelialization of the reconstructions without dehiscence, stenosis, or recurrence of fistulas. The flow-volume loop was preserved in all patients and dynamic virtual bronchoscopy revealed no significant difference in the endoluminal cross surface areas of the airway between inspiration and expiration above (45 ± 21 mm2), at the site (76 ± 23 mm2) and below the reconstruction (65 ± 40 mm2).

CONCLUSIONS: Intrathoracic airway defects of up to 50% of the circumference may be repaired using extrathoracic muscle flaps when an end-to-end reconstruction is not feasible.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The increasing use of complex reconstructions of the intrathoracic airways and neoadjuvant therapy followed by resection for thoracic malignancies have renewed an interest in extrathoracic muscle flaps for mediastinal reinforcement after surgery [1]. The intrathoracic transposition of the serratus anterior or the latissimus dorsi muscle have been described in the treatment of infected residual spaces [2–7], postpneumonectomy empyema with or without bronchopleural fistula [8], prosthesis infection after superior vena cava replacement [9], tracheal erosion caused by posttraumatic aortic aneurysm [10], nonmalignant tracheoesophageal fistula [11], prophylactic mediastinal reinforcement after complex tracheobronchial reconstructions [12], and after radiotherapy [13]. The latissimus dorsi and serratus anterior muscle can be harvested easily through a posterolateral thoracotomy incision and their intrathoracic transposition is not associated with a significant additional morbidity [12].

Several reports have described the use of intrathoracic transposition of chest wall muscles for the closure of postpneumonectomy bronchial stump insufficiency where a primary suture of the debrided stump seemed unwise [8, 14]. The muscle was sutured into the bronchial defect without attempting a primary closure of the stump. We have extended this technique to close intrathoracic airway defects of variable localization and extent after noncircumferential resections in situations where an end-to-end reconstruction seemed risky. This study focuses on the functional and morphologic results using extrathoracic muscle flaps for the closure of large intrathoracic airway defects after noncircumferential resection.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
All patients who underwent closure of intrathoracic airway defects after noncircumferential resection using an extrathoracic muscle flap (latissimus dorsi or serrratus anterior muscle) between 1996 and 2001 were the subject of this study. Patient follow-up was prospectively by clinical and radiologic examination, repeated bronchoscopy and biopsy, pulmonary function tests including flow-volume loop measurements, and virtual dynamic computed tomographic (CT) bronchoscopy during inspiration and expiration.

Inclusion criteria consisted of patients requiring closure of an intrathoracic airway defect after noncircumferential resection in situations where an end-to end reconstruction seemed risky or not feasible. Indications for this technique in our series were the following: redo-operations for chronic bronchopleural fistula (BPF) with a short bronchial stump and empyema; repair of the airway for nonmalignant tracheoesophageal fistula (TEF) and delayed tracheal injury; and closure of airway defects after noncircumferential resection for tumors involving the intrathoracic trachea or the carina. In all patients the decision to refrain from end-to-end reconstruction was taken before the operation and was based on the length of required resection and the estimated risk of excessive anastomotic tension.

Technique
The latissimus dorsi or serratus anterior muscle were dissected through a posterolateral thoracotomy incision while preserving their proximal vascular blood supply [12]. Preference was given to the latissimus dorsi muscle, although the serratus anterior muscle was used if the latissimus dorsi muscle had been divided by a previous intervention. Noncircumferential resections of the central intrathoracic airways were performed through a standard posterolateral thoracotomy. The extrathoracic pedicled muscle flap was transposed into the chest cavity via an accessory thoracotomy through the bed of a resected segment of the second rib. It was sutured into the airway defect with resorbable interrupted sutures under slight tension and with bronchoscopic control in order to maintain stability of the airways and to prevent protrusion of the muscle into the lumen. Thirty percent of the airway circumference was the maximal circumferential extent of resection accepted for reconstruction by use of a muscle flap alone.

In patients where there was a defect of more than 30% of the airway circumference, mechanical reinforcement of the reconstruction was obtained by embedding a rib segment into the muscle flap (Fig 1). In this situation, thoracotomy was performed through the bed of the fourth rib, which was resected after deperiostation. A 15-cm long segment of the deperiosted rib was divided along its long axis while preserving its width using a lueur (Fig 1A). A pouch was then created within the latissimus dorsi flap after intrathoracic transposition. For this purpose, the muscle was carefully split along its muscle fibers with scissors and by blunt dissection and a pouch of 4-cm width and 15-cm depth was created along the long axis of the muscle. The tailored rib was then embedded in this muscle pouch (Fig 1B). The latissimus dorsi muscle was sutured to the edges of the airway defect in a way that allowed the embedded rib segment to bridge the airway defect in its long axis (Figs 1C and 2) . This was followed by deployment of an endotracheal silicon Y stent (Hood Laboratory, Pembroke, MA) at the end of the intervention just after extubation. The stent was kept in place for 4 weeks and then removed under bronchoscopic control (Fig 3). Fifty percent of the airway circumference was the maximal extent of resection accepted for coverage by use of a reinforced muscle flab using an embedded rib segment.



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  		Fig 1. Closure of a tracheal airway defect after resection of more than one third, but less than 50%, of the airway circumference using a latissimus dorsi muscle reinforced by an embedded rib segment. (a) A 15-cm long segment of the fourth rib is harvested during thoracotomy and divided along its long axis while preserving one corticalis. (b) A pouch is created within the muscle by blunt dissection along its fibers, which allows embedding of the rib segment containing one corticalis. (c) The muscle is sutured into the airway defect by interrupted resorbable sutures in a way that the embedded rib segment bridges the defect in its long axis.

 


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  		Fig 2. Intraoperative documentation demonstrating the tracheal defect with the endotracheal tube in place (*). The latissimus dorsi muscle flap (LD) with the embedded rib (RIB) is sutured into the cranial part of the airway defect.

 


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  		Fig 3. Closure of a tracheal defect of 8x4 cm by a latissimus dorsi flap reinforced by an embedded rib segment after noncircumferential resection of more than one-third, but less than 50%, of the tracheal circumference. Postoperative result assessed by bronchoscopy 8-weeks after the repair and 4-weeks after stent removal (same patient as in Fig 2).

 
Follow-up
Morbidity and 30-day mortality were recorded. At 3 and 6 months after the operation, the reconstructions were assessed by use of pulmonary function tests, measurement of the flow-volume loop and bronchoscopy including biopsy at the level of the reconstruction with histologic assessment of the specimen. A dynamic assessment of the reconstruction during respiration was performed 6 months after the operation by use of virtual dynamic CT bronchoscopy with three-dimensional reconstructions above, at the level of and below the reconstruction during inspiration and expiration (Fig 4). The endoluminal cross surface areas of the airway were measured above, at the level of and below the reconstruction during inspiration and expiration and the difference between inspiration and expiration was recorded for each level assessed [15–17]. This examination was performed in all patients except for those requiring closure of airway defects for BPF since no airway instability had been reported in previous series after airway repair for BPF using muscle flaps.



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  		Fig 4. Assessment of tracheocarinal reconstructions using muscle flaps by virtual bronchoscopy using three-dimensional reconstruction of a spiral computed tomographic scan during respiration: (a) measurements of the endoluminal cross-surface areas of the airway performed above, at the level, and below the reconstruction; (b) during inspiration; (c) during expiration.

 
The patients were followed on clinical and radiologic grounds until December 2002, or until death with respect to recurrent infection, fistula, or malignancy. The paired Student's t test and a bidirectional hypothesis were used for statistical analysis where appropriate and significance was accepted at p less than 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
From 1996 to 2001, 13 patients underwent closure of large intrathoracic airway defects using an extrathoracic muscle flap (Table 1). There were 11 men and 2 women with a mean age of 56 years old (range 14–70 years old). The mean follow-up time after the operation was 24 months, ranging from 6 to 72 months. The type of reconstruction performed in the 13 patients is illustrated in Figure 5.


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  		Table 1. Characteristics of Patients Undergoing Noncircumferential Tracheocarinal Resections and Reconstruction Using Extrathoracic Muscle Flaps

 


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  		Fig 5. Pattern of intrathoracic airway defects closed by muscle flaps: (a) defect in the main stem and intermediate bronchus resulting from BPF after right upper lobectomy in a patient who would not tolerate completion pneumonecomy; (b) defect at the level of the carina after debridement of BPF following right pneumonectomy and radiotherapy; (c) tracheocarinal defect after pneumonectomy and carinal wedge resection following neoadjuvant radiochemotherapy for centrally located NSCLC; (d) tracheocarinal defect after noncircumferential resection for tracheal malignancies, nonmalignant tracheoesophageal fistula, or delayed tracheal injury (see text). (BPF = bronchopleural fistula; NSCLC = nonsmall cell lung cancer.)

 
Redo-operations for chronic BPF with a short bronchial stump and empyema were performed in 5 patients. In these 5 patients, heavy desmoplastic reaction was foreseen at reoperation and the inability to close the airway defect by direct suture. One patient presented with a BPF and empyema following right upper lobectomy who would not tolerate a completion pneumonectomy due to congestive heart failure. He underwent decortication, debridement of the airway, and closure of the 2 x 1 cm defect of the intermediate and main stem bronchus using an extrathoracic muscle flap (Fig 5A). Four patients underwent closure of a carinal airway defect ranging from 2 x 2 to 3 x 2 cm after debridement of a large BPF and a short bronchial stump following right pneumonectomy (Fig 5B). All 4 patients had previous mediastinal irradiation ranging from 48 to 64 Gy. After double lumen intubation, rethoracotomy was performed and the serratus anterior muscle was dissected. The chest cavity was cleaned and the bronchial stump was debrided, which required division of the azygos vein and dissection of the carina. The muscle was sutured into the airway defect after intrathoracic transposition. The cavity was packed with Betadine-soaked towels that were changed every second day through a transitory open window thoracostomy until the chest cavity was covered by granulation tissue. Obliteration of the chest cavity was then performed by filling the cavity with Clagett solution and the skin was closed. Closure of the airway was successful in all patients without recurrent fistula or empyema.

Closure of central airway defects for nonmalignant TEF and delayed tracheal injury were performed in 2 and 1 patient, respectively (Fig 5D). One TEF occurred 4 years after Ivor-Levis operation and mediastinal irradiation between the distal intrathoracic membranous part of the trachea and the gastric pull-up and measured 3 x 1 cm after debridement without evidence of tumor recurrence. A 14-year-old patient presented with a destroyed right lung due to recurrent bronchoaspiration related to a large congenital TEF at the level of the distal intrathoracic trachea which measured 2 x 4 cm after debridement. The airway defect was closed using an intrathoracic transposed extrathoracic muscle flap, which was sutured into the defect and interposed between the primarily repaired esophagus and gastric pull-up, respectively. The second required a pneumonectomy for destroyed lung. One patient presented with a delayed postintubation injury of the intrathoracic trachea leaving a defect of 8 x 2 cm that was closed using an extrathoracic muscle flap. In all 3 patients a closure of the airway using a muscle flap was anticipated due to the extent of the defect and the circumstances rendering an end-to-end reconstruction hazardous. No recurrence of fistula was observed in both patients with TEF during follow-up. Postoperative healing after delayed tracheal injury was uneventful despite the fact that intubation had been required for almost 2 weeks prior to the repair.

Closure of the airway after noncircumferential resection for tumors involving the intrathoracic trachea or the carina was performed in 5 patients. Three patients presented with a noncircumferential squamous cell carcinoma of the intrathoracic trachea with an extension of greater than 4 cm in length rendering primary resection and end-to-end anastomosis hazardous. The first patient was treated with three cycles of cisplatin (100 mg/m2) and doxetacel (75 mg/m2) followed by a block of concomitant boost accelerated radiotherapy to a total dose of 64 Gy. He exhibited a near complete response as judged on endoscopic and CT evaluation and the residual tumor seemed completely resectable by noncircumferential resection. The airway defect measured 8 x 4 cm after complete resection and was closed using a latissimus dorsi flap reinforced by an embedded rib segment (Figs 1–3, 5D). The second patient revealed a 4-cm long, noncircumferential tumor of the membranous part of the intrathoracic trachea and was treated by noncircumferential resection in healthy tissue leaving an airway defect of 5 x 3 cm, which was also closed by use of a latissimus dorsi flap reinforced by an embedded rib segment (Fig 5D). The third patient revealed local tumor recurrence after resection and end-to-end reconstruction of the intrathoracic trachea for squamous cell carcinoma. The recurrent tumor was completely resected by noncircumferential resection and the resulting airway defect of 5 x 2 cm was closed by a muscle flap without reinforcement (Fig 5D). Two patients had a centrally located T4 nonsmall cell lung cancer (NSCLC) involving the main stem bronchus and the tracheobronchial angle without evidence of contralateral lymph node disease. They were treated with three cycles of cisplatin (100 mg/m2) and doxetacel (75 mg/m2) followed by a block of concomitant boost accelerated radiotherapy to a total dose of 44 Gy. Partial response occurred and resection requiring pneumonectomy in both patients was performed. A carinal wedge resection was performed in tumor-free tissue including a 2-cm long resection of the lateral tracheobronchial angle and the airway defect of 4 x 2 cm was closed by a muscle flap (Fig 5C).

All 5 patients had a complete resection with microscopically tumor-free resection margins. Three patients died due to metastatic disease during follow-up. One patient developed a local recurrence at the site of tracheal resection 12-months after resection.

Postoperative morbidity
There was no 30-day mortality. Postoperative extubation within the first 24 hours was achieved in every patient without the need for reintubation, tracheostomy, or prolonged mechanical ventilation. No stent dislocation was observed in the 2 patients requiring temporary tracheal stenting for 4 weeks. Two patients required coverage of a wound dehiscence arising over a winged scapula after a serratus anterior transposition by use of a contralateral latissimus dorsi flap.

Endobronchial assessment
Every patient had repeated postoperative endoscopic controls during hospitalization, as well as at 3 and 6 months postoperatively. No airway complications were recorded, no stenosis, muscle protrusion, airway instability, suture dehiscence, or recurrence of bronchopleural fistula were observed. This also holds true for the 2 patients with resection of the airway of up to 50% of the circumference closed by a latissimus dorsi flap reinforced by an embedded rib segment and stented for 4 weeks. At 3 months, bronchoscopy indicated that the muscle flap was covered by an intact epithelial layer in all patients. Bronchoscopic biopsies harvested at the site of repair demonstrated islets of squamous cell epithelium integrated into granulation tissue at 3 months, and a pseudostratified ciliated epithelium of respiratory type covering the muscle flap at 6 months after the operation (Fig 6).



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  		Fig 6. Histologic assessment of a bronchoscopic biopsy performed at the site of airway closure by a latissimus dorsi flap 6-months after the operation, revealing a pseudostratified ciliated epithelium of respiratory type covering the muscle flap (magnification x10).

 
Pulmonary function tests
The flow-volume loop was preserved in every patient at assessment 3 and 6 months after the operation. The mean postoperative forced expiratory volume at 50% expiration (FEF50) was 2.18 ± 0.64 L/s and the mean postoperative forced inspiratory volume at 50% inspiration (FIF50) 3.6 ± 0.92 L/s. The mean differences between the predicted and postoperative measured FEF50 and FIF50 values were 8.4% and 1.7%, respectively (p > 0.05).

Virtual bronchoscopy during inspiration and expiration was performed in all but 3 patients (patients 3, 5, and 11 of Table 1) 6 months after the operation and revealed no significant difference of the endoluminal cross surface area of the airway between inspiration and expiration above, at the level of and below the reconstruction, respectively (p > 0.05; Table 2). The mean cross surface area above the level of the resection was 364 ± 96 mm2 and decreased during expiration by 13% ± 6%. At the middle of the reconstruction these values were respectively 356 ± 156 mm2 and 21% ± 6%. Below the reconstruction they were 348 ± 134 mm2 and 19% ± 11%. In the two reconstructions where the latissimus dorsi flap was reinforced by an embedded rib segment, the CT scan at 6 months revealed an intact rib segment without signs of resorbtion, sequestration or heterotopic calcification of the muscle.


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  		Table 2. Assessment of Endoluminal Cross-Surface Areas of Airway (Mean ± SD) After Closure of Intrathoracic Airway Defects With Muscle Flaps by Dynamic Virtual CT Bronchoscopy During Inspiration and Expiration

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
End-to-end reconstructions of the intrathoracic tracheocarinal airways have demonstrated excellent results in experienced hands. However, a postoperative mortality rate of 12.7% has been reported in 135 patients undergoing carinal resections with a 30% mortality after left carinal pneumonectomy [18–21]. The major predictors of mortality and morbidity have been the length of the resection and the development of anastomotic complications. Excessive anastomotic tension has been reported to be the single greatest cause of failure after tracheal operations. However, this cannot always be avoided despite careful patient selection and meticulous surgical technique, especially if long segments have to be resected, or if a resection has to be performed in the presence of desmoplastic reactions of the airway after previous surgery, infections or mediastinal irradiation [22]. Because there is actually no clinically established substitute available for complete tracheal or carinal replacement [23], partial noncircumferential airway resection followed by autologous reconstructions may be a valid alternative procedure in situations where complete resection and end to end anastomosis seems risky [24]. Intrathoracic transposition of chest wall muscles, namely the serratus anterior or latissimus dorsi muscle have been used for many years for mediastinal reinforcement as well as for the obliteration of residual infected spaces. They have demonstrated their usefulness as well as low morbidity in relation to their harvesting. The mechanical strength and versatility of these flaps have inspired several authors to use them for closure of bronchopleural fistula associated with a postpneumonectomy empyema in order to avoid a hazardous primary closure of the airways [8, 14, 25]. The muscle is sutured to the edges of the debrided bronchial stump without any attempt to close the stump primarily.

We have extended this concept by using these muscle flaps as substitutes for closing large intrathoracic airway defects, in situations where circumferential resection and end-to-end anastomosis seemed not feasible or risky. Indications for this technique in our series were redo-operations for chronic BPF with a short bronchial stump and empyema; repair of the airway for nonmalignant TEF and delayed tracheal injury; and closure of the airway after noncircumferential resection for tumors involving the intrathoracic trachea (tracheal tumors) or the carina (centrally located NSCLC) after neoadjuvant radiochemotherapy.

Redo-operations for chronic BPF
A chronic postpneumonectomy bronchopleural fistula is usually managed by debridement and closure of the bronchial stump with interrupted sutures, reinforcement of the mediastinum by omentum or a muscle flap and packing of the cavity through a transitory open window thoracotomy [5, 7, 8]. Secondary obliteration of the cavity is performed using the Clagett procedure once the cavity and the mediastinum is covered by granulation tissue [6]. However, primary closure of an insufficient short right-sided bronchial stump after mediastinal irradiation may not be feasible due to the desmoplastic reaction of the tissues and recurrent fistulisation may occur. Recent reports have demonstrated that extrathoracic pedicled muscle flaps can be sutured under slight tension into the bronchial defect without attempting primary closure of the stump and that healing of BPF and empyema can be obtained [8, 12, 14]. Our results confirm these findings; all of the postpneumonectomy bronchopleural fistula in our series healed after closure of the airway by use of extrathoracic muscle flaps, debridement and packing of the cavity followed by its obliteration according to Clagett and Geraci [6]. Moreover, 4 of 5 patients treated in this way had previous mediastinal irradiation up to 64 Gy. In addition, this technique was also applied with success to a patient with chronic empyema after upper right lobectomy and a large bronchopleural fistula with necrotic edges rendering a sleeve resection dangerous and who would not have tolerated a completion pneumonectomy.

Airway repair for nonmalignant TEF and delayed tracheal injury
In 2 patients, intrathoracic muscle transfer was successfully used for closure of a large airway defect following debridement of nonmalignant TEF at the level of the distal trachea, and in one of an 8-cm long, delayed injury of the intrathoracic membranous part of the trachea. Small TEF can be managed by division of the fistula and direct repair of the trachea and the esophagus, but larger tracheal defects may require tracheal resection and reconstruction [26]. In case of extensive defects of the membranous wall exceeding the length of the trachea that can be safely resected, it has been suggested to primarily close longitudinally the posterior wall of the trachea, or if the reconstruction seems impossible, to cover the defect by a strap muscle and to maintain airway patency with a T-tube [27]. Our results indicate that closure of large defects of the membranous wall of the intrathoracic trachea using extrathoracic muscle flaps may be a valid alternative to a hazardous primary repair of the airway, especially after previous mediastinal irradiation. A tension-free reconstruction of the airways was achieved by suturing the muscle flap into the airway defect. At the same time, this allowed the interposition of the muscle flap between the repaired esophagus and airway [19, 20, 23, 28]. Both patients were extubated without requiring stents and did not have symptoms of stridor or dysphagia during follow-up.

The same holds true for the closure of lengthy intrathoracic defects of the membranous trachea after delayed injury. These lesions usually result from endotracheal intubation with longitudinal tears of the membranous part of the intrathoracic trachea and can involve a long segment of the trachea. Although fresh lesions can be repaired by direct suture, distal and delayed lesions may require formal debridement and reconstruction of the airway [29]. Our results suggest that closing such an airway defect after debridement may safely be done by suturing an extrathoracic muscle flap into the debrided airway defect in situations where an exceedingly long injury precludes intrathoracic end to end reconstruction of the trachea.

Closure of airway defects after noncircumferential resection for tumors involving intrathoracic trachea or carina
Extrathoracic muscle flaps were also used with success in our series for the repair of trachea or carinal defects after resection of tumors, especially after neoadjuvant radiochemotherapy. Two patients with centrally located NSCLC involving the tracheobronchial angle received neoadjuvant radiochemotheray and underwent pneumonectomy and carinal wedge resection, the resulting airway defect of 4 x 2 cm was reconstructed by use of a pedicled latissimus dorsi muscle flap. Several reports have demonstrated that long-term survival can be obtained after resection of T4 tumors involving the carina provided these tumors have undergone neoadjuvant chemotherapy or radiochemotherapy with clinical response [30, 31]. However, carinal resection and carinal pneumonectomy bear a high morbidity and mortality rate after neoadjuvant therapy. Our results suggest that complete resection may be obtained with a carinal wedge pneumonectomy instead of a sleeve pneumonectomy and that the airway defect may be successfully closed using extrathoracic muscle flaps which obviates an end to end reconstruction of the airway after induction therapy.

Three patients underwent a noncircumferential resection of the intrathoracic trachea for squamous carcinoma. One of these patients had a recurrent tumor after previous tracheal resection. The defects ranged from 5 to 8 cm in their long axis, and from 30% to 50% of the airway circumference. In order to maintain the mechanical stability of the airways after a resection of greater than 5-cm length and greater than 30% of their circumference, the reconstruction was reinforced by embedding a rib segment into the muscle which bridged the defect in its long axis, followed by the placement of an endotracheal silicon Y-stent for 4 weeks. The stent was well tolerated for up to 4 weeks by the patient and prevented the airways collapse in the early postoperative phase. The Y-shaped stent allowed its maintenance in the airways and did not interfere with the epithelialisation of the muscle flap. Complete epithelialization of the muscle flap was achieved in both patients with a rib segment embedded in the flap.

Circumferential tracheal or carinal resections with end to end anastomosis remains the standard for the treatment of tracheal malignancies [32]. However, primary tracheal tumors often present with locally advanced disease and tumor length is the most important determinant of resectability. The safe limits of tracheal resection are highly individual but an intrathoracic tracheocarinal lesion of greater than 4-cm length cannot be bridged without excessive tension [32]. Downstaging of the tumor size by means of neoadjuvant treatment in order to increase the resectability rate may be an attractive approach, however, preoperative radiotherapy can have desastrous effects on anastomotic healing. Our results suggest that noncircumferential resection after neoadjuvant chemoradiotherapy may offer a complete resection and that airway defects of less than one third of circumference ranging up to 6 cm may be closed using extrathroacic muscle flaps. Defects of up to 8 cm in length and up to one-half the circumference may be bridged using muscle flaps reinforced by an embedded rib segment. However, these observations need confirmation in a larger series of patients.

Bronchoscopic evaluation and pulmonary function testing of the reconstructions revealed patent airways in all patients without stenosis or muscle flap protrusion. In addition, the dynamics of the reconstructions were assessed by use of virtual dynamic CT bronchoscopy during respiration in order to detect stenotic or malacic segments of the intrathoracic airway [33, 34]. The endoluminal airway surfaces above, at the level, and below the reconstruction were measured at maximal inspiration and expiration and the differences in endoluminal airway surfaces during respiration were not significantly different at each level assessed.

Our results emerging from a limited number of patients suggest that closure of large intrathoracic airway defects is feasible by use of chest wall muscle flaps following non-circumferential resection of up to 50% of the airway circumference and result in a functional and morphologic integrity of the repaired airways. However, this is only indicated when an end-to-end reconstruction is not feasible, which remains the standard procedure, especially in patients with tracheal malignancy.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

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