Ann Thorac Surg 2004;78:e85-e86
© 2004 The Society of Thoracic Surgeons
Case report
Treatment of Iatrogenic Injury of Membranous Trachea With Intercostal Muscle Flap
Ilias A. Kouerinis, MDa,
Antonios E. Loutsidis, MDa,
Panagiotis A. Hountis, MDa,
Eustratios E. Apostolakis, MDa,
Ion P. Bellenis, MD, PhDa,*
a Department of Cardiothoracic Surgery, Evangelismos Hospital, Athens, Greece
Accepted for publication January 22, 2004.
* Address reprint requests to Dr Bellenis, King George 24, 11635 Athens, Greece
ionbellenis{at}hotmail.com
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Abstract
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Iatrogenic injuries of the membranous trachea are rare but potentially lethal, and most commonly require surgical treatment. Such injuries occur intraoperatively during specific thoracic surgery procedures or are associated with endotracheal anesthesia. Special technical difficulties in managing them surgically are encountered when lacerations are in proximity to the rigid rings of the trachea because of the lack of membranous tissue distal to the tear. We describe our technique used in a patient with such an iatrogenic tracheal injury during resection of invasive lung carcinoma.
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Introduction
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Iatrogenic injuries of membranous trachea have become increasingly common, and can complicate procedures such as endotracheal intubation [1], mediastinoscopy [2], percutaneous tracheostomy [3], and excision of neoplasms with mediastinal involvement [4]. Membranous trachea wall lacerations tend to be long, and therefore surgical repair is usually mandatory. Several techniques have been described to restore the wall integrity of membranous trachea [4]. Technical difficulties are posed when longitudinal lacerations are in proximity to the rigid rings, in which case the placement of interrupted sutures may prove inadequate or even hazardous.
A 67-year-old man was operated on for invasive lung carcinoma. At operation, the tumor was found to have invaded the thoracic wall and the surrounding tissues of the trachea and esophagus, but not the organs themselves (Fig 1). Tumor resection maintained macroscopically clear margins, which were confirmed by frozen section. Nevertheless, the operation proved rather catastrophic as it resulted in an approximately 3 cm x 0.4 cm longitudinal laceration of membranous trachea in proximity to its rigid rings. Our first attempt at primary interrupted suturing not only failed but also enlarged the laceration width from 0.4 cm to 0.6 cm; therefore, we decided to take the following approach to repair, which finally proved successful.
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Fig 1. The thoracic computed tomography scan of the case presented. Note the lung carcinoma and its proximity to the esophagus and trachea.
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Mobilization of the esophagus was performed, and single interrupted nonabsorbable 3-0 Prolene sutures (Ethicon, Somerville, NJ) were placed between its posteolateral muscle wall and the lowest edge of the rigid rings of trachea. By lifting the middle portion of the sutures, we created a W-shaped tunnel, through which we inserted a thick intercostal muscle flap (Fig 2). By tightening the sutures, we moved the esophagus and the muscle flap toward the posterior wall of the membranous trachea, sealing the wall laceration. To check the effectiveness of this technique, we filled the hemithorax with sterile saline and asked the anesthesiologist to raise the ventilation pressure to the tracheal port of the double-lumen tube to 40 cm H2O. Meticulous inspection for air leak proved negative. An apical tube drain was placed, and the patient was extubated in the operating theater. The postoperative period progressed uneventfully, the tube drain was removed 3 days later, and the patient dismissed on the sixth postoperative day. Analysis of permanent sections established the diagnosis of squamous cell carcinoma with margins free of disease. The patient received postoperative radiation at a total dose of 45 Gy, but stating that he was free of symptoms, he refused postoperative bronchoscopy. After 8 months of follow-up, the patient is still in good condition.
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Fig 2. The surgical technique: by placing the intercostal muscle flap under the sutures and tightening them, the intercostal muscle was interposed to the posterior wall of trachea.
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Comment
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Iatrogenic damage is in a special category, involving almost exclusively the membranous trachea. Early recognition with prompt surgery is the gold standard of managing such cases, although small tears that do not gape during respiration can be managed conservatively [5].
Several techniques [4, 6], including membranous wall tracheoplasty by means of interrupted sutures through an anterior longitudinal tracheotomy, membranous wall tracheoplasty with mesh, or even reconstruction of the trachea, have been proposed as the procedure of choice, with or without the use of jet ventilation. Nevertheless, membranous wall tracheoplasty with single sutures may fail to restore or may even enlarge longitudinal tears very close to the rigid rings, owing to the lack of membranous wall tissue in one side. Moreover, based on our previous experience, the use of surgical glue and pedicled pleural or thymus flaps has proved inadequate to control the air leak in similar cases.
The surgical use of muscle flaps, including intercostal, has already been reported for managing both combined tracheoesophageal injuries [7] and acquired nonmalignant tracheoesophageal fistulas [8]. Nevertheless, those techniques are rather complicated and require extended surgical manipulations. Our technique, when indicated, is less invasive; and without changing the planning of the scheduled operation, it can prove equally effective. The efficacy of our technique is based on the competence of the muscle wall of the esophagus to sustain the tension against the rigid rings of the trachea and, furthermore, to push the thick muscle flap toward its posterior wall, sealing the tear. Without the interposition of the muscle flap, the esophagus alone, although it limits, it fails to completely control the air leaks. Notably, a supplemental advantage of our technique is that the anesthesiologist does not have to manipulate the patient's ventilation.
We recommend this technique as an alternative approach to all membranous tracheal wall lacerations that are in close proximity to the rigid rings, since it was shown to be fast, safe, and not technically demanding.
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References
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Abstract
Introduction
