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Ann Thorac Surg 2006;82:1953
© 2006 The Society of Thoracic Surgeons
Division of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, Milan, 20141 Italy
(Email: lorenzo.spaggiari{at}ieo.it).
We read with interest the case reported by Yu and associates [1] about a new technique for tracheal reconstruction of a 6.5-cm tracheal defect after resection of a recurrent thyroid tumor. We congratulate the authors for their excellent outcome in this very challenging operation and for adding their experience on this topic. Yu and associates [1] fabricated a neo-trachea by a triple layer of biological and synthetic materials: from inside, the radial forearm fasciocutaneous flap was suspended from a resorbable mesh and reinforced with an external rigid support; a vascular graft was used. The flap vessels were microsurgically anastomosed to cervical vessels and a Montgomery T-tube was placed and then removed 2 months later.
In 2002, we encountered a similar case [2] in a 37-year-old man who underwent a 5.5-cm tracheal resection for thyroid cancer. He was reoperated on for a tracheal suture dehiscence requiring a 9-cm sublaryngeal tracheal resection. The reconstruction of this long tracheal defect was accomplished by a skin–omentoplasty–myoplasty graft. Specifically, a chest wall skin graft was used as the anterior tracheal wall. The flap was sutured to the lateral esophageal margins so that the anterior aspect of the esophagus became the posterior side of the neo-trachea. The skin graft was covered by an omental flap that assured a good blood supply to the underlying graft. One month after the operation, graft stenosis was successfully treated by stenting the neo-trachea and allowing an excellent long-term result. The patient died in August 2005 of local thyroid cancer recurrence.
Airway invasion by thyroid carcinoma is an uncommon, but important, clinical problem. The standardization and safety of the techniques of airway resection and reconstruction have made en bloc surgery possibly curative. Resection and reconstruction of a middle tracheal defect (<4 cm) may be restored by direct suture and neck flexion, laryngeal, and hilar release [3]. Extended tracheal resections (>4 cm) are usually managed by replacing the excised tracheal segment with foreign materials (ie, solid or porous prostheses), nonviable tissue (ie, bioprosthesis), or autogenous tissues (ie, free graft with and without prosthetic support, vascularized autogenous tissue flaps, or autogenous tube construction). More recently, tissue engineering [4, 5] or tracheal transplantation have been introduced [6, 7]. These latter surgical solutions offer hope to the treatment of extended tracheal replacement; however, the skin–omental or skin–fascio-cutaneous flap is a useful option in dramatic situations. As Grillo suggests, "We must continue to maintain an open mind about this intriguing but thus far unsolved surgical dilemma—replacement of the tracheal conduit" [8].
Again, we congratulate the authors for their exciting and encouraging result.
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  P. Yu Reply Ann. Thorac. Surg., November 1, 2006; 82(5): 1953 - 1954. [Full Text] [PDF]
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