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Ann Thorac Surg 2006;82:1953-1954
© 2006 The Society of Thoracic Surgeons
The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, 443, Houston, TX 77030
(Email: peirongyu{at}mdanderson.org).
Thanks for inviting me to reply to the letter by Galetta and Spaggiari [1]. In their letter, Galetta and Spaggiari [1] reported a case of a 37-year-old man who underwent tracheal reconstruction consisting of skin grafts wrapped around with an omental flap. An intraluminal stent was inserted when stenosis developed, and the patient tolerated the stent for 3 years before dying of recurrent disease. The authors are to be congratulated for this good long-term result. Our experience with such stents, however, has not been so positive.
Since our first case report [2], we have performed six more tracheal reconstructions for large defects using radial forearm free flaps as lining and prostheses to suspend the flaps to prevent collapse. In 1 obese patient, the flap was too thick, which required placement of an intraluminal stent under bronchoscopic guidance. In another patient with a circumferential defect, the trachea was reconstructed using a tubed radial forearm flap and a stent, because no suitable prosthesis was available to suspend the tubed flap. Neither patient tolerated the stent well. Constant airway irritation and thick secretions in the presence of unilateral vocal cord paralysis compromised the airway and caused repeated episodes of pneumonia. Similar problems associated with a stent inside a tubed flap were also reported by Beldholm and colleagues [3]. The stents in both patients were removed and the T-tubes were placed through the flaps as tracheostomies, which were well tolerated. The patients were able to breathe through the T-tubes and speak normally with the T-tubes capped.
Because of our unfavorable experience with the intraluminal stent, we have abandoned its use. Our approach now is to use a T-tube tracheostomy at the end of reconstruction to allow the flap to heal and to decannulate at a later time as tolerated. Even with the T-tube in place, the patients have a good quality of life and a voice, which is a result superior to that of a total laryngectomy with a possible mediastinal tracheostomy. Our first 2 patients have now lived normal lives for 2 years and 18 months, respectively, without the need for a stent. They are symptom and disease free.
Galetta and Spaggiari [1] report the use of an omental flap, which is a well-vascularized flap that is commonly used for osteomylitis of the sternum after a sternotomy. This approach has potential disadvantages; however, in addition to the need for a stent: (1) a laparotomy is required, and the omentum must be pulled through the chest and mediastinum to reach the tracheal defect; (2) the skin grafts used to wrap around the flap tend to contract over time, possibly causing stricture; and (3) skin grafts do not tolerate external-beam radiation well, and it is often required, as in our series in which 6 of the 7 patients received up to 60 Gy of postoperative external-beam radiation.
There are several advantages to using free tissue transfer, but this technique requires advanced microsurgical skills to achieve a flap success rate approaching 100%. Because of its many advantages, however, this approach has become our preference, and we perform nearly 400 free-flap reconstructions every year at our institution for any defect in the body. Free tissue transfer gives the surgeon more freedom in choosing flaps, and free flaps can be placed virtually anywhere in the body. Most tracheal defects are accessible through a neck incision, even if they extend below the sternal notch. Therefore, free-flap reconstruction can avoid a thoracotomy or sternotomy, as well as a laparotomy. This becomes important in patients who have minimal pulmonary reserve due to chronic obstructive pulmonary disease, which is commonly seen in our patient population. Free-flap reconstruction for head and neck defects, with restoration of form and function, has made extensive tumor extirbation possible, a major contribution to the success of head and neck surgery. Successful reconstruction of the trachea will similarly expand the indications for tracheal surgery, possibly making the surgery curative for certain patients, such as those with papillary thyroid cancer.
Skin lining the reconstructed trachea seems well tolerated, whether it is a skin flap or skin grafts. However, the main problem we still face in tracheal reconstruction is the supporting material. Currently available prosthetic materials are workable but not ideal, and without rigid support, airway collapse is inevitable. I agree that the future of tracheal reconstruction may be tissue engineering or transplantation. Before that becomes a reality, however, both our approach and that of Drs Galetta and Spaggiari are viable options. In the meantime, we need to continue to improve our techniques and search for new solutions.
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