Ann Thorac Surg 2007;83:1213-1215
© 2007 The Society of Thoracic Surgeons
How To Do It
Long-Segment Tracheal Stenosis Treated with Vascularized Mucosa and Short-Term Stenting
Steven Stamenkovic, MDa,
Robert Hierner, MD, PhDb,
Paul De Leyn, MD, PhDa,
Pierre Delaere, MD, PhDc,*
a Department of Thoracic Surgery, University Hospital K. U. Leuven, Leuven, Belgium
b Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospital K. U. Leuven, Leuven, Belgium
c Department of Otolaryngology Head and Neck Surgery, University Hospital K. U. Leuven, Leuven, Belgium
Accepted for publication April 6, 2006.
* Address correspondence to Dr Delaere, Department of Otolaryngology Head and Neck Surgery, University Hospital K. U. Leuven, Kapucijnenvoer 33, Leuven, B-3000 Belgium (Email: pierre.delaere{at}uz.kuleuven.ac.be).
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Abstract
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A free, vascularized radial forearm fascia flap lined with two full-thickness buccal mucosa grafts can be used in cases of acquired, long-segment tracheal stenosis. To compensate for the absence of supportive tissue, the reconstructive tissue has to be supported by a stent for a period of 4 weeks. A case with an airway stenosis with a length greater than 5 cm is presented. The vascularized mucosa allowed for primary healing of the augmented airway. The tracheostomy could be closed shortly after stent removal.
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Introduction
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Segmental tracheal resection with end-to-end anastomosis is the treatment of choice for stenosis encompassing less than 50% of the tracheal length [1]. A challenging situation, in which segmental resection is not possible, is a stenosis with a length greater than 5 cm. A long-segment stenosis resulting from ischemic scarring is resistant to laser treatment. As a temporary solution, a silicone stent may be used to bypass the stenosis. Although silicone stents are widely used, they have certain disadvantages that render them unsuitable for long-term use. Resolution after stenting is illusory and the stricture will recur after stent removal.
A radial forearm fascia flap lined with buccal mucosa and short-term stenting may be used to correct a long-segment stenosis.
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Technique
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A 60-year-old woman presented with a long-standing stenosis of the subglottic region and the cervical trachea after intubation. Several laser resections had not been successful. A Dumon (Novatech, Aubagne, France) silicone stent with a diameter of 12 mm and a length of 6 cm had been placed and had supported the airway for the last 2 years. Repeated bronchoscopic control and cleaning of the stent was necessary. Because of this and because she suffered from halitosis, she sought definitive treatment for her airway stenosis.
After obtaining informed consent, a tracheoplasty with a mucosa-lined fascia flap in combination with short-term stenting was performed. The subcutaneous tissue at the site of the radial forearm was grafted with two full-thickness mucosa grafts measuring 1.0 by 2.5 cm (Fig 1). The mucosa-lined fascia was fully dissected based on the radial vessels and transferred to the neck. It was sutured into the tracheal defect (Fig 2) and the radial blood vessels were sutured to the neck vessels (radial artery end-to-end to superior thyroid artery; radial vein end-to-side to internal jugular vein). A tracheostomy was sited below the reconstruction as a safety measure. The stent was removed by bronchoscopy 4 weeks after reconstruction, and the tracheostomy was closed a week later under local anesthesia. One year after reconstruction, the patient has a stable airway with good phonation and no stridor (Fig 3).
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Fig 1. Mucosa-lined fascia flap. A full-thickness mucosal graft measuring 1 x 2.5 cm is taken at the left and right buccal area and sutured (arrow) to the subcutaneous tissue of a radial forearm flap (Vicryl 5.0). A mucosa-lined area of 1 x 5 cm is obtained. After mucosal grafting, the fascia flap is dissected based on the radial artery and vein. The distal skin paddle (asterisk) will serve as a flap monitor. The donor defect can usually be closed without using a skin graft.
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Fig 2. Surgery for long-segment stenosis. (A) Stenosis located in subglottic area with extension into cervical trachea. Length of stenosis: 6 cm (A2) Dumon (Novatech, Aubagne, France) stent with diameter of 12 mm (A1, double arrow) and length of 6 cm has been placed. The stenosis is incised longitudinally (A1, double arrow) and expanded (A1, dotted arrow). (B) A Dumon stent with a diameter of 16 mm (B1, dotted arrow) and a length of 5 cm is inserted in the expanded airway (B2). The anterior defect is reconstructed with the mucosa-lined fascia. The stent supports the reconstruction. A tracheostomy is placed below the reconstruction. The distal skin flap is exteriorized and serves as a monitor for the viability of the flap. (C) Situation after stent removal and before closure of the tracheostomy (C2). The mucosa-lined forearm flap repairs the airway anteriorly.
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Fig 3. Computed tomographic scan of long-segment stenosis. (A) Coronal view before reconstruction. A Dumon stent (between white arrows) with a diameter of 12 mm and a length of 6 cm preserves the airway. The stenosis is incised longitudinally (double arrow). The axial computed tomographic (CT) scans B, C, D are taken at the same level (white line) before and after reconstruction. (B) Axial CT scan before reconstruction with the stent in place. (C) Axial CT scan after reconstruction with the stent in place. (D) Axial CT scan after reconstruction and after stent removal. Double arrow shows luminal concavity after excision and expansion of stenosis. Mucosa-lined fascia repairs the defect linearly. Asterisk indicates fascia flap.
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Comment
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In cases of long-segment stenosis, definitive treatment may be provided by incision, expansion, and introduction of reconstructive tissue. Optimal reconstructive tissue is difficult to find. It should resemble the native trachea and be composed of a cartilaginous framework lined with a vascularized ciliated epithelium. This optimal tissue is available in revascularized tracheal allografts, but tracheal transplantation is not feasible in the clinical situation. Pericardium [2] and costal cartilage [3] have been used as reconstructive tissue to resolve a long-segment stenosis. However, these tissues will heal by secondary intention because the epithelial lining and the blood supply are both lacking [2, 3]. In search of the optimal tracheal repair tissue, experiments in rabbits were performed. From these studies, it seemed that composite tissue consisting of vascularized mucosa and cartilage provided the best autologous tissue for airway repair [4]. However, with this choice of tissue, flap prefabrication for several weeks before the actual reconstruction would be necessary to allow for mucosal covering of the bare cartilage grafts.
The optimal autologous tissue that can be used in a single-stage procedure was provided by a mucosa-lined fascia flap. Vascularized buccal mucosa lends itself extremely well to the repair of an airway stenosis that is difficult to treat by conventional techniques. It is used in combination with short-term stenting to prevent re-collapse of the incised and expanded airway during healing. Wound healing with mucosa-lined fascia is comparable with the wound healing seen when using skin-lined flaps [5]. However, a mucosal lining is preferable for airway lining, because it prevents the crusting and desquamation seen when using skin grafts. Another advantage of the mucosa-lined fascia is that the donor defect at the forearm site can be closed primarily, resulting in a less visible scar compared with the defect after dissection of a fasciocutaneous flap.
The reliability of the mucosa-lined fascia flap in treating cases of re-stenosis after segmental resection was previously published [6]. This article shows the usefulness of the tissue in the definitive primary treatment of long-segment stenosis.
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References
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- Wright CD, Grillo HC, Wain JC, et al. Anastomotic complication after tracheal resection: prognostic factors and management J Thorac Cardiovasc Surg 2004;128:731-739.[Abstract/Free Full Text]
- Idriss FS, DeLeon SY, Ilbawi MN, Gerson CR, Tucker GF, Holiger L. Tracheoplasty with pericardial patch for extensive tracheal stenosis in infants and children J Thorac Cardiovasc Surg 1984;88:527-535.[Abstract]
- Jaquiss RD, Lusk RP, Spray TL, Huddleston CB. Repair of long-segment tracheal stenosis in infancy J Thorac Cardiovasc Surg 1995;110:1504-1511.[Abstract/Free Full Text]
- Delaere PR, Hardillo J, Hermans R, Van Den Hof B. Prefabrication of composite tissue for improved tracheal reconstruction Ann Otol Rhino Laryngol 2001;110:849-860.[Medline]
- Peirong Y, Clayman GL, Walsh GL. Human tracheal reconstruction with a composite radial forearm free flap and prosthesis Ann Thorac Surg 2006;81:714-716.[Abstract/Free Full Text]
- Delaere PR, Hierner R, Vranckx J, Hermans R. Tracheal stenosis treated with vascularized mucosa and short-term stenting Laryngoscope 2005;115:1132-1134.[Medline]
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Abstract
Introduction
