HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Abel Gómez-Caro Josep Maria Gimferrer Paolo Macchiarini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gómez-Caro, A. Articles by Macchiarini, P. Search for Related Content PubMed PubMed Citation Articles by Gómez-Caro, A. Articles by Macchiarini, P. Related Collections Trachea and bronchi

---

How To Do It

Technique to Avoid Innominate Artery Ligation and Perform an Anterior Mediastinal Tracheostomy for Residual Trachea of Less Than 5 cm

Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain

Accepted for publication August 1, 2007.

^_* Address correspondence to Dr Macchiarini, Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, 170 Villaroel, Barcelona E-30889, Spain (Email: pmacchiarini{at}ub.edu).

	Abstract

Top Abstract Introduction Technique Comment References

 
A 47-year-old man was admitted with recurrent autolimited bleeding arising from a cervical tracheostoma made 2 years earlier during a total laryngectomy. Stomal recurrence of the past laryngeal cancer invading the neighboring innominate artery was diagnosed by angiographic computer tomography and bronchoscopic biopsies. The malignant tracheostoma-innominate fistula was approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, and manubriectomy. It was treated with an anterior mediastinal tracheostomy with omental major transposition, right latissimus dorsi myocutaneous flap for tissue coverage, and brachiocephalic artery rerouting with cadaveric homograft. The patient was discharged on postoperative day 14 after an uneventful postoperative course.

	Introduction

Top Abstract Introduction Technique Comment References

 
Stomal recurrence after total laryngectomy occurs in about 5% to 15% of cases. Repetitive bleeding through the permanent tracheostoma usually reflects a tracheoinnominate fistulization [1]. This entity management represents a difficult challenge because of the vascular structures encompassing the upper aerodigestive system and destruction of surrounding previously irradiated tissues [2, 3]. However, selected patients can be managed successfully with an anterior mediastinal tracheostomy (AMT) with or without cervical exenteration. The innominate artery involvement can be solved by artery ligation [2, 4], redirection along another path, or endoluminal stents placement [5]. In addition, tissue coverage such as with the major omentum or myocutaneous flaps should be used to bury deep structures [2, 3] and to replace deteriorated skin and soft tissues [6]. However, the condition sine qua non is to have a length of residual trachea of at least 4 to 5 cm [2, 3].

We here present a technique to avoid innominate artery ligation and perform a safe AMT in patients whose residual intrathoracic trachea is less than 5 cm in length.

	Technique

Top Abstract Introduction Technique Comment References

 
The patient was placed supine with the neck hyperextend. The operative field extends from the chin to the pubis. Ventilation was assured by using an armored 8F cross-field tracheal cannula. A horizontal supraclavicular skin incision below the tracheostoma was performed to make the dissection of the previously irradiated structures belonging to the median thoracic outlet.

The manubrium, clavicles heads, and first and second ventral ribs were resected to facilitate the approach to the retrosternal diseased region and supraaortic vessels [2]. After systemic administration of 2500 U of heparin, the innominate vein was sectioned not only for a better control of the proximal innominate artery but also to visualize the tumor recurrence, which was located on the right lateral aspect of the tracheostoma and involved the innominate artery. Stepwise dissection revealed a tumor-free innominate artery at its distal bifurcation and a mediastinal extension of the tumor to involve the right lateral wall over 3 to 4 cm, leaving only 3 cm of healthy residual airway. Because of this, we decided to perform an AMT and to control the aortic arch by associating a median sternotomy.

The aortic arch was released carefully and the left carotid artery was taped and reflected to the left. The aortic arch was then clamped to include the takeoff of the innominate artery, followed by clamping of the right prescalenic subclavian and carotid arteries beyond the innominate artery bifurcation. The diseased innominate artery was en bloc resected, and its proximal stump sutured with a continuous 3-0 polypropylene suture (Fig 1).

View larger version (132K): [in this window] [in a new window]   Fig 1. Intraoperative view of the medial compartment of the thoracic aperture approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, manubriectomy, division of the innominate vein, and upper median sternotomy (MS). The damaged innominate artery has been resected, its proximal aortic takeoff sutured (arrow), and its distal stump clamped (*). Before performing the mediastinal neo-stoma and to avoid the risk of pressure necrosis, the omentum major was transposed and split to separate the aorta ascendens (AA) ventrally from the ventral bony structures of the sternum and dorsally from the neo-stoma. (LL = left lung; DOM = dorsal omentum major; VOM = ventral omentum major.)

Because the residual trachea was only 3 cm long, we decided to use a right myocutaneous latissimus dorsi flap to anchor the neo-stoma, thereby reducing its tension [7] while providing it with further indirect vascularization and protection (Fig 2). The thoracodorsal artery and vein were identified and skeletonized, and the pedicled flap was tunneled beneath the right major pectoralis to reach the anterior mediastinal defect. A circular stoma was created by excision of the skin, fat, and muscle, avoiding injury of the vessels on the deep surface of the flap. Interrupted 3-0 polyglactin sutures were first placed through the tracheal rim, and then brought through the opening stomal of the flap. The flap was folded down with the sutures tied sequentially to appose the skin to the residual trachea. Absorbable sutures were placed circumferentially, between 1 or 1.5 cm of the remaining trachea hedge and muscular flap tissue to reduce tension of the tracheocutaneous anastomosis.

View larger version (127K): [in this window] [in a new window]   Fig 2. Mediastinal tracheal neo-stoma created between the residual 3-cm-long trachea and a circular incision made on the middle of the transposed right latissimus dorsi (LD) myocutaneous flap. Care must be maximally addressed to create the flap large enough to be able to fold it down in the mediastinum and the close defect. (* = Left hemiclaviculectomy; MS = median sternotomy.)

	Comment

Top Abstract Introduction Technique Comment References

 
The surgical management described here presents several advantages compared with more conservative methods and appears to open the door to new considerations of the field of anterior mediastinal tracheostomy.

First, the use of cryopreserved arterial allografts may avoid the unnecessary ligation of the innominate artery, preventing any early or late neurologic affection [8]. Cryopreserved arterial allografts remain infection-free and do not need long-term anticoagulation therapy, which further increases their clinical application. Whether the allograft should be interposed between the residual distal innominate artery stump and the aortic arch or left carotid artery depends on the individual situation, although it would be reasonable to make an end-to-side interposition between the left carotid artery and distal innominate artery because this allows sufficient and safe distance from the neo-stoma.

Second, anchoring the new tracheostoma into the middle mediastinum by transposing a latissimus dorsi myocutaneous flap may extend the indication of ATM to include patients whose residual trachea is even less than 5 cm long [2, 3]. Moreover, the use of a remote transposed viable myocutaneous flap may provides the opportunity to (1) perform the new tracheostoma without tension, (2) avoid any pressure necrosis, and (3) encompass the neo-stoma with viable, not previously irradiated tissues. This is in contrast to Maigpan and colleagues [7] who proposed the pectoralis major flap; however, this muscle may be frequently irradiated and if so, would have reduced coverage and healing capacity.

In conclusion, the presented technique may represent a further evolution of the AMT described by Grillo [2, 4] and Orringer [3] because it avoids unnecessary ligation of the innominate artery and extends the indication to this surgery to include patients with less than 5 cm of residual trachea.

	References

Top Abstract Introduction Technique Comment References

 

1. Imauchi Y, Ito K, Takasago E, et al. Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx Otolaryngol Head Neck Surg 2002;126:63-66.[Medline]
2. Grillo HC, Mathisen DJ. Cervical exenteration Ann Thorac Surg 1990;49:401-408.[Abstract/Free Full Text]
3. Orringer MB. Anterior mediastinal tracheostomy with and without cervical exenteration Ann Thorac Surg 1992;54:628-636.[Abstract/Free Full Text]
4. Grillo HC. Repair of tracheobranchicephalic artery fistula Surgery of the trachea and bronchi. London, Ontario: BC Decker; 2003. pp. 581-586.
5. Guibaud JP, Laborde MN, Dubrez J, et al. Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea Ann Vasc Surg 2001;15:412-414.[Medline]
6. McCarthy CM, Kraus DH, Cordeiro PG. Tracheostomal and cervical esophageal reconstruction with combined deltopectoral flap and microvascular free jejunal transfer after central neck exenteration Plast Reconstr Surg 2005;115:1304-1310.[Medline]
7. Maipang T, Singha S, Panjapiyakul C, Totemchokchyakarn P. Mediastinal tracheostomy Am J Surg 1996;171:581-586.[Medline]
8. McCready RA, Bryant MA, Divelbiss JL, et al. Arterial infections in the new millenium: an old problem revisited Ann Vasc Surg 2006;20:590-595.[Medline]

This article has been cited by other articles:

				E. Martinod, J.-Y. Guillaume, D. M. Radu, and G. Despreaux A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea Interact CardioVasc Thorac Surg, May 1, 2011; 12(5): 672 - 675. [Abstract] [Full Text] [PDF]

				M. Conti, L. Benhamed, G. Mortuaire, D. Chevalier, C. Pincon, and A. Wurtz Indications and Results of Anterior Mediastinal Tracheostomy for Malignancies Ann. Thorac. Surg., May 1, 2010; 89(5): 1588 - 1595. [Abstract] [Full Text] [PDF]

				A. Gomez-Caro, E. Martinez, A. Rodriguez, D. Sanchez, J. Martorell, J. M. Gimferrer, A. Haverich, W. Harringer, J. L. Pomar, and P. Macchiarini Cryopreserved Arterial Allograft Reconstruction After Excision of Thoracic Malignancies Ann. Thorac. Surg., December 1, 2008; 86(6): 1753 - 1761. [Abstract] [Full Text] [PDF]

				A. Gomez-Caro and P. Macchiarini Reply Ann. Thorac. Surg., September 1, 2008; 86(3): 1059 - 1059. [Full Text] [PDF]

				A. J. Wurtz, M. M. Conti, L. M. Benhamed, N. Courtois-Purgass, and H. L. Porte The Pectoralis Major Myocutaneous Flap in Mediastinal Tracheostomy Reconstruction Ann. Thorac. Surg., September 1, 2008; 86(3): 1058 - 1059. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Abel Gómez-Caro Josep Maria Gimferrer Paolo Macchiarini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gómez-Caro, A. Articles by Macchiarini, P. Search for Related Content PubMed PubMed Citation Articles by Gómez-Caro, A. Articles by Macchiarini, P. Related Collections Trachea and bronchi