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Correspondence

The Pectoralis Major Myocutaneous Flap in Mediastinal Tracheostomy Reconstruction

Clinique de Chirurgie Thoracique, Hôpital Calmette, CHU Lille, F 59037 Lille Cedex, France

(Email: awurtz{at}chru-lille.fr).

To the Editor:

We read with great interest the article by Abel Gómez-Caro and colleagues [1] regarding the anterior mediastinal tracheostomy (AMT) reconstruction. The authors performed an arterial replacement with cryopreserved allograft and used latissimus dorsi myocutaneous flap plus epiploplasty for AMT reconstruction after the resection of a stomal recurrence invading the innominate artery (IA).

Anterior mediastinal tracheostomy reconstruction is a major challenge. This procedure has been associated with high morbidity and mortality, owning particularly to IA rupture resulting from tracheal stoma separation, with exposure of the great vessels, mediastinal sepsis, pressure necrosis from the trachea to the IA, or a combination of these.

The key points to avoid these major complications are as follows:

1 reduce skin suture line tension of the stoma,

2 fill the dead space in the upper part of the mediastinum, and

3 avoid apposition of the trachea to the IA.

The pectoralis major myocutaneous island flap (PMF) was first used in 1980 for a reconstruction after resection for stomal recurrence by Biller and colleagues [2]. This confident flap is useful for AMT reconstruction because it provides bulky muscle to fill the dead space after resection, avoiding the need for epiploplasty, and it also creates an interposition between the trachea and the IA. Furthermore, it provides viable skin coverage, avoiding stomal separation or necrosis.

Finally, when the tracheal stump is too short to perform a stoma above the IA, relocation of the trachea behind the IA is undertaken to avoid ligation of this vessel.

Since 1985, we have performed 13 AMT reconstructions in cancer patients, including 6 patients previously reported [3]. Eight patients had received radiation therapy in the head and neck area. Six patients underwent cervical exenteration, with gastric pullup in 5 and colonic interposition in 1. Transposition of the trachea below the IA was performed in 9. PMF, including the entire pectoralis major muscle, was routinely used for AMT reconstruction. We experienced only one failure of the flap in a patient in whom the right PMF had been previously used in the head and neck area and who underwent ligation of the left innominate vein during the procedure. Venous congestion and then necrosis occurred in the left PMF, leading to stomal disruption, IA rupture, and death.

In the postoperative course, 7 patients received radiation therapy, without immediate and mid-term adverse effects, including 3 who underwent redo radiation therapy.

According to our experience, we agree with the unnecessary and potentially hazardous ligation of the IA and the usefulness of arterial reconstruction. On the other hand, we disagree with author's opinion about reduced healing capacity of the irradiated PMF. Indeed, the acromiopectoral blood supply and the skin paddle of the flap are out of the area during radiation therapy for head and neck malignancies.

Finally, like others [2] we suggest the PMF as a suitable technique in constructing an AMT. The latissimus dorsi myocutaneous flap, previously described in the AMT reconstruction [4], should be only used only when PMF is not available for this purpose.

	References

Top References

 

1. Gómez-Caro A, Gimferrer JM, Macchiarini P. Technique to avoid innominate artery ligation and perform an anterior mediastinal tracheostomy for residual trachea of less than 5 cm Ann Thorac Surg 2007;84:1777-1779.[Abstract/Free Full Text]
2. Biller H, Krespi YP, Lawson W, Baek SM. A one stage flap reconstruction following resection for stomal recurrence Otolaryngol Head Neck Surg 1980;88:357-360.[Medline]
3. Wurtz A, Darras J, Sobecki L, Maetz E, Quandalle P. Surgery for malignant lesions of the upper trachea. Report of a series of six cases of médiastinal tracheostomy. Ann Chir 1988;42:209-213.[Medline]
4. Shinoda M, Takagi I. Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap Br J Plast Surg 1992;45:160-162.[Medline]

This article has been cited by other articles:

				M.-H. Wu A Simple Myocutaneous Flap for Short-Stump Mediastinal Tracheostomy Ann. Thorac. Surg., September 1, 2009; 88(3): 1032 - 1033. [Abstract] [Full Text] [PDF]

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

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Alain J. Wurtz Massimo M. Conti Henri L. Porte Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wurtz, A. J. Articles by Porte, H. L. Search for Related Content PubMed PubMed Citation Articles by Wurtz, A. J. Articles by Porte, H. L. Related Collections Trachea and bronchi Related Article