Ann Thorac Surg 2009;87:608-610. doi:10.1016/j.athoracsur.2008.06.062
© 2009 The Society of Thoracic Surgeons
Case Reports
Tracheal Reconstruction With the Use of Radial Forearm Free Flap Combined With Biodegradative Mesh Suspension
Adam Maciejewski, MD, PhD*,
Cezary Szymczyk, MD,
Stanis
aw Pótorak, MD,
Maciej Grajek, MD
Department of Oncologic and Reconstructive Surgery, Centre of Oncology, M. Skodowska-Curie Memorial Institute, Branch Gliwice, Gliwice, Poland
Accepted for publication June 19, 2008.
* Address correspondence to Dr Maciejewski, Department of Oncologic Surgery, Centre of Oncology, Wybrze
e Armii Krajowej 15, Gliwice, 44-101, Poland (Email: adammac{at}o2.pl).
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Abstract
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The main aim of tracheal restoration is to provide a noncollapsible construction with a functional epithelial lining and well-vascularized coverage. The authors present the case of a successful tracheal reconstruction in a patient with recurrent thyroid gland cancer infiltrating the trachea. The free radial forearm flap was formed as a tube and suspended to the mesh rings placed outside. Currently the patient has no problems with breathing.
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Introduction
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Trachea reconstruction is a real challenge due to the need for rigidity, maintenance of an open lumen, and of epithelialization. The reconstructive method depends mainly on the length of trachea to be resected. For a short postressective defect (1 to 2 rings), it is possible to close it primarily. For limited resections, the larynx can be released by a procedure known as suprahyoid release, bringing the cricoid cartilage close to the stump of the trachea. This technique with neck flexion will permit a drop of the larynx by up to 4 cm. In addition, airway mobilization and hilar release may provide another 1.5 cm of tracheal length. However, anastomotic complications and the risk of death increase exponentially with the increasing length of the defect. Defects longer than 6 cm cannot be reconstructed with locoregional methods. In the past, reconstruction of large tracheal defects has mostly been unsuccessful. The authors present the case of a successful tracheal reconstruction in a patient with recurrent thyroid gland cancer infiltrating the trachea.
A 34-year-old man was referred to the Cancer Center in Gliwice with recurrent papillary thyroid cancer. Initially, 1 year before, the patient underwent subtotal thyroidectomy in one General Surgery Department in Poland complicated by bilateral vocal cord palsy requiring a permanent tracheostomy. On physical examination, a 5-cm mass fixed to the trachea and bilateral enlarged lymph nodes were evident. Computed tomographic scans showed a recurrent tumor with destruction of tracheal rings and confirmed large neck nodes on both sides of the neck. At operation, the tracheal recurrence and bilateral lymph nodes were removed. Multiple frozen sections proved that the resection margins were clear. The total length of the tracheal defect was 7 cm (Fig 1). For the reconstruction, a left radial forearm flap (11 x 8 cm) was designed for the neotracheal lining and harvested with a small (3 x 2 cm) additional monitor skin island (Fig 2). Then the mesh was cut into four strips (0.5 x 10 cm each), and the strips put into hot water to soften. The softened stripes allowed the creation of circles with a diameter of 3 cm. The radial forearm flap was formed as a tube and suspended to the mesh rings placed outside with multiple 4.0 sutures. This procedure allowed the tube to be constructed with skin lining inside and a rigid support outside (Fig 3). Then the complex was transferred to the defect and revascularized with micro-anastomoses between the radial and right facial vessels. The internal lining of the radial tube was sutured to the cricoids cartilage above and the remaining cervical trachea below (Fig 4). A temporary tracheostomy was placed below the neotrachea. The monitor skin island was sutured to the edge of the skin wound. No postoperative complications were observed. The patient was discharged on postoperative day 6. Four weeks later, the CO2 laser evaporation of vocal cords was performed, and an intraluminal stent was placed inside the neotrachea (Fig 5). The stent was introduced temporarily for a period of approximately 1 year to protect the formation of the neotrachea. Four weeks later, a bronchoscopy revealed a well healed flap with almost no paradoxical movement into the lumen. The entire airway appeared clean, with no evidence of mucus accumulation or debris secretion. The only problem was hair growing from the skin island, which was removed. Eventually the tracheostomy was removed. The patient currently has no problems with respiration, continues to tolerate a regular diet, and maintains a voice quality that he has not had for 2 years. The control computed tomography did not show any evidence of local recurrence or distal metastases.
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Fig 3. (Top) Biodegradative mesh before cutting into rings. (Bottom) Radial forearm flap formed as a tube with biodegradative rings suspension.
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Fig 4. (Left) Insetting the complex flap-biosupport for trachea restoration. (Right) The complex after insetting.
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Comment
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Airway invasion by thyroid cancer is not common, but an important clinical problem. The standardization of airway resection and reconstruction can make en block surgery radical and curative. Resection and restoration of middle tracheal defects of up to 4 cm are usually reconstructed by primary suture with neck flexion, laryngeal, and hilar release. Extended tracheal resection of more than 4 cm is most often replaced with prosthetic materials or autogenous tissues. Various types of artificial trachea have been used with little success. Although most organs are successfully transplanted, the trachea remains an exception. Tracheal replacements with allografts have not given satisfactory results [1].
Walles and colleagues [2] presented a very promising study of experimental generation of a functional tissue engineered and vascularized trachea. He demonstrated that the fundamental elements of a bio-artificial trachea were successfully engineered in vitro in a vascularized bio-artificial matrix. He concluded that this study is far from clinical application and needs further experimental work.
In last few years, the use of free flaps combined with artificial materials represents a promising technique that might be able to create a functional tracheal substitute. To restore the upper airway, the skin island of the flap used for tracheal lining must be supported by rigid material placed outside the lumen. In Yu's [3] opinion Gore-Tex grafts (W. L. Gore & Associates Inc, Flagstaff, AZ), as well as PolyMax resorbable mesh (Synthes, Oberdorf, Switzerland), were found to be an adequate material providing rigidity, flexibility, and longitudinal elasticity. In the presented case, the authors used four separate rings of resorbable mesh to support the tube of radial skin island from the outside. The biodegradable mesh is a plastic-like perforated glucose polymer easily formable at a temperature of 70°C hot water (Fig 4) that molds within a few seconds in contact with air, and it lasts for 18 to 24 months before resorption. This procedure created a noncollapsable construction. Postoperative scarring would maintain the rigidity once the mesh resorbs. The flap was not lined with mucosa, because based on previous experience with radial forearm free flap in oropharynx reconstruction, the skin island has a great potential to adapt to new conditions. Currently the skin looks like a mucosa, and the hair removed during tracheoscopy (performed every month) has almost perished. Due to the fact that during primary treatment, both laryngeal recurrent nerves were paralyzed, the patient underwent endoscopic vocal cords evaporation, followed by internal stenting 4 weeks later.
The endoluminal stent had to protect the tube from the inside during the long-term healing process. As an edema usually occurs after surgery, the stent was incorporated after 4 weeks. The stent did not cross any of the anastomoses between the larynx, neotrachea, and trachea, and after 6 months it was removed.
With this single-stage reconstruction, no laryngeal or hilar release was necessary and the patient returned to normal, physiological activity. Despite the lack of vocal cords, the patient has no problems with aspiration.
In conclusion, this report demonstrates that the combination of a thin and pliable skin flap, such as a radial forearm, combined with adequate artificial support, like biodegradable rings, led to a complete regeneration of a tracheal structure with a satisfactory functional outcome.
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References
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- Martinod E, Seguin A, Holder-Espinasse M, et al. Tracheal regeneration following tracheal replacement with an allogenic aorta Ann Thorac Surg 2005;79:942-949.[Abstract/Free Full Text]
- Walles T, Giere B, Hofmann M, et al. Experimental generation of a tissue-engineered functional and vascularized trachea J Thor Cardiovasc Surg 2004;6:900-906.
- Yu P, 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]
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Abstract
Introduction
