Ann Thorac Surg 2009;88:288-291. doi:10.1016/j.athoracsur.2008.11.030
© 2009 The Society of Thoracic Surgeons
Case Reports
Novel Method to Repair Tracheal Defect by Pectoralis Major Myocutaneous Flap
Jianxing He, MD, PhD, FACSa,b,*,
Xin Xu, MDa,b,
Manyin Chen, MDb,c,
Shuben Li, MDa,b,
Weiqiang Yin, MDa,b,
Susheng Wang, MDd,
Yingying Gu, MDb,e
a Division of Cardiothoracic Surgery, First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China
b Guangzhou Research Institute of Respiratory Disease, Guangzhou, China State Key Laboratory of Respiratory Disease, Guangzhou, China
c Toronto General Hospital Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
d Division of Plastic Surgery, Guangzhou, Guangdong, China
e Division of Pathology, First Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong, China
Accepted for publication November 12, 2008.
* Address correspondence to Dr He, 151 Yuanjiang Rd. Guangzhou, Guangdong, 510120, China (Email: jianxing{at}gird.cn).
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Abstract
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Inflammatory myofibroblastic tumor is extremely uncommon in the trachea. Surgery is recommended when airway obstruction becomes evident. The surgical technique and material used for repairing a massive tracheal defeat is a challenge for the thoracic surgeon. We present a case of repair and reconstruction of a massive defect of the thoracic trachea and right mainstem bronchus with a pectoralis major myocutaneous flap after resection of an inflammatory myofibroblastic tumor. The myocutaneous flap provides reliable material to repair and reconstruct a massive central airway defect. This novel surgical procedure may present new strategies for the treatment of extensive defects of the trachea.
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Introduction
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The reconstruction of massive tracheal defect after tumor resection remains a challenge in thoracic surgery. Although primary end-to-end anastomosis has been reported to allow for successful resection of adult trachea up to nearly half of its length [1], more extensive removal of the tracheal segment usually requires use of artificial materials or autogenous tissues for repair of the resulting defect. We presented a case in which reconstruction of a massive airway defect was performed with the pectoralis major myocutaneous flap after resection of a large inflammatory myofibroblastic tumor.
A 28-year-old woman presented with shortness of breath on exertion over the course of more than 1 year. Before her admission to our institution (Guangzhou Institute of Respiratory Diseases) on November 12, 2007, she had been diagnosed with asthma and treated as such, but her dyspneic symptom worsened and gradually became prominent even when at rest. A pre-hospital computed tomographic (CT) study suggested that this patient had an "upper mediastinal tumor." For re-evaluation, she underwent another CT scan on admission (Fig 1), which showed a soft tissue silhouette (approximately 6.7 cm in length) that originated from just below the sternal notch level and extended along the inner coating of lateral right tracheal wall toward the right mainstem bronchus. The azygos vein appeared slightly deformed because of compression from the soft tissue mass. There were no visible infiltrates in either of the lungs. Based on these findings, primary tracheocarcinoma or tracheal lymph node metastasis from a distant malignancy was suspected.
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Fig 1. Preoperative computed tomographic scan and flexible bronchoscopy: the tumor was 55 mm in the trachea and 12 mm in the right main bronchus. The total length from the sternal notch to the right main bronchus was 67 mm. (a) Reconstructed CT scan of the mass in coronal section; (b) CT scan of the mass in transverse section; (c) Preoperative flexible bronchoscopy. (Arrow shows tumor.)
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A flexible bronchoscopy (Fig 1) revealed edematous bulging of mucosa over the right middle and lower parts of the tracheal wall with a mass protruding from under the mucosa into the lumen. The mass protruded the most at 3 to 4 cm above the carina and passed downward to approach the right main bronchial orifice. Endoluminal biopsy and cytologic brushings were performed, which noted chronic inflammation of the tracheal mucosa. No evidence of a tumor or tuberculosis was detected.
Because chronic inflammatory tracheal mucosa as the pathologic outcome did not correlate with clinical symptoms for a definitive diagnosis, the mass was consequently biopsied by needle thoracoscopy with the patient placed under general anesthesia. Histology revealed a neoplastic proliferation of fusiform cells with pleomorphism and infiltrating lymphocytes embedded in a collagenous stroma. Immunohistochemistry revealed strong expression of vimentin, smooth muscle actin, and s-100 protein, as well as formation of actin foci. These features were typical of inflammatory myofibroblastic tumor, leading to a pathologic diagnosis as such. On December 18, 2007, the patient received a right thoracotomy performed through the fourth intercostal space. The mass was found adhering to, but not substantially invading the superior vena cava, ascending aorta, and esophagus, with its center at 3 to 5 cm above the carina. The azygos vein was ligated and divided to expose the trachea. Then the trachea and mass were dissected from the esophagus and superior vena cava, and together with the right mainstem bronchus they were mobilized from the mediastinum. The length of the mass was 6.5 cm along its longitudinal axis, and its widest part occupied approximately one half the circumference of the lateral trachea wall. Enbloc removal of the tumor and adjacent airway tissue were performed, leaving a large defect in the lateral parts of the trachea (approximately one half) and the right mainstem bronchus. The resulting long and ovoid defect measured 8.5 x 3.9 cm in size. The surgical margins were found to be pathologically negative by frozen sections.
A pectoralis major myocutaneous flap measuring 11 x 5 cm in size was preoperatively planned. We carefully created the flap by blunt dissection to prevent injury to its blood supply, the lateral thoracic artery, which had been identified and marked using Doppler ultrasound in advance. The flap was tailored off epidermis at the edges to make it suitable for anastomosis. Approximately 4 cm of the right second rib was removed to create a working space through which the flap was introduced into the thoracic cavity. A suture was placed on the trachea above the defect and the trachea was retracted into the surgical field for adequate visualization. Using a continuous 4-0 Prolene suture (Ethicon, Somerville, NJ), the long ovoid flap was anastomosed to airway defect, with its cutaneous surface positioned to cover the tracheal and bronchial lumens and the dermis layer sutured to the membranous and cartilaginous portions (Fig 2).
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Fig 2. Resection of the lesion and repair of the defect. (a) Sketch map. (b) Resection of lesions. (c) The resulting defect on the bronchus and trachea. (d) Continuous sutured trachea and pectoralis major myocutaneous flap. (A = removed trachea tumor; B = open lumen of trachea; C = endotracheal tube; D = continuous suture with 4-0 Prolene [Ethicon, Somerville, NJ].)
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A steel wire was inserted into the dermis layer to create a circular steel ring (2.5 cm in diameter) at 3 cm above the carina to support the flap. A right upper lobectomy was also performed to prevent the right upper lobe compromising the flap or the flap caused atelectasis of the right upper lobe.
The patient was mechanically ventilated after operation until weaning off on day 8. Before and after her extubation on day 14, a CT scan showed that the flap was free of support by the endotracheal intubation and there was no collapse of the airway.
The patient was discharged home on day 35 after surgery; she did not ever complain of difficulty breathing thereafter. Approximately 2 months later, flexible bronchoscopy revealed a healthy flap with normal-looking granulation tissue along the boundaries of anastomosis. The airway lumen was not narrowed (Fig 3); this was further confirmed by a follow-up CT study on postoperative day 180 (Fig 3).
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Fig 3. Postoperative computed tomographic (CT) scan and flexible bronchoscopy: (a) CT scan on postoperative day 180. (b) Flexible bronchoscopy on postoperative day 100. (A = trachea; B = shrunk granulation tissue; C = skin of pectoralis major muscle flap; D = carina; arrow = steel wire ring.)
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Comment
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According to the World Health Organization (WHO) classification [2], an inflammatory myofibroblastic tumor is a neoplasm with a tendency for local recurrence and a very low rate of metastasis. Given no proven benefits provided by chemotherapy and radiotherapy [3], surgical resection remains critical for treatment of this disease.
Ideally, surgical resolution for tracheal tumors is to perform a radical resection followed by an end-to-end anastomosis. Although end-to-end anastomosis of the intrathoracic airways has been demonstrated by excellent results in experienced hands, the length of resection remains a major predictor of mortality and morbidity from tracheal operations. Typically, a resection length of less than 4 to 5 mm is considered safe [4]. However, in this case, the tracheal defect was 8.5 cm in length, extending from the suprasternal notch to the right mainstem bronchus, and involving nearly one half of the tracheal circumference. These factors added to the difficulty and complexity of the circumferential resection and end-to-end anastomosis.
Alternatively, autologous substitutes, such as muscle flaps and pedicled myocutaneous flaps have been used in a wide range of tracheal surgeries due to favorable mechanical strength and versatility. In particular, pedicled myocutaneous flaps have been shown to provide more rigidity, flexibility, air-tightness, and reliable healing.
Considerable rigidity of a myocutaneous flap allows for its capacity to stand against pressure differences across the pleural cavity and the trachea. In this patient, we also used a circular steel ring inside the middle area of the flap as an enhancing architecture. A similar technique has been described by Antoine and colleagues [5] who embedded a segmented rib into the muscle flap for mechanical support. However, the intended benefit from a rib implant can be compromised with extensive graft calcification, as well as ossification of the bone marrow, which has been reported to result in airway stenosis [6, 7]. Another noteworthy advantage of a myocutaneous flap over a "pure" muscle flap in repairing massive tracheal defect is the reduced endotracheal secretions after surgery. Closure of a tracheal defect with the skin-covered surface of a myocutaneous flap facing lumen space would perceivably minimize the secretory actions as seen with a muscle flap, and in turn, reduce the risks of pulmonary complications, such as pneumonia and atelectasis.
As a safety precaution, the patient was kept intubated for 2 weeks postoperatively. First, this would help with the recovery from the surgical trauma. Second, the balloon cuff could prevent sputum from reaching the anastomosis area, potentially reducing the risk of infection.
Postoperative CT reconstruction images were helpful to assess the growth of the flap and the possibility of airway collapse. In addition, maintaining adequate nutritional support, monitoring serum albumin level, and regular clearance of airway secretions to prevent infections were also part of our postoperative management.
In conclusion, pectoralis major myocutaneous flap can be a safe and reliable material to repair massive defects of the central airway. The techniques presented in this case may lead to a novel surgical procedure for similar conditions, although further study is warranted to verify the clinical benefits.
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References
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- Grillo HC, Dignan EF, Miura T. Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft: an anatomical study in man J Thorac Cardiovasc Surg 1964;48:741-749.[Medline]
- World Health Organization Classification of TumorsCoffin CM, Fletcher JA. Inflammatory myofibroblastic tumourIn: Fletcher CDM, Unni KK, Mertens F, editors. Pathology and genetics of tumors of soft tissue and bone. Lyon: IARC Press; 2002. pp. 9193.
- Hagenstad CT, Kilpatrick SE, Pettenati MJ, et al. Inflammatory myofibroblastic tumor with bone marrow involvement. a case report and review of the literature. Arch Pathol Lab Med 2003;127:865-877.[Medline]
- Grillo HC. Surgery of the tracheaIn: Ravitch MM, editor. Current problem in surgery. Chicago: Yearbook Medical Publishers; 1970.
- Meyer AJH, Krueger T, Lepori D, et al. Closure of large intrathoracic airway defects using extrathoracic muscle flaps Ann Thorac Surg 2004;77:397-404.[Abstract/Free Full Text]
- Deeb ME, Sterman DH, Shrager JB, Kaiser LR. Bronchial anastomotic stricture caused by ossification of an intercostal muscle flap Ann Thorac Surg 2001;71:1700-1702.[Abstract/Free Full Text]
- Prommegger R, Salzer GM. Heterotopic ossification in pedicled intercostal muscle flaps causing clinical problems J Thorac Cardiovasc Surg 1998;115:466-467.[Free Full Text]
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Abstract
Introduction
