Ann Thorac Surg 2009;88:1032-1033. doi:10.1016/j.athoracsur.2008.11.027
© 2009 The Society of Thoracic Surgeons
How To Do It
A Simple Myocutaneous Flap for Short-Stump Mediastinal Tracheostomy
Ming-Ho Wu, MD, FCCP*
Division of Thoracic Surgery, Department of Surgery, Chia-Yi Christian Hospital, Chia-Yi City, Taiwan, Republic of China
Accepted for publication November 12, 2008.
* Address correspondence to Dr Ming-Ho Wu, 539 Jhongsiao Rd. Chia-Yi City, Taiwan, Republic of China (Email: m2201{at}mail.ncku.edu.tw).
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Abstract
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A long, U-shaped myocutaneous flap was designed to construct mediastinal tracheostomy in patients with a short tracheal stump. The technique was used in 1 patient who had tracheal carcinoma and whose tracheal stump was 1.5 cm and in 2 patients whose posterior part of the tracheal stump was 3 cm and 5 cm, respectively, and who had advanced cervicothoracic esophageal carcinoma. The flap provides a cosmetic effect and its construction saves time in the surgery of long-segment tracheal carcinomas and locally advanced cervicothoracic esophageal carcinomas.
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Introduction
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Several types of myocutaneous flaps have been used for mediastinal tracheostomy to reduce complications [1–5]. To reduce the operative morbidity and to save time, a simple myocutaneous flap was used in the surgery of 1 patient with carcinoma involving a long segment of the trachea and in the surgeries of 2 patients with carcinoma of the cervicothoracic esophagus with airway invasion.
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Technique
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Patient With a Long Segment Tracheal Carcinoma
A 44-year old woman had progressive dyspnea and hoarseness. The chest computed tomographic scan showed a 6.5-cm tracheal tumor, and biospy showed adenoid cystic carcinoma. A long, U-shaped myocutaneous flap containing the platysma, with the upper pedicle part at the neck and its tip extended 3.5 cm below the sternal notch, was made before partial resection of the clavicosternum (Fig 1). With this exposure, the whole trachea, including its tumor, can be easily palpated and dissected free from the adjacent structures. Total laryngectomy, with complete resection of the trachea, including the tumor and the esophageal muscle, invaded by the tumor and neck lymph nodes dissection were performed. The orifice of the left main bronchus was visible after these resections. A 5.5-mm, nonkinking, endotracheal tube was inserted into the left main bronchus for continuing general anesthesia. The tracheal stump was transposed to the right of the innominate artery (Fig 2). The tip of the myocutaneous flap was sutured to the posterior part of the tracheal end. A skin rotation flap of the anterior chest wall was made and was sutured to the anterior part of the tracheal end (Fig 3). The whole procedure was completed within 4 hours, and the patient was uneventfully discharged on postoperative day 10.
Patients With Locally Advanced Carcinoma of the Cervicothorax With Airway Invasion
There were 2 patients who had locally advanced squamous cancer of the cervicothorax with airway invasion. They had progressive dysphagia, dyspnea, and hoarseness. In patient 1 (a 75-year-old man), the esophageal cancer invaded 6 cm of the trachea. In patient 2 (a 45-year old man), the esophageal cancer invaded 8 cm of the trachea. Design of the myocutaneous flap was carried out as previously described. Laryngectomy, resection of the cervicothoracic trachea and esophagus, and neck lymph nodes dissection were performed. In patient 1, the tracheal remnant was 5 cm of the posterior part and 8 cm of the anterior part; in patient 2, the tracheal remnant was 3 cm of the posterior part and 5 cm of the anterior part. Transhital esophagectomy was done after laparotomy. Esophageal reconstruction was performed using the ascending and transverse colon in patient 1 and using the gastric tube in patient 2. The posterior part of the tracheal end was sutured to the flap and the anterior part of the tracheal end was sutured to the skin overlying the preserved sternum. The whole procedure was smoothly completed withing 7 hours and the 2 patients were discharged on postoperative days 15 and 25, respectively.
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Comment
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Apprximately 30% of the tracheal carcinomas can not be resected during diagnosis because of the tumor length or extension [6]. To complete resection of a long tracheal carcinoma, only a short thoracic trachea can be preserved. Hence, a majority of long tracheal carcinomas are considered to be unresectable in clinical practice. In the preserved thoracic trachea, the posterior wall is usually shorter than the anterior wall after ablation of esophageal carcinomas (Fig 4). Hence, it is possible to construct a short-stump mediastinal tracheostomy using a simple myocutaneous flap. The flap should be designed before surgery based on chest computed tomographic findings. If the anterior tracheal wall is preserved longer than the posterior part, mobilization of the skin of the anterior chest wall is not necessary. However, in patients who have tracheal carcinoma, and whose tracheal stump is 1.5 cm, a rotation skin flap of the anterior chest wall can be made to ensure nontension of tracheocutaneous anastomosis. In conclusion, a simple myocutaneous flap is designed to construct a short-stump mediastinal tracheostomy. The technique is suitable for a thoracic stump shorter than 5 cm (even for a stump that is 1.5-cm long). It can provide a cosmetic effect and its construction can save time in the surgery of long-segment tracheal carcinomas and locally advanced cervicothoracic esophageal carcinomas.
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Fig 4. The posterior tracheal wall is usually shorter than the anterior tracheal wall after ablation of the esophageal carcinoma.
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References
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- Kato H, Tachimori Y, Watanabe H, Nakatsuka T, Mashima K, Ebihara S, Harii K. Mediastinal tracheostomy during esophagectomy for cervicothoracic esophageal carcinoma invading the proximal trachea J Surg Oncol 1994;55:78-83.[Medline]
- Shinoda M, Takagi I. Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap Br J Plast Surg 1992;45:160-162.[Medline]
- Withers EH, Davis JL, Lynch JB. Anterior mediastinal tracheostomy with a pectoralis major musculocutaneous flap Plast Reconstr Surg 1981;67:381-385.[Medline]
- Kamikawa Y, Naomoto Y, Haisa M, Inoue F, Tanaka N. Mediastinal tracheostomy using a tubed pectoralis major myocutaneous flap for postoperative tracheal necrosis after cervical excision Eur J Surg 1998;164:467-469.[Medline]
- Wurtz AJ, Conti MM, Benhamed LM, Courtois-Purgass N, Porte HL. The pectoralis major myocutaneous flap in mediastinal tracheostomy reconstruction Ann Thorac Surg 2008;86:1058-1059.[Free Full Text]
- Gaissert HA, Grillo HC, Shadmehr MB, Wright CD, Gokhale M, Wain JC, Mathisen DJ. Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina Ann Thorac Surg 2004;78:1889-1896.[Abstract/Free Full Text]
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Abstract
Introduction
