Ann Thorac Surg 2009;88:2042-2043. doi:10.1016/j.athoracsur.2008.11.035
© 2009 The Society of Thoracic Surgeons
How To Do It
Spiral Tracheoplasty After Tangential Resection of Trachea
Ming-Ho Wu, MD*
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 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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Spiral anastomosis was used in 1 patient with recurrent thyroid carcinoma and in another patient with secondary thyroid carcinoma, both involving the right posterolateral wall of the trachea, 3.5 cm and 4 cm, respectively. Before anastomosis was done, both tracheal ends were separated from the esophagus by 2 cm and were rotated by 90 degrees in opposite directions: one clockwise and the other counterclockwise. These 2 patients obtained good patency and received healing of the tracheal anastomosis. Spiral tracheoplasty can reduce the tension at the anastomotic site of the trachea after tangential wall resection.
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Introduction
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Carcinomas of the thyroid occasionally invade the trachea, and removal of the tumor often requires tracheoplasty [1]. Traditionally, this surgical management was associated with a high risk of tracheal dehiscence. Several types of tension release have been used for tracheal anastomosis to reduce complications [2]. Spiral anastomosis was used in one patient with recurrent thyroid carcinoma and in another patient with secondary thyroid carcinoma; both involved the right posterolateral wall of the trachea.
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Technique
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Spiral anastomosis of the trachea can be performed after resection of tangential tracheal lesions. Before the anastomosis is performed, both tracheal ends are separated from the esophagus by 2 cm and are rotated by 90 degrees in opposite directions: one clockwise and the other counter clockwise (Fig 1). The tracheal ends are trimmed if they have irregularities. The anastomosis described below was performed using running sutures with polydioxanone (PDS) II monofilament suture (Ethicon, Somerville, NJ).
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Fig 1. Spiral anastomosis of the trachea is performed after resection of a tangential tracheal lesion. The tracheal ends are rotated by 90 degrees in opposite directions: one clockwise and the other counterclockwise.
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Patient 1
Ten years ago, a 65-year-old woman underwent total thyroidectomy and adjuvant therapy using iodine-131. At admission, she had progressive dyspnea and hoarseness. A chest computed tomography (CT) scan showed a 3.5-cm tumor located at the right posterolateral wall of the trachea. The biopsy specimen showed recurrent thyroid papillary carcinoma.
General anesthesia was initiated and the patient was placed in the supine position. The noncircumferential tracheal lesion was resected. A negative malignant margin was confirmed by frozen section at surgery. Spiral tracheoplasty was performed. The patient was discharged uneventfully on postoperative day 11.
Patient 2
A 65-year old man had hoarseness. Panendoscopy revealed a 1.5-cm esophageal squamous cell carcinoma 35 cm away from the incisors. A chest CT scan showed a 4-cm right thyroid lesion invading the right posterolateral wall of the trachea. A specimen obtained by fine needle aspiration of the thyroid lesion was suspected as papillary carcinoma. He underwent total thyroidectomy, esophagectomy, and noncircumferential resection of the trachea. The reconstructive procedures included spiral tracheoplasty and esophageal reconstruction using a gastric tube. The final pathology was metastatic squamous cell carcinoma of the thyroid involving the trachea. The patient was discharged uneventfully on postoperative day 20 and is undergoing adjuvant chemoradiotherapy.
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Comment
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Techniques have been developed for tracheal operations that allow resection of approximately half of the adult trachea with primary reconstruction, largely by anatomic mobilization procedures [2]. The daunting problem of long congenital tracheal stenosis appears to be largely solved by slide tracheoplasty [3]. Surgical treatment is the first-choice therapeutic modality for primary tracheal cancer and thyroid cancer with airway invasion when prognosis is considered [4, 5]. When the operation is performed, safety of the anastomosis should take precedence over the completeness of the resection. Also, surgical margins from the tumor should be preserved for as large as possible when the submucosal spread of malignant cells is considered [5, 6].
The proper length that can be safely cut is currently controversial. It is important to reduce the tension at the anastomotic site to avoid postoperative leakage, which is almost always fatal. Spiral tracheoplasty can be applied after tangential tracheal wall excision instead of circumferential resection and end-to-end anastomosis. Actually, the resected tracheal length is nearly 50% of the tangential resection compared with the circumferential resection. Closer margins from the tumors are avoided in the noncircumferential resection of the trachea.
The tension created by twisting is acceptable after both tracheal ends are separated from the esophagus by 2 cm. Good viability of the tracheal end was observed after release of the distal trachea. Laryngeal release or other types of release of the proximal trachea is unnecessary. The proximal end, which is fixed closer to the larynx, and the distal end, which is fixed closer to the carina, might be more difficult to twist. In conclusion, spiral tracheoplasty is suitable in the surgery of tangential lesions of the cervicothoracic trachea.
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References
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- Tsai YF, Tseng YL, Wu MH, Hung CJ, Lai WW, Lin MY. Aggressive resection of the airway invaded by thyroid carcinoma Br J Surg 2005;92:1382-1387.[Medline]
- Grillo HC. The history of tracheal surgery Chest Surg Clin N Am 2003;13:175-189.[Medline]
- Beierlein W, Elliott MJ. Variations in the technique of slide tracheoplasty to repair complex forms of long-segment congenital tracheal stenoses Ann Thorac Surg 2006;82:1540-1542.[Abstract/Free Full Text]
- Teng MS, Malkin BD, Urken ML. Prefabricated composite free flaps for tracheal reconstruction: a new technique Ann Otol Rhinol Laryngol 2005;114:822-826.[Medline]
- Watanabe S, Takagi K, Nakamura Y, Sakata R. Tracheal release and thymus wrapping of the tracheoplasty anastomosis through mini-sternotomy Eur J Cardiothorac Surg 2004;25:287-289.[Abstract/Free Full Text]
- Yoshimura Y, Nakajima T. Tracheoplasty with palatal mucoperiosteal graft Plast Reconstr Surg 1990;86:558-562.[Medline]
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Abstract
Introduction
