Adult Chest Surgery

Chapter 57. Mediastinal Tracheostomy 

Despite progress in tracheal surgery over the past 60 years, to date, there is no suitable substitute for the trachea to bridge long gaps after resection. The adult trachea is usually approximately 9–13 cm long. Currently, approximately half of the adult trachea can be removed surgically and reanastomosed with various tracheal release and mobilization maneuvers. More extensive tracheal resections are limited by the lack of dependable and predictable replacements. This limitation is quite apparent by the occasional necessity of creating an anterior mediastinal tracheostomy (MT) in palliative, curative, or sometimes emergent or "bail out" procedures.

An anterior MT involves the construction of a tracheostomy stoma on the anterior chest wall using the intrathoracic trachea when there is insufficient length to reanastomose the remaining trachea or to bring the trachea out of the superior mediastinum for a standard suprasternal stoma. The procedure involves laryngectomy (if not done previously) and resection of the upper sternum, the medial third of the clavicles, and the first and usually second ribs. This provides access to the intrathoracic trachea with excellent exposure of the superior mediastinum and brings the chest wall down to the remaining shortened trachea to avoid tension on the stoma. The primary indications for this operation are mostly limited to advanced cervicothoracic neoplasms in the superior mediastinum, although it is done occasionally for benign disease. The indications for this procedure have become less common with the refinement of radiation therapy and tracheal surgery and are confined to very select clinical scenarios. Tumors in this location that are amenable to resection are quite rare.

Few thoracic surgeons or institutions have any extensive experience with this procedure. MT is a complex procedure that is performed in a difficult, unfamiliar anatomic location and is associated with very high morbidity and mortality. However, as described in multiple series in the literature, curative and palliative resections of advanced or recurrent carcinomas in this region can be accomplished with acceptable outcomes. Often the patient will experience a prolonged recovery with a high risk of associated serious complications. MT requires dedicated postoperative care delivered by experienced medical and nursing teams. With a successful outcome, however, the functional result is the equivalent of laryngectomy.1 When undertaking this radical procedure, one must show good clinical judgment in patient and case selection. Also, it is imperative to determine if the procedure is being done for cure or palliation because 1 or 2 cm of length can change the complexion of the procedure.

PATIENT CHARACTERISTICS, INDICATIONS, AND ONCOLOGIC PRINCIPLES

Patient Characteristics

Patients must be selected carefully, and the surgeon's preoperative preparation should be meticulous. The typical patient requiring an anterior MT usually is afflicted with an advanced cervicothoracic malignancy involving either the thyroid, larynx, pharynx, trachea, or esophagus that often invades adjacent structures (Fig. 57-1). It also can be a recurrent tumor at the site where trachea or larynx was resected previously, such as a recurrence at the site of the tracheal stoma.

Figure 57-1.

 

Anterior mediastinal anatomy. Note the relationship of the sternal angle of Louis to the carina and inferior trachea.

An important consideration is whether the patient will need to have restoration of alimentary continuity (Table 57-1) because this adds substantially to the duration, complexity, and stress of the operation. The general condition of the patient should be good enough to tolerate this radical procedure. A thorough history, physical examination, and clinical workup should focus on the following: preoperative nutritional status, weight loss, cardiac and respiratory function, smoking status, and a history of diabetes or steroid dependence. All these conditions should be optimized, and the patient should cease smoking several weeks before surgery. The patient also should undergo preoperative respiratory conditioning, including incentive spirometry and respiratory physical therapy. Other important details include a history of prior abdominal surgery (important to know in esophageal substitution), laryngectomy, tracheal resection, chemotherapy, and radiation therapy. A prior history of radiation therapy will make the neck structures, including the great vessels, more fixed. In addition, tracheal blood supply may be compromised, increasing the risk of ischemic breakdown and delayed healing. Finally, and perhaps most important, it is the surgeon's job to make sure that the patient is psychologically prepared for the morbidity of this procedure (including loss of speech) and a potentially long recovery.

Table 57-1. Surgical Considerations for Restoration of Alimentary Continuity

Procedure

Procedure-Specific Considerations

Complications

Mediastinal tracheostomy

·   Reduce tension intraoperatively with tracheal transposition or innominate artery division

·   Avoid circumferential dissection around stoma

 

·   Innominate artery rupture

·   Stomal disruption with mediastinitis

·   Stomal stenosis (treatment: place sanded end of a Hood silicone salivary tube)1

 

 

·   Careful dissection around left subclavian vein, and when dividing clavicle, first ribs

 

·   Chyle leak or arm swelling

 

 

·   Smoking cessation

·   Preoperative respiratory exercises

 

·   Poor respiratory dynamics—anterior flail chest or lung herniation2

 

Innominate artery division

·   Preoperative arteriogram

·   Intraoperative electroencephalogram

 

·   Stroke

 

Thyroidectomy

·   Postoperative thyroid function tests

·   Postoperative cancer monitoring and replacement

·   Consider partial thyroidectomy

·   Consider reimplantation of parathyroids

 

·   Hypothyroidism

·   Hypoparathyroidism

 

Cervical exenteration with colonic interposition or other esophageal substitute

·   Nasogastric tube

·   Postoperative barium swallow

 

·   Anastomotic leak

 

 

·   Preoperative visceral arteriogram

 

·   Ischemic colitis

 

 

·   Preoperative colonoscopy, barium enema

 

·   Colon cancer

 

 

Indications

MT, whether for palliation or for cure, is indicated after tracheal resection, laryngectomy, or laryngopharyngectomy in cases where there is insufficient length of intrathoracic trachea to either reanastomose it superiorly or bring it out suprasternally (Fig. 57-2). This determination depends on various factors, including the patient's anteroposterior diameter (one needs more length in a barrel chest), the effectiveness of tracheal mobilization, and the malleability of the remaining trachea. Some surgeons suggest that the optimal length for MT is greater than 5 cm from the carina.2 The procedure also may be indicated in some patients with a cervicothoracic malignancy and "impending airway obstruction." However, if the disease is unresectable or the patient has significant comorbidities, an airway stent may be more appropriate.

Figure 57-2.

 

Common indications for a mediastinal tracheostomy. A. Laryngeal carcinoma involving the trachea. B. Carcinoma involving the larynx, proximal trachea, and pharynx. C. Recurrence of carcinoma in a tracheostomy site.D. Thyroid carcinoma invading the proximal larynx and mediastinal trachea.

Oncologic Principles

Upper aerodigestive system malignancies severely affect quality of life, and careful consideration must be given not only to cure but also to palliation. The most important oncologic principle is to understand clearly if the goal is cure or palliation. One or two centimeters can change the approach to the procedure. That is, if palliation is the goal, clear margins are not critical, and the additional preserved length may facilitate the procedure. On the other hand, if the procedure is being performed for cure, one must not sacrifice oncologic margin for the sake of tracheal length. Most important, in either case, this procedure must be completed without tension on the anastomosis. Otherwise, neither palliation nor cure may be achieved. Instead, the patient will be at severe risk of complications such as innominate artery rupture or stomal breakdown with mediastinitis.

PREOPERATIVE ASSESSMENT

Preoperative bronchoscopy, esophagogastroduodenoscopy, CT, and MRI should be done to assess if the operation is technically possible. The surgeon should assess the length of tumor-free trachea distal to the lesion and the involvement of adjacent vital structures. A metastatic workup is necessary and may include a whole-body PET scan, bone scan, and head imaging. MT is not contraindicated in patients with metastatic disease if the goal is palliation. However, with metastatic disease, other therapies, such as airway stents or radiation therapy, may be considered. If there are plans to divide the innominate artery, a preoperative arteriogram assessing the patient's cranial perfusion is important. A visceral arteriogram also may be useful in evaluating the blood supply to the colon as an esophageal substitute. In this case, a barium enema and colonoscopy are recommended to assess the colon as an appropriate conduit. Finally, a bowel preparation should be performed if there is any possibility of esophageal substitution.

TECHNIQUE

The intraoperative preparation depends on the surgeon's technical preferences. For surgeons who consider dividing the innominate artery, arrangements may be made for intraoperative electroencephalography after the artery has been clamped. Arterial line monitoring, nasogastric tube drainage, a Foley catheter, and two large-bore peripheral intravenous lines are ideal. Jugular and subclavian lines may interfere with the operative field. Close coordination between the surgeon and anesthesiologist is required to safely obtain an airway prior to the surgery. Furthermore, after division of the trachea, it is ideal to have the appropriate tracheostomy available. The tracheostomy used for this procedure has a low-pressure, high-volume balloon with a short distance of tubing distal to that balloon.

Positioning, Incisions, and Tracheal Exposure

The patient is positioned supine with the head extended on a cushioned head support and the scapula on a folded blanket. One arm may be abducted for arterial or venous access. A left-sided radial arterial line is ideal if there is any chance of dividing the innominate artery. Sterile preparation may extend from the chin to the pubis and midaxillary line bilaterally. The abdomen is included if esophageal substitution or omental wrapping of the tracheostomy is planned. The thighs may be prepared as well for a potential split-thickness skin graft or vein graft.

The common incisions used for MT are the extended collar incision and the bipedicled/apron incision1,2 (Fig. 57-3). When the tracheostomy is being performed for a recurrence in the tracheostomy site, the peristomal skin must be resected and a rotational pectoralis flap is necessary (see Fig. 57-3C). The preferred incision is the extended collar incision. However, if there is any hint of tension at the tracheocutaneous anastomosis, we perform a rotational pectoralis flap and prepare the thigh for a split-thickness skin graft for the residual defect.

Figure 57-3.

 

Three commonly used incisions. A. Collar incision. B. Bipedicled (apron) incision. C. Pectoralis rotational flap often used for recurrence in a tracheostomy site.

The surgeon's first goal is to assess the appropriateness of the procedure before proceeding with potentially irrevocable actions such as resecting the breastplate. Occasionally, the surgeon may find either that the tumor is unresectable or that tracheal reanastomosis is possible with adequate mobilization.

Using the extended supraclavicular collar incision (see Fig. 57-3A), bilateral subcutaneous platysma flaps are created exposing the strap muscles superiorly. The carotid sheaths, sternum, and hyoid bone are exposed. The sternocleidomastoid muscles and carotid sheaths are displaced laterally. Unilateral vessel involvement by tumor is not a contraindication because they can be divided and reconstructed. The anterior trachea, posterior trachea, and prevertebral fascia are exposed while preserving the important lateral blood supply of the trachea. For tracheal tumors, the prevertebral space is bluntly dissected, ruling out invasion of the vertebral column and the pharynx superiorly. In general, invasion of the larynx and either the esophagus or the trachea within the thoracic inlet necessitates an MT to obtain adequate margins for cure.

Breastplate Resection

The inferior flap is developed after declaring the need for MT. The goal of this flap is to expose the breastplate, including the upper sternum, clavicle, and first two ribs (Fig. 57-4). The muscular insertions (i.e., straps and sternocleidomastoid) are divided to expose, the sternum, clavicle, and ribs. The decision to extend the resection down to the second rib depends on the level of anticipated tension on the tracheocutaneous anastomosis. If there is any doubt, the upper sternum and second rib should be resected.

Figure 57-4.

 

The breastplate is resected along with the first one or two ribs. Depending on the final tracheal length, sometimes only the clavicle, manubrium, and first rib are resected. However, it is more usual to include the second rib and the superior portion of the body of the sternum. In the technique shown here, both the manubrium and upper body of the sternum have been resected for better visualization.

First, the mammaries are protected and isolated by locating them at the level of the second rib. Next, the midline pectoralis fascia, from the sternal notch to the angle of Louis, is bisected with electrocautery. The pectoralis muscle then is elevated off the first two medial costochondral joints. The sternum is transected transversely just above the third rib. By elevating the sternum with bone hooks, underlying structures can be swept away. The pectoralis flap will be used to cover the wound defect later. The upper sternum and manubrium are bisected with the electric saw. The mammary and subclavian veins are swept clear, and the Gigli saw is used to encircle the first and second cartilages individually and to divide the medial thirds in a subperiosteal plane. Our technique for resecting the clavicle and first rib includes the precaution of sliding a ribbon between the Gigli saw and the subclavian vessels. The sawing sound changes if the "protective" ribbon is encroached. The free breastplate is removed.

Tracheal Division and Laryngectomy

After the breastplate has been removed, the surgeon prepares to divide the trachea. A complete node dissection appropriate to the tumor should be done. The innominate vein is preserved unless invaded directly. The level of tracheal division is determined by considering the margins and whether the goal of the particular surgery is palliative or curative. A Penrose drain may be passed behind the specimen portion of the trachea to facilitate further exposure (Fig. 57-5). Again, attention should be paid to preserving the lateral blood supply of the remaining trachea and stoma (Fig. 57-6, inset). Circumferential devascularization of the trachea (particularly within 1–2 cm of the transected edge) should be avoided to prevent peristomal breakdown and mediastinitis. Prior to division, stay sutures are placed at the inferior tracheal margin. The trachea is divided obliquely at the inferior margin. This facilitates the tracheocutaneous anastomosis such that it may curve anteriorly flush with the skin (see Fig. 57-5, inset). After division, it is reintubated (see Fig. 57-6) with sterile tubing across the field. The tracheostomy tube is secured with stay sutures to the trachea and to the skin. To preserve the airway, the inferior division is dealt with first. Next, the superior division usually is made at the level of the thyrohyoid membrane, preserving the hyoid bone. The larynx then is oversewn with running sutures. Total or partial thyroidectomy may be required depending on the extent of tumor involvement. All efforts should be made to preserve a parathyroid, with reimplantation if necessary. If there has been prior radiation, however, this may be difficult.

Figure 57-5.

 

The trachea and surrounding structures are exposed and divided. Reintubation immediately follows the distal division, and the proximal division occurs later. Note how the trachea is divided obliquely (inset). This leaves as much posterior membranous trachea as possible to reach the anterior chest wall surface.

 

Figure 57-6.

 

After the airway is divided, it is secured with an endotracheal tube. The surgeon bluntly develops the avascular plane posterior to the trachea and anterior to the esophagus. Note how deviation in either direction laterally threatens the blood supply to the mobilized trachea (inset).

Transposition of the Trachea

Tension on the trachea as it reaches the anterior chest wall and skin may result in complications, including peristomal breakdown leading to mediastinitis and even fatal postoperative innominate artery rupture. For this reason, if there is any doubt, we and other authors strongly recommend transposition.2,3 The standard MT will rest interposed between the innominate artery and the left carotid artery (Fig. 57-7). With transposition, the trachea will follow a shorter path to the skin by coursing to the right of and underneath the innominate artery. Thus its path lies between the innominate artery and the superior vena cava (Fig. 57-8). Although we do not recommend it, innominate artery division is another option for patients who can tolerate it (Fig. 57-9). This can be demonstrated with preoperative angiogram or even intraoperative electroencephalogram after clamping for 10 minutes. It may be best suited when the distance from the carina to the end of the remnant trachea is less than 5 cm.1 After transposition, we recommend wrapping the trachea as it passes underneath the artery with a well-vascularized strap muscle. Other options include omentum or pectoralis muscle. The most important factor, however, is that the trachea is well vascularized and reaches the skin without any tension. Wrapping the trachea will not prevent arterial rupture if there is significant tension.

Figure 57-7.

 

The normal position of a mediastinal tracheostomy.

 

Figure 57-8.

 

If the trachea does not appear to reach the new "depressed" chest wall, then either more sternal body may be resected, or the trachea may be transposed to the right of the innominate artery. The transposed trachea should be wrapped with viable tissue such as a strap muscle to help reduce the likelihood of innominate artery rupture.

 

Figure 57-9.

 

Other options to decrease tension include dividing the innominate vein or artery. Before dividing the innominate artery, it should be clamped and tested with electroencephalography.

Tracheocutaneous Anastomosis and Closure

The route of the trachea to the anterior skin must be secured, wrapped, and buttressed by all available tissue. With the exception of the specific strap muscle that protects the innominate artery (in tracheal transposition), all muscles should be reapproximated with interrupted absorbable sutures. As the cervical incision is sutured closed, the tracheocutaneous anastomosis is begun. It must be secured to the skin with full-thickness skin and subcutaneous purchases as well. This is done in interrupted fashion (Fig. 57-10). A few absorbable sutures may be placed from subcutaneous tissue to distal trachea to reduce the tension on the tracheocutaneous anastomosis.1 Drains are placed beneath the inferior and superior flaps and for any alimentary tract anastomoses. If there is a defect in the apron incision a split-thickness skin graft can be used for coverage (Fig. 57-11).

Figure 57-10.

 

In making the tracheocutaneous anastomosis, the trachea is secured to the inferior flap of skin with the endotracheal tube in place. To reduce tension, a rotational myocutaneous flap always can be created.

 

Figure 57-11.

 

Note the depressed chest wall in the closure of the collar incision (A) and in the apron incision (B). A skin graft can be used to cover the inferior defect in the apron incision.

 

At this point, if there appears to be any tension, there are several options. A button of skin can be excised below the transverse incision, and the trachea can be brought out through this new defect.2 In this scenario, we prefer to use the pectoralis rotational flap. Development of the pectoralis flap began when it was lifted off the chest wall before the breastplate resection. This thoracoacromial "nipple" flap (Fig. 57-12) can be done, even in patients without a tracheostomal recurrence.

Figure 57-12.

 

Rotational myocutaneous flap. This can be used to cover large defects (as in tracheostomal recurrence) or to reduce tension. The blood supply comes from the pectoral branch of the thoracoacromial artery. A skin graft covers the inferior defect (inset).

Rotational Flaps

A thoracoacromial flap is used most often in a patient with laryngeal cancer who suffers recurrence at the stoma site. In these patients, the surrounding skin is resected (see Fig. 57-3C). However, it also may be performed after a standard extended collar incision if there is tension at the end of the case. Simply extend the incision inferiorly along the sternum and around the inframammary crease (see Fig. 57-3C) to the preferred side. Both pectoralis muscles will have already been lifted off the chest wall in the prior dissection. The rotated muscle is based on the thoracoacromial vessels. A split-thickness skin graft can cover the remaining defect (see Fig. 57-12).

POSTOPERATIVE CARE, SPECIFIC COMPLICATIONS, AND RESULTS

As with any surgery, postoperative care is very important to a successful outcome. As a unique airway, this surgery requires special attention. ICU care is required for all of these patients at least until postoperative day 1 or 2. Many will be mechanically ventilated if they have undergone a more extensive procedure, such as esophagectomy or cervical exenteration. However, patients undergoing MT only will be weaned off mechanical ventilation early in the postoperative period. All should have continuous oxygen saturation monitoring. Some surgeons also recommend warm mist treatments through a tracheal collar to moisturize the tracheal mucosa.4Flexible endotracheal tubing (that extends from the tracheostomy) should be secured overhead with ties, not resting on the wound or skin graft. The tracheostomy tube is sutured to the end of the trachea at the time of distal tracheal division. The nursing staff must be familiarized with the location of the balloon just within the stoma, and balloon pressures should be monitored. Ideally, a low-pressure, high-volume balloon is used.

Postoperative studies include a chest x-ray to check nasogastric tube position and the tip of the short portion of tracheostomy tube. Functional nasogastric tube decompression is imperative, especially if the patient has had alimentary continuity restored. Aspiration of gastrointestinal contents can be devastating and is common with the unprotected trachea's new position relative to the mouth. Serial calcium determinations should be done in the case of parathyroidectomy.

There are various unique and not-so-unique complications with this procedure. Of course, the most devastating is innominate artery rupture. This must be treated with prevention. The importance of creating a tension-free path of trachea to skin via the innominate artery and aortic arch cannot be overemphasized. Another particular complication is the anterior flail segment (also referred to as lung herniation) from the breastplate resection.4For this reason, preoperative respiratory exercises and smoking cessation should be encouraged. Peristomal breakdown also can occur secondary to tension or paroxysmal coughing fits. Depending on adjunct procedures performed, other complications to watch for are hypoparathyroidism, hypothyroidism, perioperative stroke, anastomotic leak, cervical chyle leak, arm swelling (secondary to subclavian vein displacement), and dumping syndrome (secondary to vagus division in esophagectomy).

Perioperative morbidity and mortality are disease- and procedure-specific with regard to MT. In 1996, Orringer reported a 13% mortality in 45 patients. One death was due to innominate artery rupture. He also recorded a secure airway in 100% of patients.2 Orringer's patient population consisted of 35 patients who underwent MT with concomitant cervical exenteration and esophageal substitution. Grillo and colleagues reported one perioperative mortality in their series of 18 cervical exenterations with MT. This occurred secondary to ischemic necrosis of the stomach graft used to replace the esophagus.1 With regard to loss of speech, some of these patients may learn a form of "esophageal speech" or artificial speech with the latest electrical appliances.

SUMMARY

The MT is a radical procedure that must be performed judiciously. Although, airway security is achieved in almost every case, patients experience a high frequency of complications. Prevention of these complications, in particular, innominate artery rupture, can be achieved through different methods. Until a safe and reliable replacement for the trachea is found, this will continue to be a palliative, curative, and emergency lifesaving procedure.

EDITOR'S COMMENT

Careful preoperative imaging and multidisciplinary discussions among the thoracic surgeon, otolaryngologist, plastic surgeon, and vascular surgeon are helpful. On occasion, the omentum can be brought up substernally and used to cover the vessels and wrap the tracheostomy.

–RB

REFERENCES

1. Grillo HC, Mathisen DJ: Cervical exenteration. Ann Thorac Surg 49:401–8; discussion 408–9, 1990. 

2. Orringer MB: Anterior mediastinal tracheostomy. Chest Surg Clin North Am 6:701–24, 1996.[PubMed: 8934003]

3. Waddell WR, Cannon B: A technic for subtotal excision of the trachea and establishment of a sternal tracheostomy. Ann Surg 149:1–8, 1959.[PubMed: 13617903]

4. Nesbitt J, Wind G, Orringer M: Thoracic surgical oncology: Exposures and techniques. In Nesbitt JC, Wind GG (eds): Mediastinal Tracheostomy. Philadelphia, Lippincott Williams & Wilkins, 2003:237–52.



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