Asian Cardiovasc Thorac Ann 2006;14:66-68
© 2006 Asia Publishing EXchange Ltd
Wide Sleeve Resection of Lower Trachea Through Anterior Approach With Omentopexy
Ichiro Yoshino, MD,
Masafumi Yamaguchi, MD,
Yoshihiro Kakeji, MD,
Yukito Ichinose, MD1,
Yoshihiko Maehara, MD
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University
1 Department of Thoracic Oncology, National Kyushu Cancer Center, Fukuoka, Japan
For reprint information contact: Ichiro Yoshino, FACS Tel: 81 92 642 5462 Fax: 81 92 642 5482 Email: iyoshino{at}surg2.med.kyushu-u.ac.jp, Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan.
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ABSTRACT
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A 61-year-old man with tracheal adenoid cystic carcinoma (case 1) and a 28-year-old woman with benign tracheal stenosis (case 2) were treated with sleeve resection of the lower trachea through a median sternotomy and prophylactic omental wrapping. The resected tracheas were 4.5 cm (case 1) and 4.0 cm (case 2) in length. Both patients had an uneventful course after surgery despite postoperative irradiation in case 1 and preoperative infection with methicillin-resistant Staphylococcus aureus in case 2.
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INTRODUCTION
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Tracheal resection and end-to-end anastomosis in lengths of more than 2 cm usually requires anatomic mobilization to decrease tension on the anastomosis. Several mobilization techniques enable primary suturing after resection of more than half of the trachea; however, it is essential that lateral and posterior dissection of the trachea be avoided to maintain an adequate blood supply.1–3 We describe successful treatment of 2 cases by tracheal sleeve resection with extensive dissection of the thoracic trachea and bilateral main bronchus through a median sternotomy and prophylactic omental wrapping.
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CASE REPORTS
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CASE 1
A 61-year-old man presented with hoarseness and wheezing. A chest computed tomography scan showed a tracheal mass measuring approximately 4 cm in length, 4 cm above the carina. Aspiration cytology under bronchofiberscopy revealed adenoid cystic carcinoma. Tracheal sleeve resection was carried out via an anterior approach as a left-sided dissection would have been difficult, and omentopexy was easily performed in this position. Anastomosis was undertaken in an end-to-end fashion (Figure 1A
) with 30 interrupted sutures of 4/0 polydioxanone (PDS-II; Johnson and Johnson, Tokyo, Japan). Subsequently, the median wound was extended to the upper abdomen, and a laparotomy was performed. An omental flap pedicled with the right gastroepiploic vessels was mobilized to surround the tracheal anastomosis below the innominate vessels. The omental flap was placed between the tracheal anastomosis and the innominate vessels (Figure 1B). The length of the resected trachea was approximately 4.5 cm (9 cartilage rings). The left recurrent nerve was sacrificed because of tumor involvement. Extensive lymph node dissection was performed in the upper mediastinum because paratracheal lymph node metastasis was detected. The operative period was 7.5 hours, and the estimated blood loss was 270 g. During the first week postoperatively, the patient’s neck was restricted to 30 degrees of flexion by sutures between the jaw and the anterior chest. There was no adverse event after the operation. Tumor cells were detected on pathologic examination of the bronchial stump; irradiation with a total of 50 grays was applied in the 4 week period after surgery. The disease has been in remission for 7 years.
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Figure 1. Tracheal resection and reconstruction in case 1. (A) The tracheal anastomosis. (B) Omentopexy around the anastomosis.
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CASE 2
A 28-year-old woman with herpes encephalitis was ventilated for 3 months. On removal of the endotracheal tube, she complained of dyspnea with stridor. Bronchofiberscopy revealed tracheal stenosis, possibly due to pressure injury caused by the cuff of the endotracheal tube. An endotracheal T-tube was inserted through a cervical tracheostomy. Although laser ablation of endotracheal granulomatous tissue was performed three times, stenosis recurred each time, and the patient was referred for surgical treatment. Three-dimensional computed tomography showed stenosis of the lower trachea from 2 cm above the carina over a length of approximately 3.5 cm (Figure 2A). At bronchofiberscopy, granulomatous tissue was observed at the periphery of the T-tube. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the patient’s sputum. Preoperative infusion of several antibiotics showing sensitivity failed to control the MRSA infection. The patient underwent a tracheal sleeve resection in almost the same manner as case 1. It was considered that omentopexy was required following resection of a medium length of the trachea because of the high risk of anastomotic failure due to the MRSA infection. The median sternotomy approach was selected because omentopexy was easily performed in this position, and a cervical tracheal stoma could be established easily if necessary. The operative period was 8.75 hours, and the estimated blood loss was 560 g. The length of trachea resected was 4.0 cm. Vancomycin was infused for a week, and a sputum bacteriological examination became negative for MRSA on the 7th postoperative day. Bronchofiberscopy and 3-dimensional computed tomography revealed that the anastomosis was clear, and it remained fully patent at 3 months after surgery (Figures 2B and 2C). The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day. The cervical stoma was closed 3 months later.
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Figure 2. Pre- and postoperative imaging of case 2. (A) Preoperative findings of 3-dimensional computed tomography: the patency of the lower trachea was maintained by a 3.5 cm length of T-tube. (B) Postoperative findings of 3-dimensional computed tomography: no stenosis was found in the trachea 3 months after surgery.
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Figure 2. (C) Postoperative findings of bronchofiberscopy: no granuloma was detected in the anastomosis 3 months after surgery.
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DISCUSSION
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A right posterolateral thoracotomy has been considered the best approach for the lower trachea from a surgical perspective and with regard to the convenience of several releasing techniques to decrease tension for tracheal anastomosis; however, the anterior approach was selected in our cases for the reasons described above.3–4 The procedure described herein proved to be very effective in both cases as no anastomotic failure such as dehiscence, bleeding, or stenosis occurred.
The usefulness of omentopexy in thoracic surgery has been established especially in the healing of bronchopleural fistula accompanied by pyothorax.5–6 Recently, Shrager and colleagues6 reported a success rate for tracheal anastomosis of 89% in a high-risk group that included long length of resection with resulting anastomotic tension despite releasing procedures, ongoing infection, preoperative anticancer treatment, immunosuppression, and devascularization due to lymph node dissection. The pedicled omental flap supplies a number of factors related to wound healing and infection, such as blood, angiogenic factors, agents infused intravenously, mononuclear cells, and fibroblasts. The experience of these cases indicates that a wide dissection accompanied by omentopexy through an anterior approach may be successfully applied for sleeve resection of the lower trachea. This might be included among the surgical strategies for tracheal tumors and tracheal stenosis.
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REFERENCES
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- Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher CR Jr. Single-stage complete muscle flap closure of the postpneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31.[Abstract]
- Shrager JB, Wain JC, Wright CD, Donahue DM, Vlahakes GJ, Moncure AC, et al. Omentum is highly effective in the management of complex cardiothoracic surgical problems. J Thorac Cradiovasc Surg 2003;125:526–32.[Abstract/Free Full Text]
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