Primary reconstructive method for tracheal defect from invasion by differentiated thyroid carcinoma

Differentiated thyroid carcinoma is not highly malignant, and thus surgical resection is the most common treatment even if the carcinoma has invaded the trachea. Although some cases exist in which the carcinoma invades the trachea, using the tracheal window resection method allows complete resection of the carcinoma. Yet these patients must often control a large tracheocutaneous wound until reconstructive surgery is performed because such surgery occurs secondarily. Our hospital admitted three patients for which tracheally invasive, differentiated thyroid carcinoma was surgically resected. Tracheal defects of 1/2 to 2/3 of the tracheal circumference were reconstructed primarily using the free forearm flap and costal cartilage during carcinoma resection. Following surgery, only a small tracheocutaneous fistula remained open, which was closed at about three months post-operation. The reconstructed tracheal space and transferred costal cartilage thickness were monitored by CT scan imaging at about 12 months post-operation. Details of the reconstructive method and postoperative changes in the reconstructed trachea and thickness of the costal cartilage are described in this report.     

Closure of large tracheocutaneous fistula using turn-over hinge flap and V-Y advancement flap

Tracheocutaneous fistula is a frequent sequel of long-term tracheostomy or tracheal fenestration. Closure of fistula is complicated by the presence of extensive scar tissue, mucopurulent secretions, and tension from insufficient advancement of adjacent soft tissue. We report two successfully closed cases of large tracheocutaneous fistulae using a hinge flap and a V-Y advancement flap.     

Safe reconstruction of a large cervico-mediastinal tracheal defect with a pectoralis major myocutaneous flap and free costal cartilage grafts

A large cervico-mediastinal tracheal defect in a 72-year-old man as a result of surgery for thyroid carcinoma with tracheal invasion and mediastinal lymph node metastasis was reconstructed using a pectoralis major myocutaneous flap and free costal cartilage grafts. The tracheal defect (55 mm x 30 mm) was located at the thoracic inlet adjacent to the major mediastinal vessels. Our reconstructive procedure was a two-staged surgery. In the first stage, a pectoralis major myocutaneous flap was transferred to the neck to provide a well-vascularized recipient bed for free costal cartilage grafts and to cover large vessels. Two pieces of free costal cartilage were grafted on the pectoralis major myocutaneous flap, one for the lateral wall reconstruction and the other prefabricated for the anterior wall of the trachea. In the second stage, the re-vascularized cartilage graft for the anterior wall of the trachea with overlying skin was rotated onto the trough of the remaining trachea and the closure of the tracheal defect was completed. We conclude that free cartilage grafts for the reconstruction of a large cervico-mediastinal tracheal defect can be safely used when they are combined with well-vascularized pectoralis major myocutaneous flaps.     

Operative Stimmrehabilitation nach totaler Laryngektomie

Summary A procedure for the rehabilitation of the voice function following laryngectomy is reported. In a first step, a deltopectoral flap is prepared with implantation of cartilage under the skin of the flaps tip. The second step, after taking of the cartilage, follows approximately 3 weeks later. A laryngectomy is performed, the deltopectoral flap with the cartilage is mobilized and formed into a tube with the skin inside. The flap is then anastomosed to the stump of the trachea and the opened pharynx. The cartilage graft serves as a skeleton for the skin tube of the deltopectoral flap and should help to guarantee the communication between trachea and pharynx. In a last step, some weeks later, the no more needed, proximal part of the deltopectoral falp is removed and the skin fistula closed.By closing the tracheal cannula, the patient can now, during expiration, bring the walls of the skin tube to vibrate. With these vibrations, he can generate a quite useful voice.To date, 13 patients have been operated upon with this voice-reconstructive method, in most of the cases with good result. As in all similar operations, the main problem is aspiration of food in the postoperative period. It takes some weeks, until the patients have learned to swallow without aspiration. In selecting patients for such an operation, we have to consider several points: — age (not older than 55) — good cooperation — if possible, no preoperative irradiation.     

Late laryngo-tracheal cartilage necrosis with external fistula 44 years after radiotherapy

Major late complications, following radiotherapy of head and neck carcinomas, such as laryngeal oedema, perichondritis and chondronecrosis usually occur between three and 12 months after treatment. However, the present case displayed necrosis of the laryngo-tracheal cartilage and ulceration of anterior neck skin with a tracheal fistula 44 years after irradiation. The reasons for the long interval between irradiation and late complications may be explained by long-standing hypovascularity and/or infection of the irradiated area. Histological study revealed chondronecrosis without inflammatory cells in the laryngo-tracheal cartilage and bacterial colonization of subcutaneous tissue. Necrotic tissue was removed and tracheostomy was performed. The fistula was almost completely closed using a delto-pectoral cutaneous flap and the clinical course of patient has been good. This paper demonstrates the possibility of laryngo-tracheal necrosis in cases that had received radiation as long ago as 44 years.     

Prefabricated composite free flaps for tracheal reconstruction: a new technique

OBJECTIVES: Successful laryngotracheal reconstruction requires both structurally supported tissue that withstands airway pressure changes and well-vascularized epithelial lining to prevent granulation and stricture formation. For circumferential defects, end-to-end anastomosis achieves favorable results, but for long-segment or large noncircumferential defects, no proven methods have emerged. Several animal studies describe prefabricated soft tissue flaps wrapped around synthetic materials or cartilage. However, prefabricated flaps have had very little use in human airway reconstruction. We present a patient with laryngeal stenosis and tracheostomy dependence following chemoradiotherapy for hypopharyngeal carcinoma. METHODS: In an attempt to widen the patient's laryngeal airway, a thyrotracheal autograft procedure, previously described by our institution, was performed. We transferred a segment of hemitrachea cephalad using the thyroid gland as a "vascular carrier," thus creating an 8-cm-long trough inferiorly that involved a 40% defect of the anterior tracheal circumference. Severe radiation damage to the cervical skin precluded use of traditional tracheoplasty methods. We used a technique whereby costal cartilage strips were implanted into a radial forearm free flap, designed to replicate the anterior tracheal wall. RESULTS: Four weeks later, we harvested the prefabricated composite flap and placed it into the defect, using forearm skin as tracheal lining. The cervical skin defect was closed with an island deltopectoral flap. A soft stent was kept in the neotrachea for 3 weeks, and a tracheostomy tube was left beneath it. The tracheostomy was subsequently closed with local advancement flaps, and the patient currently maintains an excellent airway. CONCLUSIONS: Prefabricated composite free flaps are an attractive option for certain challenging cases of airway reconstruction.     

Allograft tracheoplasty technique for management of refractory tracheal stenosis

OBJECTIVES: Extensive tracheal airway defects represent a clinical dilemma. Although resection and reanastomosis and staged tracheoplasty may prove beneficial in some cases, recurrent or extensive circumferential stenosis remains a reconstructive challenge. We report the use of the allograft tracheoplasty technique for the reconstruction of recurrent, extensive defects of the trachea and cricoid. METHODS: Nine consecutive patients with recurrent tracheal stenosis were treated with the two-stage allograft tracheoplasty technique. A retrospective review was performed to evaluate for prior surgery, length of stenosis, surgical technique, and outcome. All 9 patients underwent multiple surgical procedures for acquired tracheal stenosis (average, 3.4 procedures) before undergoing the allograft tracheoplasty technique. Before surgery, all patients were tracheotomy-dependent. RESULTS: The patients were assessed 8 to 39 months after allograft tracheoplasty. The primary airway disorders included postintubation stenosis (n = 6), surgical resection for malignancy (n = 1), and idiopathic stenosis (n = 2). Three defects involved 30% to 60% of the cricoid cartilage, and 4 defects were complete circumferential tracheal defects. Five patients underwent an island deltopectoral flap for closure of the tracheoplasty site. One patient had a superficial wound infection at the cartilage recipient site, and 1 patient had a hematoma at the deltopectoral flap donor site. All 9 patients were successfully decannulated without shortness of breath, stridor, or recurrent stenosis at the time of follow-up. CONCLUSIONS: Allograft tracheoplasty is a new technique for the reconstruction of recurrent tracheal stenosis. It appears to be reliable for extensive airway defects that are refractory to conventional tracheoplasty techniques.     

超长皮瓣修复头颈部瘢痕切除后组织缺损

为增加皮瓣的长度，设计肩胸部两极又蒂超长随意皮瓣、旋转覆盖受区创面，供区创面直接缝合或游离植皮覆盖。临床应用１０例，术后皮瓣全部成活，创面得到覆盖和修复并功能恢复较理想。认为超长疲瓣是修复头颈部瘢痕切除组织缺损的良好材料。     

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection

ObjectiveThe thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection.MethodsFrom April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery—including end-to-end tracheal anastomosis and simple pharynx closure—was performed after thyroid carcinoma resection. The patients’ records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed.ResultsWhen our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used.ConclusionOur analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.     

Composite auricular graft in laryngeal reconstruction

When injury to the larynx and/or trachea results in significant loss of tissue, primary closure may predispose to stenosis. Reconstruction of the airway should include the addition of cartilage to maintain the lumen as well as a replacement for interior mucoperichondrium and exterior skin. The auricle provides an excellent source for a composite graft consisting of cartilage with its attached skin on one side and perichondrium on the other. A case is presented in which a 2 cm. defect was successfully closed with such a composite graft. The patient sustained a self-inflicted wound which removed the lower portion of the thyroid cartilage in the midline, the anterior third of the cricoid cartilage and the anterior third of the first tracheal lumen. Several weeks later a composite graft was taken from the auricle, and a three-layer closure was accomplished. After an initial period of cyanosis, the graft remained viable and survived in toto. Long term follow-up showed survival of the graft, normal laryngeal function and normal tracheal diameter.     

Laryngeal repair after resection of advanced cancer: an optimal reconstructive protocol

Tracheal autotransplantation allows for reconstruction of extended hemilaryngectomy defects after resection of laryngeal cancer. With this technique, optimal functional results were obtained after a learning curve of more than 50 patients. The objective of this paper is to present the final reconstructive concept with the typical indications. Unilateral glottic cancer and lateralized chondrosarcomas of the cricoid cartilage are resected with a hemilaryngectomy including one-half of the cricoid cartilage. After tumor resection, a radial forearm flap with a skin paddle and a fascial paddle are taken. The skin paddle restores the laryngeal defect temporarily, and the fascial paddle wraps the upper 4 cm of cervical trachea. A tracheostomy is preserved in the area between the reconstructed larynx and the fascia-wrapped trachea. The radial forearm vessels are sutured to the neck vessels. After 4 months, the skin island of the radial forearm flap is removed from the defect and the revascularized, fascial enwrapped trachea is transplanted to the laryngeal defect. The tracheal continuity is re-established with preservation of a tracheostoma. The tracheotomy can be closed after 6 weeks. Two case reports are presented: a unilateral T3 glottic cancer and a chondrosarcoma of the cricoid cartilage. The two patients showed normal oral feeding 1 week after the operation. Hand-free speaking was possible after closure of the tracheostomy. Tracheal autotransplantation after vascular induction of the trachea with the radial forearm flap leads to optimal repair of extended hemilaryngectomy defects.     

Laryngotracheal reconstruction with autogenous rib cartilage graft for complex laryngotracheal stenosis and/or anterior neck defect

To study the effectiveness of laryngotracheal reconstruction with rib cartilage graft for complex laryngotracheal stenosis and/or anterior neck defect, 62 patients with complex laryngotracheal stenosis and/or anterior neck defect underwent laryngotracheal reconstruction with autogenous rib cartilage graft. The surgical procedures were laryngotracheotomy with rib cartilage graft interposition and silicon-tube stent placed in the region of laryngotracheal stenosis and/or anterior neck defect for the period of between 10 days and 12 months. Three patients with complex subglottic stenosis and anterior neck defects underwent a single-stage reconstruction with a combined rib cartilage graft interposition and fasciocutaneous flap reparation. One patient with a complex subglottic and superior thoracic tracheal stenosis underwent a staged operation. Of the 62 patients, 46 patients (74.1 %) were successfully decannulated. One patient had combined subglottic stenosis, which was healed, and superior thoracic tracheal stenosis, which is undergoing treatment. 15 patients (24.2 %) had failure in decannulation due to either wound infection followed by rib cartilage necrosis, or granulation tissue formation and restenosis. Of these 15 patients, ten required revision operations and delayed healing. The duration of follow-up ranged from 1 to 10 years. Of 46 patients, who were successfully decannulated, 36 had a satisfactory airway and a functional voice; two had restenosis due to partial laryngectomy for laryngocarcinoma recurrence 1 year after decannulation; eight were lost to follow-up after successfully decannulated. We conclude that this method can provide effective treatment for complex laryngotracheal stenosis and/or anterior neck defects. It is relatively simple with a high decannulation rate in selected patients.     

Local repair of persistent tracheocutaneous fistulas

Tracheocutaneous fistulas may persist after tracheostomy. Suture closure of the fistula may result in complications, including infection, wound dehiscence, and pneumomediastinum. We present a simplified and relatively safe technique to close persistent fistulas that may be performed under local anesthesia. A retrospective chart review was performed on 13 patients who were successfully treated, including 1 with incomplete closure that was successfully addressed by additional procedures. Our review included analysis of reported risk factors for persistence of tracheocutaneous fistulas: previous irradiation of the neck, an extended duration of cannulation, previous tracheostomies, obesity, and use of a Bjork flap or 4-flap epithelial-lined tracheostomy. All 13 patients in the study were found to have at least 1 of these risk factors.     

Organ preservation surgery for advanced unilateral glottic and subglottic cancer

OBJECTIVES: Functional surgery of unilateral T(2b) to T3 glottic cancer and cricoid chondrosarcoma is possible using the technique of tracheal autotransplantation. The objective of this paper is to report the functional and oncologic outcome of 24 consecutive patients treated with this technique between 2001 and 2007. METHODS: Seventeen patients, of whom nine were previously irradiated, had unilateral glottic cancer with impaired mobility of the vocal fold. Clinical staging was T(2b) to (3)N(0). Seven patients had a chondrosarcoma of the cricoid cartilage. In a first operation, an extended hemilaryngectomy was performed, and a radial forearm flap, comprising a distal fascial and a proximal skin component, was transferred to the neck. The fascial paddle was wrapped around the upper 4-cm segment of cervical trachea, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction was performed after 2 to 3 months and consisted of removal of the skin paddle from the laryngeal defect and a transplantation of a patch of revascularized cervical trachea to reconstruct the laryngeal defect. RESULTS: Swallowing and speech were restored after the first operation. The glottic and subglottic airway lumen was restored during the second operation. The tracheostomy could be closed in 20 patients. After a median follow-up period of 33 (range, 1-66) months or almost 3 years, 23 patients remained free of tumor recurrence. CONCLUSIONS: Tracheal autotransplantation can be recommended as a functional treatment for selected T(2b) to T(3) glottic cancers and for unilateral chondrosarcomas of the cricoid cartilage. The technique is oncologically robust while resulting in good postoperative function.     

Management of the flap tracheostomy. An experimental study.

The flap tracheostomy was studied in 25 adult canines to further investigate its best management. Tracheostomies were performed by employing the inverted U flap incision in the trachea. After decannulation, the flap was either formally resewn to the trachea, bluntly dissected from the surrounding soft tissues, or left in place. The time required for epidermal closure over the tracheostomy site was measured, along with fixation of skin to soft tissues in the area. Histologic examinations were made, and tracheal dimensions were calculated on sections through the stomal area. More rapid skin closure and less soft tissue fixation occurred in animals that underwent resuturing or release of the tracheal flap. In all groups, cartilage viability and regrowth were noted. Tracheal diameters were maintained in all groups, but smoother contouring was seen with resuturing. Additional support for the flap tracheostomy is provided from this animal experimentation.     

Modified spiral tracheoplasty after extensive window resection of trachea for advanced thyroid cancer

Papillary thyroid carcinoma (PTC) occasionally invades tracheal cartilages. We adapted a reconstructive procedure “modified spiral tracheoplasty” to extensive tracheal defect after resection of locally advanced thyroid cancer. Extensive window resection of tracheal wall was performed in a 72-year-old woman and a 48-year-old man with PTC invading intraluminal trachea. Remaining stumps of trachea were separated from the esophageal wall and were rotated by 90 degrees in opposite directions. Posterior and lateral walls were anastomosed and tracheocutaneous fistula was created to prevent postoperative airway obstruction. Postoperative course was uneventful in both cases. Tracheocutaneous fistula was successfully closed 3 to 4 months after the initial surgery. Modified spiral tracheoplasty is a safe and useful method to recreate a framework of trachea after extensive window resection for advanced thyroid cancer.     

Treatment of stenoses of the laryngotracheal junction and the cervical trachea

In the past 20 years we have operated on 187 patients for tracheal stenoses. Dilatation, tracheopexy with ring support, sleeve resection, and the gutter procedure are described. In recent years we have replaced open treatment of the tracheal gutter with our closed method. After expanding the posterior wall, the anterior tracheal wall is closed with a myocutaneous island flap, rib cartilage or a myomucosal flap. The merits of the different methods are discussed. Dilatation of the trachea and reconstruction of the anterior tracheal wall over a silicone tube in a one stage procedure creates a sturdy trachea, which is better able to resist scar contracture and pressure from the soft parts of the neck than an open U-shaped gutter. The number of operations and days of treatment per patient are materially reduced by the closed method.     

Laryngotracheal separation

The popularity of the motorcycle, specifically trail bike riding, in the past several years has produced an increasing incidence of severe “clothesline” injuries to the larynx and trachea. Even at moderately high speed the impact of a horizontal cable with the neck of the rider causes a sudden hyperextension of the neck, and an avulsion of the larynx from the trachea, separating at the relatively rigid fibrous connective tissue between the cricoid cartilage and the first tracheal ring. Interruption of the strap muscles, the recurrent laryngeal nerves, laceration of the esophagus, and compression fracture of the cervical vertebral bodies can occur. The unseated rider requires immediate assistance, airway obstruction being his greatest problem. In the early minutes after the accident he must be transported to an emergency facility where tracheostomy and resuscitation can be provided. Mediastinal infection, tracheoesophageal fistula, subglottic stenosis, and intermittent depression many follow the initial repair. Rehabilitative measures include permanent tracheostomy, the use of neuromuscular pedicle graft, hyoid bone graft, intracordal injection of teflon paste, and carbon dioxide laser excision of webs and cicatricial tissue.     

Closure of persistent tracheocutaneous fistula following "starplasty" tracheostomy in children

OBJECTIVE: The "starplasty" technique of pediatric tracheostomy was introduced in 1990 as an alternative pediatric tracheostomy technique associated with several advantages. The only apparent drawback of this technique is the higher incidence of persistent tracheocutaneous fistula following decannulation. Several methods have been proposed for closure of persistent tracheocutaneous fistula in children, including fistulectomy with primary closure and fistulectomy with healing by secondary intent. Some authors advocate placement of a drain at the time of primary closure. We present our experience with closure of persistent tracheocutaneous fistula following starplasty in children over the past 15 years. METHODS: Ninety-six starplasty procedures were performed on 96 children from 1990 to present, all by the senior author or under the guidance of the senior author. Twenty-eight of these children have been decannulated. Three fistulas closed spontaneously following decannulation. Of the remaining 25 children, 13 have undergone surgical closure of the tracheocutaneous fistula by the senior author. All tracheocutaneous fistula closures were performed as a fistulectomy with primary closure in three layers. Drains were not used in any of the patients. RESULTS: There were three minor complications in the postoperative period (wound infection and airway granuloma) and no major complications. None of the patients have experienced any degree of airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good. CONCLUSIONS: "Starplasty" is a safe, reliable pediatric tracheostomy technique that has been shown to decrease the incidence of perioperative morbidity and mortality. The only drawback appears to be a high incidence of postoperative tracheocutaneous fistula. Our method of persistent tracheocutaneous fistula closure following starplasty is safe and effective, with no major complications and no incidence of postoperative airway narrowing.     

甲状腺癌侵犯颈段气管的气管缺损与修复

目的总结甲状腺癌侵犯颈段气管的气管缺损修复经验，提高术中气管缺损修复的治疗效果。方法收集2011年8月—2019年2月诊治的32例甲状腺癌侵犯颈段气管患者资料，其中6例术中采用锐性削除受侵气管外壁，8例气管袖式切除+端端吻合，6例胸锁乳突肌锁骨骨膜瓣，8例胸锁乳突肌锁骨骨膜瓣联合生物膜，2例前臂皮瓣+自体软骨移植，2例气管造瘘+Ⅱ期修复。结果6例锐性削除气管外壁患者中，有1例患者术后第6天出现气管瘘，予以换药后出院；余26例患者中，24例于术后6个月内恢复正常呼吸功能，1例前臂皮瓣+自体软骨移植患者术后出现局部气管狭窄，黏痰堵塞，带管生存，1例带蒂胸锁乳突肌骨膜瓣+生物膜患者术后气管局部塌陷伴双侧声带麻痹，带管生存。结论对于侵犯气管的甲状腺癌患者，根据不同的侵犯范围，选取合适的气管切除和缺损气管的修复方式，才能取得较高的手术成功率和较好的治疗效果。