Tracheal resection and primary reanastamosis is the preferred treatment for the majority of both benign and malignant tracheal neoplasms. The ability to perform this preferred management is predicated upon patient-, tumor-, and surgeon-related factors. Patient factors that are important include body habitus, medical comorbidities, and patient preference. Increasing body mass index (BMI) and a thick and short neck may be impediments to the execution of tracheal resection and reanastamosis. In this patient group, the mobilization of the trachea inferiorly and superiorly may be limited, and access to the segment of trachea containing the tumor may not be able to be accomplished solely through a cervical approach. Patients with coexisting chronic obstructive pulmonary disease may require a longer intubation and may be more prone to coughing exacerbations that may place additional strain on the tracheal repair. Furthermore, patients who have diabetes mellitus or are otherwise immunocompromised may have poorer wound healing, especially with longer segment resections that are under tension.
Tumor factors are important in decision making. The length of the proposed segment that would require resection for adequate margins represents one of the key factors in determination of treatment. Segmental resections of greater than 4 cm or six tracheal rings represent conditions in which the tracheal repair is under increased tension and dehiscence may be more likely. Submucosal, esophageal, mediastinal, and extensive tracheal or bronchial extension may require combined cervicothoracic procedures or nonsurgical treatment. A variety of extended tracheobronchial resections have been described and are best managed in a multidisciplinary approach with otolaryngologist and thoracic surgeon. Premature tracheotomy in the securing of an airway may create additional scar tissue and potential seeding of the soft tissues of the neck and make subsequent surgical resection efforts more difficult. Prior radiation therapy may additionally have an impact on the ability to dissect soft tissues, mobilize the trachea and larynx, identify critical structures, and allow for optimal wound healing.
Surgeon preference and experience may influence approach. Experience with benign tracheal stenosis, laryngectomy, and tracheal resection increases the confidence and ability of the surgeon to manage these lesions. Cooperation between otolaryngologists and thoracic surgeons allows for improved patient selection, procedure selection, and technical execution of these complicated cases (2
). Contraindications for tracheal resection are relative rather than absolute in many cases. Because airway patency represents a fundamental goal in the management of patients with tracheal neoplasms, resection may be offered even in the face of primary tracheal tumors with regional or distant metastatic disease as well as selected metastatic lesions to the trachea. Lesions
that are involve greater than 4 cm or are greater than six tracheal rings may not be eligible for resection; factors ultimately affecting this decision include body habitus, ability to adequately mobilize the upper respiratory tract, and experience of the surgical team in both the procedure and management of its complications. Extensive extratracheal disease in the mediastinum involving the esophagus, mediastinal vessels, and prevertebral spaces represents cases in which resection is contraindicated and tracheotomy, endoscopic tumor ablation, and stent placement may be preferred.
Standard resection steps are predicated upon adequate bronchoscopic evaluation of the airway, imaging of the trachea and related neck and mediastinal structures, pathological confirmation, surgical team selection and approach, anesthetic preparation and management plan, and finally execution of the procedure. The steps of the tracheal resection procedure are as follows: transverse cervical incision outlined in cervical crease at midpoint between the sternal notch and the inferior border of the cricoid cartilage that are readily palpable landmarks. In extended cases or in cases in which cervical and extensive mediastinal dissection or proximity to the innominate artery is anticipated, both the neck and chest should be sterilely prepped and draped. The transverse cervical incision can be readily connected to a vertical chest incision for addition of a median sternotomy (total or partial). After preparation and skin incision choices are made, the steps of tracheal resection with primary repair are as follows:
Elevation of a subfascial, supramuscular flap above the strap musculature and the sternomastoid muscles sternal heads both superiorly and inferiorly into the suprasternal space of Burns.
Separation of the strap muscles from the thyroid cartilage to the sternal and clavicular origins of the muscles. Retraction of the wound may be done with a variety of self-retaining retractors, elastic stays, or sutures.
Exposure of the trachea requires the surgeon to anticipate extratracheal extension. For example, thyroidectomy may be required if resection is being performed because of well-differentiated thyroid cancer with focal tracheal invasion. In cases of endoluminal primary tracheal neoplasms, the thyroid isthmus should be divided with careful hemostasis, and the thyroid lobes mobilized laterally.
Recurrent (inferior) laryngeal nerve identification is not performed routinely, although identification of the nerve may be required for adjunctive procedures such as thyroidectomy, central lymphadenectomy, or extended cricotracheal procedures. Monitoring of the recurrent nerves may be helpful in maintaining integrity of the nerves and monitoring the condition of the nerve during retraction; there is no current evidence that use of neural monitoring improves recurrent laryngeal nerve outcome in these procedures.
Tracheal mobilization. The trachea should be carefully mobilized from the cricoid to two to three rings below the intended inferior margin of resection. Concomitant use and measuring of the lesion with imaging studies and intraoperative bronchoscopy may add accuracy to the determination of the segment requiring resection. Mobilization of the resection segment must be circumferential. Beyond the resection segment inferiorly, care should be taken to perform anterior and posterior mobilization, but careful lateral preservation of soft tissues in order to preserve the blood supply to the distal trachea from the inferior thyroid artery and other thyrocervical trunk arterial tributaries.
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