HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John Odell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Odell, J. Search for Related Content PubMed Articles by Odell, J. Related Collections Trachea and bronchi

Ann Thorac Surg 2004;77:405
© 2004 The Society of Thoracic Surgeons

Invited commentary

Mayo Clinic Jacksonville, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA

e-mail: odell.john{at}mayo.edu

Fortunately, in any thoracic surgical practice the need for more extensive tracheal procedures is uncommon. Lengthy tracheal lesions that cannot be safely reconstructed are usually managed by irradiation and patency is preserved by T-tubes or stents. An excellent review of the requirements for tracheal replacement has been provided by Grillo [1]. These requirements, iterated by Grillo, appear almost unattainable and are listed below:

Requirements for Tracheal Substitution: Lateral rigidity Airtightness Integration into adjacent tissue No immunosuppressive therapy Biocompatible Nontoxic Nonimmunologic Noncarcinogenic No dislocation No erosion Should provide or facilitate epithelialization No buckling Stenosis should not develop Resist bacterial colonization Avoid accumulation of secretions Must be permanent

The quest for a tracheal replacement has continued over years. Many isolated, small experimental or case reports have been described. The technique of lateral tracheal excision with patching, even with autogenous material, frequently failed because of tumor recurrence due to inadequate margins accepted because structural stability was the prominent consideration. The airway is never sterile and foreign materials, even porous, allowing tissue ingrowth failed. Attempts at tracheal transplantation, either fresh or preserved and devascularized or indirectly vascularized, invariably fail except in short grafts because of necrosis, infection, or rejection.

The paper by Meyer and colleagues is particularly relevant when reviewed in the light of the previous paragraphs. They have utilized autogenous, vascularized muscle tissue, supported in two instances by rib (similar to a sail batten) to close, in some instances, large defects. Many of their patients had radiation and chemotherapy. Their results are excellent. There has been no mortality. Extubation was within 24 hours; epithelialization without dehiscence, stenosis, or recurrence of fistulas occurred in all patients. Individually, others may have managed some of the cases described differently, but would the results have been similar or worse? This question is difficult to answer and despite contrary views regarding management, one cannot help but be impressed by what has been achieved. Other surgeons may have individual cases that they may have managed in similar fashion, but most, in contradistinction to this series, have been in unprepared circumstances. The reviewer vividly remembers removal of a hen-egg-sized lymph node anterior to the trachea in a 15-month child with pulmonary tuberculosis [2]. After removal, a large anterior defect in the trachea was visible which was successfully repaired with a pectoralis muscle flap.

Based on this paper, surgical thinking may change, particularly in respect to two clinical circumstances: the large lateral defect and patients requiring carinal resection. Caution is advised, however, because of the small numbers. There were only three patients with large lateral tracheal defects (two supported by rib) and only two where resection of the carina took place. Support of the muscle by rib is an excellent idea. The rib provides stability externally, but it must not be forgotten that internal support with a stent also took place. Stability, by fibrosis, may have occurred over time in any event. Carinal resection with preservation of the left lateral wall of the lower trachea and left main bronchus may obviate reattachment of the left main bronchus under tension when the carina is excised. Dartevelle has the largest experience with tracheal sleeve pneumonectomy. His recent experience was associated with no operative mortality, but a 7% incidence of bronchopleural fistula (4/55pts) [3]. Presumably, some of his patients could have been managed as advocated in this paper, but conclusions that lack of tension may have resulted in fewer fistulas are impossible to make. It is nevertheless a good surgical principle.

There are still unanswered questions. How strong is the repair? Nearly half the patients in this series had pneumonectomies: Until fluid collects in the space, there is no additional support laterally. Will excessive coughing and increased intrabronchial pressure disrupt the repair? Should temporary stenting be part of the procedure? Is there a size threshold for this type of repair, or need for supportive stenting? The fate of the rib within muscle is not known. Does heterotopic calcification or mysositis ossificicans develop and if so, is it relevant? To answer these questions, further experience by this group and others will be carefully awaited.

References

1. Grillo H.C. Tracheal replacement: a critical review. Ann Thorac Surg 2002;73:1995-2004.[Abstract/Free Full Text]
2. Worthington M.G., Brink J.G., Odell J.A., Buckels J., De Groot M.K., Klein M., Gunning A.J. Surgical relief of acute airway obstruction due to primary tuberculosis. Ann Thorac Surg 1993;56:1054-1062.[Abstract]
3. Dartevelle P.G., Macchiarini P., Chapelier A.R. Tracheal sleeve pneumonectomy for bronchogenic carcinoma: report of 55 cases. Ann Thorac Surg 1995;80:1854-1855.

This article has been cited by other articles:

				H.-B. Ris, T. Krueger, C. Cheng, P. Pasche, P. Monnier, and L. Magnusson Tracheo-carinal reconstructions using extrathoracic muscle flaps Eur. J. Cardiothorac. Surg., February 1, 2008; 33(2): 276 - 283. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John Odell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Odell, J. Search for Related Content PubMed Articles by Odell, J. Related Collections Trachea and bronchi