Ann Thorac Surg 2004;78:720-721
© 2004 The Society of Thoracic Surgeons
How to do it
An alternative method of neck flexion after tracheal resection
Dale K. Mueller, MDa*,
John Becker, MDb,
Steven K. Schell, MDb,
Kishore M. Karamchandani, MDc,
James R. Munns, MDa,
Brian Jaquet, PAa
a HeartCare Midwest, Peoria, Illinois, USA
b Department of Anesthesiology, Order of St. Francis Medical Center, Peoria, Illinois, USA
c Peoria Pulmonary Associates, and University of Illinois at Peoria, Peoria, Illinois, USA
Accepted for publication September 4, 2003.
* Address reprint requests to Dr Mueller, HeartCare Midwest, Medical Park Physicians Center, 515 NE Glen Oak, Ste 210, Peoria, IL 61603, USA
e-mail: mue{at}heartcaremw.com
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Abstract
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Tracheal resections for benign and malignant disease are well described. The addition of release procedures, including suprathyroid and suprahyoid laryngeal release, has increased the capability of extended tracheal resection and primary reconstruction. Constant neck flexion by a suture between the skin of the point of the chin and midline of the chest over the manubrium is also widely considered paramount to successful tracheal resections. We designed a straightforward alternative to this method for patient comfort and compliance.
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Introduction
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Tracheal resection can be associated with anastomotic dehiscence. If attempts to approximate the divided airway result in undue tension, various mobilization and release procedures can be used to resolve this problem. Continuous neck flexion maintained by a suture placed from the chin to the chest is an effective technique [1]. This suture, which is maintained for a week, can cause patient discomfort from the pulling and tearing due to unintentional neck extension. We therefore designed an easily constructed, readily available cast that replicates this position.
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Technique
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A 53-year-old woman presented with a 1-year history of asthma. Computed tomography demonstrated a tracheal tumor nearly obstructing the tracheal lumen 3 cm distal to the vocal cords and 6 cm in length. Broncoscopy at the time of resection confirmed these measurements and was topographically consistent with adenocystic carcinoma. The patient underwent median sternotomy with neck extension, a standard tracheal resection of 8 cm, and primary reconstruction with use of jet ventilation. The total length of the trachea was approximately 15 cm. A suprahyoid tracheal release maneuver was also performed. Constant neck flexion was maintained by a suture placed between the skin of the point of the chin and the midline of the chest over the manubrium. To further limit movement in the sagittal plane and release any tension on the skin created from this suture, an orthosis was fashioned. This extended from superior to the external occipital protuberance caudally to the lumbar spine. This support was formed by using a 12.7 x 76.2 cm premad fiberglass splint (3M Scotch Cast One Step, St. Paul, MN). With the patient's neck in extreme flexion, the splint was applied, contoured to the patient's neck, and allowed to set. Because of the width of the splint, the area of the cervical spine also allowed for limitation of lateral bending. Once the splint material had set, the patient was placed in a binder to secure the orthosis. This allowed minimal movement of the cervicothoracic area and minimized side-to-side movement of the orthosis, (Figs 1 and 2). The splint was maintained for 1 week, and the patient was discharged 10 days after the operation without complications. Secondary to the success of this orthosis, we currently apply the splint to all tracheal resections. This has been used 4 times with excellent patient compliance and no complications.
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Comment
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Tracheal resection and primary reanastomosis for tracheal tumors and stenosis is a well-described procedure [1]. Because of the lack of suitable replacement material for the trachea [2], various mobilization and release maneuvers have been demonstrated to increase the length of tracheal resection by elevation of the carina. These include hilar [1], suprahyoid [3], and suprathyroid laryngeal release [4]; anterior and posterior digital tracheal dissection; and constant neck flexion. Approximately half of the trachea can safely be removed with a low incidence of anastomotic complications [1].
We believe that constant neck flexion after cervical tracheal resection is essential to relieve any undue anastomotic tension that predisposes to dehiscence. We have in the past performed the standard suture between the skin of the point of the chin and the midline of the chest over the manubrium [1]. Patients have described a tearing and pulling from this stitch when they unintentionally extended the neck. This suture can also fracture, obviously losing its effectiveness. Because of this discomfort, we designed a simple, reproducible orthosis that can effectively maintain constant neck flexion without discomfort from this suture. Each patient with whom this was used has expressed minimal discomfort associated with the orthosis.
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References
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- Pearson F.G., et al. Thoracic surgery. . New York: Churchill Livingstone, 1995.
- Shields TW. General thoracic surgery. Baltimore: Williams & Wilkins, 1994:482–3
- Montgomery W.W. The surgical management of supraglottic and subglottic stenosis. Ann Otol Rhinol Laryngol 1968;77:534-546.[Medline]
- Dedo H.H., Fishman N.H. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol 1969;78:285-296.[Medline]
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Abstract
Introduction
