Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1645e1653

Reconstruction of the (Crico)trachea for malignancyin the virgin and irradiated neck

Sydney Ch’ng a,*, Carsten E. Palme b, Gerald L. Wong c, Markus Brunner a,Bruce Ashford d, John McGuinness d, Jonathan R. Clark a,d

a Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, NSW, AustraliabHead & Neck Cancer Service, Westmead Hospital, University of Sydney, Westmead 2145, Sydney, NSW, AustraliacDepartment of Anesthesia, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, NSW, AustraliadDepartment of Head & Neck Surgery, Liverpool Hospital, Liverpool 2170, NSW, Australia

Received 27 March 2012; accepted 11 July 2012

KEYWORDSTrachealreconstruction;Malignancy;Irradiated neck

* Corresponding author. The SydneySydney, NSW, Australia.

E-mail address: snchng@xtra.co.nz

1748-6815/$-seefrontmatterª2012Brihttp://dx.doi.org/10.1016/j.bjps.2012.0

Summary Background: Reconstruction of the trachea following resection for malignancy ischallenging. We present our experience over a 5-year period, and a reconstruction algorithmwith particular emphasis on minimising complications associated with radiotherapy.Methods: Amaximumof six tracheal rings canbe resectedandanastomosedprimarilywithaccept-able tension. A more conservative approach is required in an irradiated trachea. For a limiteddefect localised anteriorly or laterally, a tracheal flap can be fashioned. As for more eccentricdefects, anoption is to convert thedefect into anasymmetrical segmental defect, and toprimarilyanastomose the trachea with rotation of the distal stump. Our workhorse loco-regional flaps forpatch reconstruction or suture line reinforcement include the sternocleidomastoid, internalmammary artery perforator and pectoralis major myocutaneous flaps. For extensive defects,a radial forearm free flap (RFFF) with rib cartilage struts for rigidity provides a good solution.Results: Fifteen patients (M:FZ 4:11,median age 69 years)were identified. Six caseswere locallyaggressive papillary thyroid cancer. Mean follow-upwas 17months. Five and two patients had hadradiotherapy prior to and following tracheal resection, respectively. Ninepatientswereextubatedat theend of surgery, twowere successfully decannulated from their T tube subsequently, and onefromhis tracheostomy. The two surgical complications included a partial RFFF dehiscence causingminor air leak, andmajor haemorrhage that warranted urgent operation and pectoralis major flapreconstruction.Conclusion: Reconstruction of the trachea requires individualised techniques suited to thepatient’s body habitus, co-morbidity, previous treatment and the configuration of the defect.ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Head & Neck Cancer Institute, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050,

(S. Ch’ng).

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.7.008

1646 S. Ch’ng et al.

Level of evidence: IV nasendoscopy to assess the degree of airway obstruction.

Reconstruction of the trachea requires a wide range oftechniques from primary anastomosis and simple patchesfor short segmental resections through to complicatedcomposite reconstructions for salvage post radiotherapy. Itsanatomic composition and blood supply e part cervical partthoracic, and close association with major vascular struc-tures, larynx, oesophagus, pulmonary ligaments andbronchi e pose specific technical challenges to its recon-struction. The risks of fatal complications in the event ofanastomotic breakdown leading to airway obstruction,mediastinal sepsis and/or catastrophic haemorrhage fromerosion of major vessels, are not insignificant.

Airway management is a critical component of success-ful reconstruction. Intra-operative and postoperativeairway management in these cases is based on carefulpreoperative planning.

This article focusses on autologous reconstruction of thecervical trachea following resection for malignancy. Theadvanced stage of disease in these cases often mandatespostoperative adjuvant radiotherapy for improved loco-regional control, and many patients have undergoneradiotherapy prior to tracheal resection. Radiotherapyrenders the trachea less distensible, disrupts surgicalplanes, causes fibrosis, tissue fragility and vasculitis oblit-erans, all contributing to increased complexity in recon-struction. We present an algorithm for reconstruction oftracheal defects based on our early experience withparticular emphasis on minimising complications associatedwith radiotherapy.

Figure 1 Once the trachea is opened, the orotracheal tube ismanipulated to allow optimal surgical exposure. It is with-drawn into the larynx, and ventilation maintained via a rein-forced tracheal tube passed across the surgical field into thelower trachea (white arrow). A suture is attached to the oro-tracheal tube (black arrow) to facilitate advancement of thetube when the anastomosis is almost complete. Anastomoticsutures are places in the posterior half of the trachea first ()).

Patients and methods

Patients

Patients treated over a 5-year period were identified froma prospectively maintained head and neck database. Theywere analysed for pathology, surgical defect and recon-struction, and postoperative complications. All patientswith malignant pathology were included in the studyregardless of previous surgery and/or radiotherapy to theregion. Patients who underwent (crico)tracheal resectionfor idiopathic subglottic stenosis and other benign stric-tures were excluded as were patients undergoing totallaryngectomy.

Anaesthesia and airway management

All the patients underwent thorough preoperative work-upby anaesthetist and surgeon to form a plan for perioper-ative airway management. An anaesthetist experienced indifficult airway management was assigned in all cases, andclear communication between the surgeon and anaesthetistmaintained throughout. Clinical assessment included eval-uation of the patient’s ability to lay supine and clearsecretions, and the extent of neck fibrosis secondary toradiotherapy restricting neck extension, and mouthopening. Standard preoperative investigations includedhigh-resolution computed tomography imaging and flexible

Further investigations included rigid tracheoscopy tofurther assess the extent, nature and severity of trachealstenosis.

A preoperative tracheostomy was avoided as this wouldhave made the tracheal resection more difficult and limitedthe reconstructive options.

For patients at risk of airway obstruction on induction ofanaesthesia, or where visualisation of the larynx wasanticipated to be difficult, options for securing the airwayincluded awake fibreoptic intubation, video laryngoscopyand inhalational induction with maintenance of sponta-neous ventilation. During all intubations, the surgeon wasready to perform rigid laryngoscopy/bronchoscopy orsurgical tracheostomy. No patients in our series requiredthe use of cardiopulmonary bypass since our cases did notinvolve the thoracic trachea.

In most cases, a cuffed orotracheal tube was placed viadirect laryngoscopy, anaesthesia maintained with anintravenous-based technique and the patient receivedpositive pressure ventilation. The patients were positionedsupine with the neck slightly extended to allow mobilisationof the trachea. Once the trachea was opened, the oro-tracheal tube was manipulated to allow optimal surgicalexposure. During resection, it was withdrawn into thelarynx, and ventilation maintained via a reinforced trachealtube passed across the surgical field into the lower trachea(Figure 1). The neck was flexed to prevent tension on thesuture line, and once sutures were placed in the posteriorhalf of the tracheal circumference, the reinforced tube wasremoved and the orotracheal tube advanced back acrossthe defect into the distal trachea.

Figure 2 Algorithm for tracheal reconstruction.

Tracheal reconstruction 1647

Surgical reconstruction technique

An algorithm of surgical reconstruction technique is pre-sented in Figure 2.

Primary anastomosisOur anecdotal experience suggests that for most patientsundergoing segmental excision, a maximum of six trachealrings (4 cm) can be resected and anastomosed primarilywith acceptable tension in a non-irradiated trachea withneck flexion, and transcervical mobilisation depending onpatient body habitus. Mobilisation is carried out with digitalblunt dissection in the plane just superficial to the tracheaand deep to the innominate artery to preserve laterallybased blood supply down to the level of the carina. We, asa rule, avoid the suprahyoid release as the resultantdescent of the laryngeal framework increases the risk ofaspiration. The posterior aspect of the trachea, that is,trachealis, does not need to be resected to completea segmental excision if oncologically uninvolved. It can beconcertinaed into a blind pouch in the tracheal anastomosis(Figure 3).

Figure 3 Trachealis in the posterior wall of trachea can be leftTrachealis is concertinaed into a blind pouch in primary anastomos

Amore conservative approach is required in an irradiatedtrachea where segmental excision of four rings is probablythe maximum limit for which a primary anastomosis can beperformed. We routinely use a regional or free flap foranastomotic reinforcement in all cases where a segmentalresection is performed in the setting of prior radiotherapy.Major composite reconstruction is planned if a long resectionor undue tension is anticipated (see below).

Lateral resectionA number of options are available for non-circumferentialresection. For a limited defect localised anteriorly orlaterally, a tracheal flap can be fashioned to even outtension across a wider surface (Figure 4). The tracheareceives its primary blood supply from transversesegmental branches from the superior and inferior thyroidarteries, which are often sacrificed in such operations.Axial blood supply from fine collateral branches from thesubclavian, supreme intercostal and internal thoracicarteries, and brachiocephalic trunk are relied upon instead.It is therefore important to minimise horizontal incisions increating tracheal flaps.

unresected in segmental resection if uninvolved with tumour.is (asterisk) (C Z cricoid).

Figure 4 Large lateral defect reconstructed with anadvancement rotation tracheal flap based laterally.

1648 S. Ch’ng et al.

When structural integrity is not required, a local muscleflap alone (strap or sternomastoid) can be used to seal thetrachea. For larger eccentric defects (>6 rings), an optionis to convert the defect into an asymmetrical segmentaldefect, and to primarily anastomose the trachea withrotation of the distal trachea without excision of theremaining trachea (Figure 5).

Figure 5 In reconstructing a large eccentric defect, configurationdistal trachea, and rotating and advancing the distal segment cep

Loco-regional flap reconstruction/reinforcementOur workhorse loco-regional flaps include the sternoclei-domastoid muscle flap to patch small non-segmentaldefects, internal mammary artery perforator (IMAP) flapfor circumferential wraparound of the anastomosis toreinforce the suture line and the pectoralis major myocu-taneous flap where there are concurrent cutaneous defectsand large amounts of dead space. Local and regional flapsare liberally used to separate the tracheostomy/suture linefrom the innominate artery to prevent tracheoinnominatefistula, a frequently fatal complication. The same is appliedto any exposed major vascular structure (carotid or internaljugular vein). Local muscle flaps, such as the sternomas-toid, are unreliable in irradiated patients, whereas theIMAP flap provides healthy vascularised tissue withoutmicrovascular reconstruction and limited donor-sitemorbidity.

Free-flap reconstructionFor extensive defects where primary anastomosis or localflap reconstruction are not feasible options, a radial fore-arm free flap (RFFF) with rib cartilage struts placed verti-cally bridging the tracheal defect for rigidity provides

of the defect can be drastically changed by disconnecting thehalad for anastomosis.

Tracheal reconstruction 1649

a good solution (Figure 6). Despite a surface devoid ofciliated respiratory epithelium, patients can generally clearsecretions effectively by cough. The cartilage struts do notneed to be circumferential but must provide sufficientrigidity to prevent tracheal collapse in response to negativethoracic pressure.

Figure 6 (Top) Large anterior defect ()) following excision ofrecurrent papillary thyroid carcinomawith a focus of anasplasticthyroid carcinoma in an irradiated trachea. Part of the cricoid(C) was resected with the tumour specimen. The carotid artery(CCA) was skeletonized in resection of the tumour.(I Z innominate artery). (Middle) Cartilage struts (black arrow)were used to bridge the defect to add rigidity to the recon-struction. (Bottom) A radial forearm free flap (white arrow) wasused to reconstruct the defect. A sternocleidomastoid flap(black arrow) was fashioned to separate the carotid artery fromthe reconstructed trachea and the innominate artery.

Cricoid and laryngeal invasionInvasion of the larynx represents a difficult problem, partlydue to the functional consequences if the vocal cord is fixedor needs to be resected, and also due to the non-flexiblenature and irregular shape of the laryngeal framework. Thismakes anastomosis to the trachea more challenging, andincreases the need for free-flap reinforcement or recon-struction. The trachea can be advanced into the cricoid ring(or remaining section) in the same manner as described forcricotracheal resection in benign subglottic stenosis.

Oesophageal invasionWe have found that extensive oesophageal invasion isuncommon in the resectable patient not requiring a totallaryngectomy; however, minor oesophageal invasion is notrare, and in thyroid cancer patients can be managed byresection of the oesophageal and pharyngeal constrictormuscles preserving the mucosa. In this setting separation ofthe oesophagus from the tracheal anastomosis is important toprevent erosion into the gastrointestinal tract using similartechniques as described above for the innominate artery.

Post-reconstruction airway managementWhen safe, our preference is immediate extubation withouta tracheostomy. A tracheostomy tube causes mucosal irri-tation, airway drying and increased secretions leading tocough, which jeopardises the anastomosis. Furthermore,a horizontal incision in the trachea is prone to tear undertension and interrupts axial blood supply since usually thesegmental supply has been ligated. In cases where airwayaccess is felt to be critical, particularly following flapreconstruction, a Montgomery T tube is used for stenting ofthe neo-trachea for up to 4 weeks, but capped immediatelyor on day 1 postoperatively to maintain airway humidifica-tion, and to prevent crusting in the tube. The T tube may beplaced through the reconstructed defect when tension free,or more than 1 cm below the anastomosis to prevent necrosis(Figure 7). In complicated reconstructions where it is antic-ipated that sputum retention is likely to be problematic for

Figure 7 T-tube site (black arrow) fashioned at 1 cm inferiorto the tracheal anastomosis to decrease the risk of anastomoticbreakdown. This figure also illustrates a laryngofissure that isused where the anastomosis is close to the vocal cords forvisualization ()).

1650 S. Ch’ng et al.

a prolonged period, such as following recurrent laryngealnerve (RLN) sacrifice, a tracheostomy tube is used. Anyincisions placed in the lower trachea are made vertically forreasons described above, and positive pressure ventilation isavoided to minimise air leaks. Penrose drains are used toprevent tension mediastinum and, finally, a Grillo guardianstitch spanning the mentum and sternal notch is applied toprevent inadvertent neck extension that might threatenintegrity of the tracheal repair.

Results

Our experience is summarised in Table 1. Fifteen patients,four males and 11 females, median age 69 years (range29e80 years) were identified. Six cases were locallyaggressive papillary thyroid cancer, of which four repre-sented recurrent/persistent disease. The other pathologieswere recurrent squamous cell carcinoma (n Z 2), adenoidcystic carcinoma (n Z 2), follicular thyroid carcinoma(n Z 2), mucoepidermoid carcinoma (n Z 1), anaplasticthyroid carcinoma (nZ 1) and poorly differentiated thyroidcarcinoma (n Z 1). Mean follow-up was 17 months (range6e59 months). Five and two patients had radiotherapytreatment prior to and following tracheal resection,respectively. One patient underwent radiotherapy bothbefore and after tracheal surgery.

Of the 15 patients, six had segmental defects, fiveanterior, two lateral and two eccentric. In five patients, thedefect included part of the cricoid. In reconstruction ofthese defects, three free flaps and 13 loco-regional flaps(sternocleidomastoid (n Z 9), IMAP (n Z 3) and pectoralismajor (n Z 1)) were used. Four patients had multiple-flapreconstruction.

Nine patients were extubated at end of surgery, twowere successfully decannulated from their T tube subse-quently, and one from his tracheostomy. Three (20%)patients are still tracheostomy dependent, two due tobilateral RLN sacrifice, and one due to surgical complica-tions described below. One patient with bilateral RLNsacrifice underwent laser cordotomy 6 months followingsurgery, and is capping her tracheostomy at the time ofwriting of this article tube with a view to decannulation.

Two surgical complications included a partial trachealdehiscence post radiotherapy causing minor air leak in onepatient, which did not escalate due to containment bya radial forearm flap placed at the time of initial surgery toreinforce the anastomosis and was managed by observa-tion.1 The second complication was a major trachealdehiscence and haemorrhage in a patient where threetracheal rings were resected post radiotherapy, and thedefect reconstructed primarily tension free with a T tubeand sternocleidomastoid muscle-flap reinforcement. Thisrequired a second operation and pectoralis major flapreconstruction to prevent recurrent haemorrhage withtracheostomy. The patient developed tracheal stenosis andhas not been decannulated.

Discussion

There is surprisingly little literature directed at thereconstruction of tracheal resection for malignancy. This

may partly be due to the large series of benign trachealstrictures published by Grillo2 and others. Fortunately, theincidence of tracheal strictures from prolonged intubationand ventilation has decreased significantly since the adventof low-pressure endotracheal tube cuffs and cuff pressuremonitoring. Whilst Grillo’s landmark work is helpful inmanaging some malignant tracheal resections, the varietyof defects encountered requires a fluid reconstructiveapproach. The majority of resections in this series are forthyroid carcinomas of low-grade malignancy, wherecomplete margin-free resection is likely to result in sus-tained loco-regional control and survival.

Small defects, either lateral or segmental, in non-irradiated tissue are simple to manage. The challenge ari-ses in irradiated tissue, complicated or long defects. Theaims of reconstruction in these patients are to achieve goodvoice and a patent airway, and to avoid major complica-tions such as airway dehiscence, which may lead to airwayobstruction, haemorrhage and death. The most importantconcept in the post-irradiation patient is that of anasto-motic reinforcement. This can be achieved using a thinfasciocutaneous flap that can be wrapped circumferentiallyaround the trachea. The reinforcement serves three aims,first strengthening the anastomosis, second containment ofminor tracheal leaks and third separation of the suture line(and tracheostomy site) from surrounding structures that itmay erode into such as the oesophagus and innominateartery. A healthy flap also imports new vascularity to thearea that aids overall healing. We have found that the IMAPflap,3 if appropriately planned, provides high-quality thinand pliable regional tissue with minimal donor-sitemorbidity that can be wrapped completely around thetrachea. A thin fascial free flap is preferred in patientswhere a more complicated defect is anticipated, or inpatients where a scar on the chest is unacceptable from anaesthetic perspective.

The length of trachea that can be resected with primaryanastomosis achieved depends on the patient’s age,posture, body habitus and previous radiation therapy.Mobilisation of the right hilum with division of the pulmo-nary ligament and intrapericardial dissection of pulmonaryvessels are thoracic procedures employed in mediastinaltracheal reconstruction,2 which for the large part are notroutine for head and neck surgeons.

Autologous tissue reconstruction provides the mostpredictable outcome in an irradiated and heavily scarredtissue bed. Loco-regional flaps, for example, pectoralismajor myocutaneous, IMAP and deltopectoral, and freeflaps, for example, radial forearm and jejunum,4e6 withtheir independent vascular supply, provide the best chanceof wound healing. For much smaller defects, fascia lata,pericardium, periosteum, bone strips with fibrocollagen,periosteal patch applied to staggered buccal mucosa andauricular cartilage, rib and ear perichondrium, nasal septalmucocartilage, epidermis, and bronchial and trachealpatches have shown that small defects can be successfullymanaged with non-vascularised graft repairs.7e15 To addrigidity to the reconstruction, and to prevent collapse ofthe reconstructed lumen, nasal, auricular and costalcartilage grafts have been added to the grafts andflaps. Alternatively, wire, coils, tantalum and Marlexmesh, silicone, polyethylene and polyurethane stents, and

Table 1 Patient demographics, pathology, surgical treatment and complications.

Patient Age(years)

Gender Pathology Defect Reconstruction Decannulation Postoperativeairway

Complication

CN 56 M Poorlydifferentiatedcarcinoma

Eccentric, 2/3circumference(7 rings), RLNsacrificed

1� anastomosis withrotation of distaltracheaSCM flap reinforcementRFFF for part of defect

Yes Tracheostomyfollowed byT tube

HA 34 F Recurrent SCC Anterior (thyroid andcricoid cartilages)

SCM flap repair Yes Tracheostomy

JB 64 F Recurrent PTC Lateral (cricoid and5 rings), RLN sacrificedOesophageal resection(partial)

Rotation trachea flapRFFF flapreinforcement

Yes Extubatedpostop

Partialdehiscencecontainedby RFFF

OT 60 M Recurrentmucoepidermoidcarcinoma

Anterior (2 � 3 cm) Bilateral SCM flap repairIMAP flap reinforcement

Yes Extubatedpostop

JC 73 F PTC Segmental (4 rings) 1� anastomosis Yes Extubatedpostop

MM 80 F Anaplasticthyroidcarcinoma

Anterior (cricoid and4 rings), bilateralRLN sacrificed

1� anastomosisIMAP flap reinforcementSCM flap placed betweentracheostomy andinnominate artery

No Tracheostomy

TTT 77 F Recurrentfollicular thyroidcarcinoma

Segmental (4 rings)and clavicle

1� anastomosisSCM flap to separatecarotid/ innominateartery

Yes Extubatedpostop

MP 74 F Recurrent PTC Eccentric, 2/3circumference(9 rings)

RFFF and cartilagestruts

Yes T tube Minor airleak

JJ 69 F Metastatic SCC Anterior (cricoid and3 rings)

1� anastomosisSCM flap reinforcement2� PM flap salvage

No T tube Major tracheal dehiscenceand haemorrhage2� tracheal stenosis

LT 53 F Recurrent PTC Segmental (cricoidand 5 rings),bilateral RLNsacrificed

1� anastomosisIMAP flapreinforcement

No despitecordotomy

Tracheostomy

EC 29 F Persistent PTC Lateral (cricoid and4 rings)

Rotation trachealflap

Yes Extubatedpostop

CV 56 F Adenoid cysticcarcinoma

Segmental (3 rings) 1� anastomosis Yes Extubatedpostop

(continued on next page)

Trach

ealreco

nstru

ction

1651

Table

1(continued)

Patient

Age

(years)

Gender

Pathology

Defect

Reco

nstruction

Deca

nnulation

Postoperative

airway

Complica

tion

WV

75F

Adenoid

cystic

carcinoma

Segm

ental(3

rings)

1�anastomosis

Yes

Extubated

postop

PI

79M

Follicular

thyroid

carcinoma

Segm

ental(4

rings)

1�anastomosis

SCM

flapreinforcement

Yes

Extubated

postop

BA

79M

PTC

Anterior(2

rings)

1�anastomosis

SCM

flapreinforcement

Yes

Extubated

postop

Abbreviations:

MZ

male,F

Zfemale,PTC

Zpapillary

thyroid

carcinoma,

RFFF

Zradialforearm

free

flap,SC

MZ

sternocleidomastoid,RLN

Zrecu

rrentlarynge

alnerve,

IMAPZ

internalmammary

artery

perforator.

1652 S. Ch’ng et al.

polytetrafluoroethylene have been described.16e21 Foreignmaterials, however, carry increased risks of local infection,anastomotic dehiscence, vascular erosion, prostheticmigration, granulomatous lesions and stenosis.18,21e23 Theyshould be avoided and could be disastrous in patientsundergoing radiotherapy.

The Montgomery T-tube placed as the neo-tracheal stentfollowing flap reconstruction is generally well tolerated,easy to suction and removable in an outpatient setting.There is minimal risk of migration or obstruction.24,25

Patients treated with palliative intent will still benefitfrom tracheal stenting with or without endoluminal resec-tion of tumour. A number of flexible metallic stents areavailable that allow delivery across airway stenoses, thatconform to the airway and prevent tumour and granulationtissue ingrowth.26e31 Whilst vascular, coronary and biliarystents have enjoyed reasonable success, the problem ofdevice distortion, migration, erosion, over-granulation andobstruction continue to plague tracheal stents in malignanttumours.

The topic of palliative stenting, however, is beyond thescope of this article.

Tracheal transplantation may be the Holy Grail oftracheal reconstruction, but the present need for lifelongimmunosuppression will inevitably interfere with the host’stumour immunosurveillance.

Conflict of interest

None.

Funding

None.

Financial disclosure

None.

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