Cervicomediastinal Exenteration and Mediastinal Tracheostomy

Rarely, following extensive resection of the larynx and upper trachea for neoplasms, such as thyroid carcinoma, adenoid cystic carcinoma, or recurrent laryngeal carcinoma after laryngectomy, there is need for mediastinal tracheostomy, well below the sternal notch. Watson, in 1942, devised a procedure to treat a patient with squamous carcinoma 4 cm above the carina.168 The patient had undergone laryngectomy for cancer 15 years earlier, followed by radium treatment. A "V" of sternum was resected and skin flaps mobi-

figure 6 Louis Couraud, MD, Chief of Thoracic Surgery, Emeritus, Xavier Arnozan Hospital, Pessac, and Professor of Surgery Emeritus, University of Bordeaux II. Professor Couraud made Bordeaux renowned for airway surgery, producing excellent surgical results and adding to our knowledge of many aspects of tracheal disease: postintubation stenosis, laryngotracheal stenosis, juvenile tracheal growth, tracheoesophageal fistula, primary tumors, postsurgical complications, and the airway in transplantation.

figure 6 Louis Couraud, MD, Chief of Thoracic Surgery, Emeritus, Xavier Arnozan Hospital, Pessac, and Professor of Surgery Emeritus, University of Bordeaux II. Professor Couraud made Bordeaux renowned for airway surgery, producing excellent surgical results and adding to our knowledge of many aspects of tracheal disease: postintubation stenosis, laryngotracheal stenosis, juvenile tracheal growth, tracheoesophageal fistula, primary tumors, postsurgical complications, and the airway in transplantation.

lized to allow closure of the margins of the tracheal stoma. In 1951, Sloan and Cowley managed the problem of tracheal compression by an aortic aneurysm by establishing a side tracheostomy, the tube of which emerged from the back medial to the right upper scapula, after removal of proximal rib segments.169 After wrapping the aneurysm, it was possible to remove the tube. The authors discussed earlier proposals and even attempts to establish transpleural bronchial fistulae for this purpose, and a proposal, not acted upon, by Gluck in 1907, to perform posterior bronchotomy.

In 1952, for mediastinal tracheostomy, Kleitsch removed the upper sternum and inserted a polythene tube.170 A sequence of irradiation necrosis and recurrent tumor frustrated plans to line the opening with skin grafts. In the same year, Minor, after removal of recurrent carcinoma of the tracheal stoma, brought skin flaps as a tube through a sternal opening to connect with the trachea.171 Healing failed, and the patient bled to death 4 months later. Waddell and Cannon, in 1959, pulled a short tracheal stump to the right of the ascending aorta and created a skin tube from crossed anterior chest skin flaps which passed through a hole rongeured in the sternum and was anastomosed to the tracheal end.172 Two of 4 patients, all with squamous cell carcinoma, died of massive hemorrhage.

In 1962, Sisson and colleagues, operating for recurrent laryngeal carcinoma at the tracheal stoma, excised a large portion of surrounding skin with the specimen and removed the manubrium and the heads of the clavicles.173 Skin flaps were turned up to effect closure about the stoma, and an inferior defect was skin grafted. After 2 patients died from innominate artery hemorrhage postoperatively, the pectoralis muscles were undermined and rotated between the innominate and left carotid arteries and the trachea. Also in 1962, Ellis and colleagues used a tube of heavy Marlex mesh to reach the surface after low transection of the trachea.174 Granulation tissue formation and the possibility of infection, erosion, and hemorrhage make tubes of foreign material undesirable in this setting. In an effort to eliminate tension at the tracheal cutaneous anastomosis, which carried the threat of subsequent nonhealing and fatal innominate hemorrhage, Grillo in 1966 proposed fashioning a broad full-thickness bipedicled flap of anterior chest wall skin and subcutaneous tissue formed with two long, horizontal incisions (Figure 7).175 This flap was depressed to meet the end of the trachea in the mediastinum, made accessible by resection of manubrium, heads of clavicles, and upper two costal cartilages. The stoma emerged in midflap, resulting in a simple suture line more likely to heal well. Two end stomas and one in-continuity stoma were reported. Grillo and Mathisen subsequently offered further guard against vessel erosion in the event of deficits in peristomal healing by 1) advancing omentum routinely to separate trachea and great vessels, and 2) electively dividing the brachio-cephalic artery under electroencephalographic monitoring, where the tracheal stump was very short, following preoperative angiography.176 One operative death occurred in 18 patients. Additional experiences have been recorded in this area by Stell, Krespi, Gomes, and Orringer and their colleagues.177-180 Withers and colleagues suggested use of a pectoralis musculocutaneous flap, which has particular application to cases where a wide resection is necessary around an existing stoma for reason of peristomal carcinoma or irradiation damage.181

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