Clinical Experience

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In 1967, I saw a 54-year-old patient who 6 years earlier had undergone a thyroid lobectomy and radical neck dissection for differentiated carcinoma of the thyroid, and who subsequently received 4,800 cGy of radiotherapy because of invasion of the tracheal wall by tumor. She presented with severe airway obstruction due to recurrent cancer. The invaded tracheal segment was resected and an end-to-end anastomosis was performed. The trachea failed to heal, turned grayish-green, and necrosed, and the patient ultimately died from brachiocephalic artery hemorrhage. It appeared judicious to withhold tracheal reconstructive surgery in patients who had had a significant dose of irradiation given remotely.

This rule was later broken for an 8-year-old boy who had undergone very high-dose radiotherapy (3,728 and 5,040 cGy), 93 and 67 months earlier, for rhabdomyosarcoma in the neck. A short segment of the cervical trachea obstructed by a recurrent nodule of tumor was resected, and the anastomosis was buttressed with a substernally pedicled omental flap. Healing was satisfactory, except for a minor air leak at the fifth post-

figure 42-5 Histological damage to the trachea due to irradition. A 76-year-old female underwent subtotal thyroidectomy for invasive papillary carcinoma of the thyroid and subsequently received irradiation to a total dose of 6,080 cGy to the tumor bed. Four years later, she manifested laryngotracheal invasion, with hemoptysis. Laryngotracheal resection was performed with substernal omental advancement. A temporary tracheostomy was necessary. The anastomosis healed slowly, but well. A, Photomicrograph of an irradiated small artery, showing characteristic hyalinization of the wall, intimal hyperplasia, and small lumen. B, Degeneration of cartilage. The hyaline cartilage at the left shows typical grouped chondro-cytes. The fibrocartilage at the right is also abnormal. C, Atrophic tracheal glands.

«s operative day. This healed with a tiny granuloma at the suture line, which was managed bronchoscopically.

Between 1979 and 1992, 22 consecutive patients underwent major airway resection and reconstruction following significant irradiation.15 Excluded were patients who underwent resectional surgery only (ie, pulmonary resection or exenteration) without anastomoses, since these are lesser albeit still major problems. The average dose of irradiation received by these patients was 4,979 ± 1,112 cGy (range 3,150 to 7,768 cGy) in between 20 to 44 fractions, with an average fractional dose of 150 to 200 cGy. The time interval between irradiation therapy and surgery was 42.6 ± 105 months (range 1 to 488 months).

Patients fell into four categories: 1) symptomatic postirradiation tracheal stenosis, 2) recurrent tracheal tumor after irradiation either primary or adjunctive, 3) recurrent extratracheal tumor invading the trachea, and 4) preoperative radiotherapy. Six patients had postirradiation tracheal stenosis, causing dyspnea at rest. Three had been irradiated for positive margins after resection of adenoid cystic carcinoma of the trachea, 1 had received mediastinal irradiation for stage IA Hodgkin's lymphoma 13 years before, and a fifth developed stenosis following radiation for cervical tuberculosis as a child 40 years earlier. A sixth patient had been irradiated for recurrent thyroid cancer. Ten patients had recurrent primary tracheal tumors after prior radiation therapy. In 5 patients, the therapy had failed as primary treatment. Two had received radiotherapy for recurrence after resections for primary squamous cell carcinoma. Others included squamous cancer in an area of radiation for a primary lingual cancer, and another had been radiated following two prior tracheal resections for squamous cell carcinoma and now had yet another. There were 3 patients who had had a previously resected extratracheal tumor, with recurrence that now invaded the trachea. Three additional patients had preoperative irradiation and chemotherapy shortly before tracheal resection as part of a protocol extended to stage IIIB lesions.

Six patients underwent resection for benign stricture, 4 of these resulting from prior tracheal resections, whereas the other 2 had received radiation many years before but had not undergone surgery. Ten of the patients had primary tracheal cancer, 5 of who were referred because of failure of irradiation and laser therapy. The diagnoses of the patients who had extratracheal tumors invading the airway were rhabdo-myosarcoma, laryngeal squamous cell carcinoma, and carcinoma of the lung.

It was planned to buttress the anastomosis with a vascularized and unirradiated tissue flap if the patient had received more than 4,500 cGy of irradiation or if irradiation therapy had been completed more than 12 months prior to surgery. This was intended to provide a healthy source of regenerating tissue for healing of the anastomosis and also to provide a sealing layer and tissue interposition between the suture line and major blood vessels. In 19 of the patients, the anastomoses were wrapped with a vascular-ized tissue flap. In 15 patients, the airway was buttressed with a pedicled omental flap, our first choice for this type of support. In 2 patients, in whom the omentum was unavailable due to a prior gastrectomy, a pericardial fat pad flap was accepted in 1 and a pedicled intercostal muscle flap in the second whose pericardial fat pad was insubstantial. In 3 additional cases, the sternohyoid muscle was interposed between the anastomosis and the brachiocephalic artery in 1 patient, the sternohyoid muscle was placed between the tracheal anastomosis and the esophagus in the second patient, and no flap was used in the third patient who had received only 4,200 cGy of irradtiation 12 months prior to operation. Hilar releases and suprahyoid laryngeal releases were used freely as indicated (32%). Fifteen of the 22 patients had undergone prior surgery in the area of resection. Tracheal resection and reconstruction was accomplished in 20 patients and mainstem sleeve resections in 2. The cervical trachea was resected in 7 cases, the midtrachea in 8, and the carina or distal trachea in 5.

One patient died following development of respiratory distress syndrome after a right carinal pneu-monectomy. The patient with late stenosis due to Hodgkin's lymphoma died after his anastomosis had separated and innominate artery hemorrhage ensued. Although no active lymphoma was detected, the trachea was encased in massive scar, presumed to have resulted from regression of his original pathology. The qual ity of tracheal wall used for the anastomosis was unsatisfactory. This dehiscence occurred despite an omental wrap. Two subsequent patients with the same pathology were treated preferentially with T tubes.

One of the surviving patients, in whom a paratracheal abscess was encountered at resection of a necrotic tumor, suffered a dehiscence of the anastomosis, which was treated with placement of a T tube and an omental wrap. Two other patients developed wound infection, with granulations at the anastomotic site occurring in 1 of them. One patient, who had stenosis induced by primary irradiation, suffered a recurrent stenosis that required continued dilations. Seventeen of the 19 survivors had excellent results with no evidence of exertional dyspnea. The other 2 patients had dyspnea with moderate exercise.

Two subsequent patients, who underwent upper tracheal resection for squamous tracheal carcinoma after full-dose irradiation years previously for carcinoma of the base of the tongue and of a vocal cord, and who were buttressed with omentum, developed late (about 2 weeks after resection) limited necrosis of a portion of the anastomosis. Both were managed with T tubes. One of them healed slowly, with full epithe-lization. However, a partial stenosis occurred at the anastomosis and this was treated with an expandable uncoated stent, apparently successfully. The other patient is under treatment and may evolve similarly.

Shrager and colleagues recently described 14 patients who underwent prophylactic omental wrapping of high-risk tracheobronchial anastomoses.7 These included 4 carinal pneumonectomies and 10 tracheal reconstructions, a number of which had received prior irradiation. Primary healing was attained in 12 patients. One, previously noted here, had been remotely irradiated for Hodgkin's lymphoma. Omentum was also used in 20 lung transplantation patients with 19 successes, in 7 cervicomediastinal exenterations with success, and in 6 pneumonectomy patients thought to present special risk (irradiation in 4, immunosuppression in 3, and infection in 3). Four of the pneumonectomy patients healed without complication. The overall success in these patients was 89%. Thirteen of 15 patients with complex postpneumonectomy bronchopleural fistulae were successfully closed with omental transposition and reclosure of a bronchial stump.

With careful surgical technique and avoidance of excessive tension on tracheal and bronchial anastomoses and of interruption in blood supply, separation or stenoses are relatively uncommon. Massive necrosis, such as that described in our earliest patient, has not subsequently been seen. With the known effects of irradiation on tissue healing, it becomes important to approach the patients in whom this factor is present with great caution. The limited experience described indicates that airway reconstruction can be performed fairly safely in irradiated patients, despite the hindrance to healing that radiation causes. The use of vascularized tissue flaps and preferably the omentum to enhance blood supply and fibroplasia is always advised. In this group of patients, there is unquestionably a greater likelihood of anastomotic problems, including localized necrosis and subsequent evolution to stenosis or malacia. Ultimately, the final resort in such patients may be to use a permanent T tube or other type of stent.

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