Resection of the airway may require 1) simple circumferential removal of a segment of the upper trachea, 2) bevelled resection of one side of the anterolateral cricoid if it is involved, or 3) complex resection in which a portion of subglottic larynx on the invaded side is removed in a "bayonet" fashion and the distal trachea is tailored to repair the defect (Figure 8-10). "Window" resections are to be avoided because of the increased likelihood of leaving residual tumor and the less kindly healing of a trachea patched with
figure 8-10 Modes of resection of thyroid cancer invading tracheae. A, Cylindrical tracheal resection. Because of the location of the thyroid gland, invasion most frequently requires that proximal transection of the trachea be just below the cricoid cartilage. B, Varying amounts of cricoid must often be removed on the side of the tumor, from a slightly oblique bevelled resection to a nearly complete lateral excision, as diagrammed. C, "Bayonet" resection, where invasion of the cricoid is so extensive that the line of transection must lie somewhere beneath the vocal cord on that side. The inferior line of tracheal transection in this case is fashioned to fit the proximal laryngeal defect.
autologous mesenchymal tissue. The mesenchymal surface encourages granulation tissue formation and subsequent contraction. If such a window can be managed by insertion of a tracheostomy tube alone, the resection is usually of an inadequate extent. Surgical approach and techniques of resection and reconstruction are described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection," and Chapter 25, "Laryngotracheal Reconstruction." The technique of cervicomediastinal exenteration is described in Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy."
Cervicomediastinal exenteration should be applied selectively; that is, only in the rare case where an invasive anaplastic or undifferentiated carcinoma appears to be totally resectable by such en bloc resection, or where there is highly symptomatic massive late recurrence of differentiated carcinoma, usually after multiple unsuccessful treatment by thyroidectomy, 131I, and sometimes external beam irradiation. Such an effort is principally palliative, but it does indeed provide the patient with a measure of comfort, as an alternative to the misery caused by a progressively extensive local disease.
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