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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
190
Bisected manubrium
P.J. de CavalcantiSiebra et al.
Fig. 1 Most commonly used skin incisions. (Reproduced from Sugarbaker etal. [24], with per-
mission. Copyright Mcgraw-Hill Education. All rights reserved)
Fig. 2 The inferior skin ap is elevated and the upper sternum is divided to facilitate evaluation
for resectability
and upper sternum
Fig. 3 The Manubrium is
bisected and the upper
sternum is removed.
(Reproduced from
Sugarbaker etal. [24], with
permission. Copyright
Mcgraw-Hill Education.
All rights reserved)
arterv
Mediastinal Tracheostomy
Tumor
Oblique division
of trachea
Innominate vein
Sternum
Fig. 4 Tumor site and trachea, divided obliquely. (Reproduced from Sugarbaker etal. [24], with
permission. Copyright Mcgraw-Hill Education. All rights reserved)
Fig. 5 The inferior portion
is reintubated and the superior portion is resected
along with the affected
structures. Tracheal relocation. (Left: reproduced
from Sugarbaker etal. [24],
with permission. Copyright
Mcgraw-Hill Education.
All rights reserved)
191
Left carotid
Innominate
artery
between the tissues. Sisson etal. described the importance of separating the innominate
artery from the trachea by using a PM ap, thereby reducing the occurrence of vessel
rupture and stula. For Orringer, the most important factor to avoid this disastrous
192
Source: D. J. Sugarbaker, R. Bueno, Y. L. Colson, M. T. Jaklitsch, M. J. Krasna, S. J. Mentzer,
M. Williams, A. Adams:
Copyright © McGraw-Hill Education. All rights reserved.
ba
P.J. de CavalcantiSiebra et al.
Lateral
blood supply
Adult Chest Surgery, 2nd Edition: www.accesssurgery.com
Fig. 6 Releasing the trachea from the esophagus by blunt dissection, with preservation of the
vascularization. (Reproduced from Sugarbaker etal. [24], with permission. Copyright McgrawHill Education. All rights reserved)
Innominate
artery
Fig. 7 Prevention of anastomosis tension by transposing the trachea inferiorly. Schematic drawing (a). Tracheal relocation-in vivo view [4] (b). (Reproduced from Sugarbaker etal. [24], with
permission. Copyright Mcgraw-Hill Education. All rights reserved)
Tracheal relocation
branches of acromiothoracic vessels
Mediastinal Tracheostomy
193
complication was considered to be a tension-free reconstruction; thus, a myocutaneous
ap can be used, such as the deltopectoral ap and thoracoacromial ap (“nipple ap”).
The pectoralis major is the preferable ap because it is able to provide a wide
quantity of myocutaneous tissue according to the defect to be reconstructed. Its
blood supply originates from the descending branch of the acromioclavicular
artery—a branch of the subclavian artery, which usually originates in the middle
third of the clavicle and has a ow direction toward the nipple. Other aps, such as
deltopectoral and bipedicled aps, may also be used (Fig.8) [8].
For development of the ap, the main reference points are outlined on the skin:
the sternal notch, xiphoid process, clavicle, and its middle third (origin of the vascular pedicle). The defect must be measured, and a similar area of skin is drawn
between the nipple and sternum (Figs.9 and 10).
Available skin surface Pectoralis major muscle and descending
Fig. 8 Available skin surface and wide myocutaneous tissue
Fig. 9 Main reference
points for the major
pectoralis ap outlined
194
Fig. 10 Another example of the Pectoralis Major Flap reference points
P.J. de CavalcantiSiebra et al.
The incision of the donor area is performed, with elevation of the skin aps
medially and laterally to the ap (Fig.11). The medial insertion of the muscle into
the sternum is released, with ligation of perforating branches of the internal thoracic
artery, and the lateral edge of the muscle is released from the pectoralis minor muscle. Elevation of the ap is initiated medially with deepening of the incision to the
level of the ribs and cranial release from the ribs and intercostal muscles, through
blunt dissection and electrocautery use, to the site of origin of the pedicle vessels
(middle third of the clavicle). The lateral limit of the muscle is incised, preserving
the pedicle (visible below the ap). The ap is mobilized to the defect area and for
coverage of the large mediastinal vessels. The tracheostoma is created by transposing the trachea through the interior of the ap (Fig.12) [8].
Prior to manufacture of the tracheocutaneous anastomosis, sutures may be placed
between the trachea and the subcutaneous tissues to ensure better stability. Drains
should be positioned below the ap, and a interrupted suture is made between the
skin and the tracheal stump.
The donor area is covered with the medial and lateral skin aps, created during
PM dissection. In cases where these remnants do not present sufcient approximation, it is possible to place cutaneous grafts in the uncovered areas (Figs13 and 14).
For tracheocutaneous anastomosis and closure, the muscles must be reapproximated and the trachea attached to the subcutaneous tissue to ensure better support.
As the skin is closed, the tracheocutaneous anastomosis is initiated. Local aps—
such as the deltopectoral ap, PM ap, and bipedicled ap—are used to cover the
Mediastinal Tracheostomy
Fig. 11 Incision of the
donor area
Fig. 12 Pectoralis
major ap dissection
195
defect generated by resection and to avoid stress on the structures. Drains are placed
beneath the ap, and an interrupted suture is fashioned (Figs.12, 13, and 14).
196
Fig. 13 Transposing the
trachea trough the Flap
P.J. de CavalcantiSiebra et al.
The main ways to reconstruct the alimentary tract are transposition of intraabdominal organs (stomach, jejunum, colon) or use of microsurgical aps (jejunum
or myocutaneous aps) [5].
The decision must take into account several factors—the main one is of reconstruction. In patients who undergo total esophagectomy in addition to laryngotracheal resection, it is necessary to transpose the intra-abdominal organs. Elevation of
the stomach is often preferred, due to the reduction in surgical time and the need for
fewer anastomoses [5, 9]. In patients who have already undergone gastric surgery,
such as a gastrostomy, the next choice may vary between a long colon segment and
the jejunum. When only a pharyngectomy is performed, without the need for a full
esophagectomy, a microsurgical jejunal ap or a tubed myocutaneous ap (from the
radial forearm or anterior thigh) can be used [5, 6, 10, 11].
There are several reasons for the technical difculties and major morbidity associated with MT: (1)a heavily irradiated surgical eld, usually impairing the healing
of soft tissue coverage; (2)paradoxical chest wall movements induced by manubrium and clavicular head resection, leading to early respiratory failure and stoma
or ap dehiscence [12]; and (3)stulization, which occurs in 65% of patients requiring complementary pharyngeal–esophageal reconstruction [13, 14].
Postoperative care should be intensive. Immediate postoperative intensive care
unit (ICU) placement is recommended in patients undergoing esophagectomy and
microsurgical anastomoses. The major cause of mortality after surgery is primary
Mediastinal Tracheostomy
197
a
b
c
Fig. 14 (a) Reconstruction of the donor area with skin aps and nal aspect. (b) Example of
Extensive Laringeal Recurrence. (c) Underwent Mediastinal Tracheostomy
rupture of the innominate artery with fatality rates of 33–55% [15–17]. To prevent
these complications, it is crucial to preserve the blood supply to the tracheal stump
and to protect the brachiocephalic artery, to ll the dead space, and to create a tracheostomy with tension-free sutures on the skin ap, using, for example, the omentum OR pectoralis major [2]. Other complications are alimentary tract stula from
anastomosis, ischemia of the trachea, skin ap loss, chylothorax, and hypoparathyroidism. Lung incarceration after anterior MT is also a described complication [12].
Nevertheless, MT can offer acceptable terms of palliation and quality of life,
similar to those of patients undergoing routine laryngectomy. Bone resection (manubrium, clavicle, sternum, rst and second ribs) can generate an area of instability in
the anterior chest with pulmonary herniation and increased susceptibility to pneumonia [9] (Table2).
198
P.J. de CavalcantiSiebra et al.
Table 2 Complications of
mediastinal tracheostomy
Complication
Rupture of the innominate artery
Alimentary tract stula
Ischemia of trachea
Skin ap loss
Chylothorax
Hypoparathyroidism
Case Report
The patient was a 52-year-old male and a smoker who presented in August 2013
with otalgia, odynophagia, dysphagia, and hoarseness, which had started 6months
prior to admission. Laryngoscopy revealed a tumor affecting the arytenoids, interarytenoid space, postcricoid region, aryepiglottic left fold, and left pyriform sinus,
with extension to the superior esophageal sphincter and cervical esophagus conrmed by MRI scanning and computed tomography (CT). The left hemilarynx was
paralyzed, and there was destruction of the cricoid and thyroid cartilages. The cervical lymph nodes were not clinically affected. Positron emission tomography (PET)
CT did not establish disease at other sites. The patient was clinically staged as
T4aN0M0. As the patient refused radical surgical treatment, he underwent an induction scheme with three doses of Taxol/platinum/5-uorouracil (TPF) on days 1, 22,
and 43, with an excellent response. As a result, we decided to continue conservative
treatment with intense modulated radiation therapy (IMRT) (7000cGy) associated
with cetuximab.
At week12 after treatment, the laryngoscopy and PET CT scan showed a complete response. The patient remained on monthly control but did not attend regular
consultations.
Fourteen months after his initial treatment, the patient presented again with otalgia and noisy breathing, and with associated dysphagia. The laryngoscopy showed
ulceration throughout the postcricoid region. Digestive endoscopy showed a 3cm–
long involvement of the cervical esophagus with tracheal invasion.
Endoscopic gastrostomy was performed and rescue surgical treatment was indicated, which was again refused by the patient. Cetuximab was initiated in a maintenance scheme.
After 2months, the patient returned with hoarseness and dyspnea, and an urgent
tracheostomy was required. In August 2015, the patient underwent a total laryngopharyngoesophagectomy, with colonic retrosternal transposition for alimentary
tract reconstruction, associated with resection of the affected trachea and fashioning
of a tracheostomy (Figs.1, 2, and 3). A left deltopectoral ap was used to cover the
colon and to avoid cutaneous tension (Figs.15 and 16).
In the postoperative period, the patient presented with a colon–pharyngocutaneous stula and severe cervical infection, which caused tracheostomy dehiscence and
collapse of the tracheal stump to the mediastinum. The stula was primarily closed,
but without success.
Mediastinal Tracheostomy
Fig. 15 Distal trachea
containing the endotracheal
tube after resection of the
lesion. The Foley catheter
is inserted into the colon
Fig. 16 Retrosternal colon
transposition
199
After extended hospitalization in the ICU, the administration of a large variety of
antibiotics and infectious process resolution, great difculty of cannula exchange
and airway patency persisted due to the depth of the tracheal stump position.
In November 2015, MT was indicated. It occurred with resection of 50% of the
manubrium, removal of the clavicular heads, and transposal of the tracheal stump