University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.
Purpose. Reconstruction of long tracheal defects has been largely unsuccessful due to the need for rigid support as well as reliable lining. The author’s experience of human tracheal reconstruction is presented here.
Methods. In 2004, two cases of tracheal reconstruction were performed by the author. The first one was a 63-year-old female with a recurrent papillary thyroid cancer involving the trachea. The resulting defect following resection included the inferior quarter of the thyroid cartilage, the anterior two-thirds of the cricoid cartilage and the cervical trachea, measuring 6.5 cm long. Immediate, one-stage reconstruction was performed using a 26-mm diameter Hemashield vascular graft reinforced with a 0.5-mm-thick PolyMax mesh as rigid support combined with a radial forearm free flap as lining. The forearm flap was suspended to the mesh using permanent sutures. A Montgomery T-tube was placed through a temporary tracheostomy to prevent potential airway compromise due to postoperative edema. The second patient was a 66-year-old male also with a recurrent thyroid cancer. The defect involved the thyroid cartilage, the anterior half of the cricoid cartilage and the cervical trachea measuring 5 cm long. Immediate reconstruction was completed using a 24-mm diameter Gortex Ring graft reinforced with Synthes PolyMax mesh as rigid support and a radial forearm flap for lining. No tracheostomy was performed. The reconstructed airway was evaluated with bronchoscopy postoperatively.
Results. The first patient was awakened at the end of surgery and kept in the ICU for 3 days without the need for ventilator support. Daily bronchoscopy through the T-tube revealed healthy flap with moderate edema. She was symptom-free and discharged on postoperative day 8 tolerating a regular diet with a normal voice. The T-tube was removed 8 weeks later without consequences. She then received 60 Gy of radiation and remained symptom-free. Bronchoscopy at 6-month follow-up showed a well healed, patent and clean airway without secretions and keratin debris. The second patient was extubated the day after surgery following a bronchoscopic confirmation of a healthy flap and patent airway. He did well subsequently and was discharged on postoperative day 7 tolerating a regular diet with a normal voice. Bronchoscopy at 2 and 3 weeks of follow-up confirmed a well healed and patent airway. He is now two months following surgery and remains symptom free.
Conclusion. This is the first report of successful human tracheal reconstruction for large defects. Prosthetic support with skin flap lining provided reliable reconstruction of the cervical trachea. The patients could handle secretions well without evidence of keratin accumulation.