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Salvage Tracheal Resection for Primary Tracheal Tumor after Combined Radiotherapy and Brachytherapy

Monday, April 14, 2014

A 58-year-old man was admitted to the authors' department for neoplastic cervical trachea obstruction, causing stridor and dyspnoea. The patient had previously undergone a tongue resection and chemo-radiotherapy for squamous cell carcinoma, and lingulectomy for pT2pN0 squamous cell carcinoma. He also underwent an emergency laser-assisted mechanical resection of the occluding lesion by negative-pressure ventilation rigid bronchoscopy for successful normal airway lumen restoration.

The patient underwent intensity-modulated radiation therapy and endotracheal brachytherapy. Due to the patient’s refusal, a tracheal resection was not preformed. Restaging PET and CT scans confirmed focal persistent pathological uptake only in the involved tracheal tract. The patient accepted the proposed operation and was scheduled for a tracheal resection after bronchoscopic biopsies confirmed a squamous cell carcinoma.

A cervicotomy was performed. The pretracheal planes were sharply and bluntly dissected from adhesions caused  by previous radiotherapy. Laryngotracheal release was performed to maximize tracheal mobilization. On the basis of tracheal measurements acquired during pre-operative rigid bronchoscopy, the trachea was proximally transected and separated from the esophagus. The orotracheal tube was then retracted, the tracheal lumen opened, and the involved tract resected. Cross field ventilation was started, followed by proximal ring resection. Laryngeal release was optimized. Airway reconstruction was accomplished by 2/0 PDS running suture of the pars membranacea and 2/0 PDS single stitches on the cartilaginous rings. The endotracheal tube across the field was removed and the orotracheal tube was drawn into the field and positioned beyond the anastomosis. Two more crico-tracheal stitches were placed to reduce tension on the anastomosis.

A suction drain was placed in the pretracheal space, and strap muscles were sutured in the midline. The platysma was closed and the skin sutured with subcuticular stitches. Two heavy "guardian" sutures were placed to prevent excessive extension of the neck in the immediate postoperative period. These sutures passed transversely through a generous bite of skin in the submental crease and then through the presternal skin. Postoperative flexible bronchoscopy confirmed the full patency of the anastomosis.

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