Advanced carcinoma of the cervicothoracic esophagus

Transcription

1 ORIGINAL ARTICLES: GENERAL THORACIC Use of Omentum for Mediastinal Tracheostomy After Total Laryngoesophagectomy Yoshiyuki Kuwabara, MD, Atsushi Sato, MD, Masami Mitani, MD, Noriyuki Shinoda, MD, Koji Hattori, MD, Tomotaka Suzuki, MD, and Yoshitaka Fujii, MD Department of Surgery II, Nagoya City University Medical School, Nagoya, Japan Background. Carcinomas of the cervicothoracic esophagus frequently invade the trachea and complete removal of the tumor often requires mediastinal tracheostomy. Traditionally, this surgical management was associated with high morbidity and mortality. Several types of myoctaneous flaps have been used for mediastinal tracheostomy to reduce the complication. We present our experience with a new technique for construction of mediastinal tracheotomy after total laryngoesophagectomy and reconstruction with the stomach. Methods. The anterior chest wall was amply resected and the distal end of the trachea was placed low between the superior vena cava and aortic arch. We mobilized the entire omentum with the stomach and brought them up to the neck through the posterior mediastinum. The omentum was put around the trachea, main arteries, and the anastomosis. Results. Seven mediastinal tracheostomies were performed using this method. There was no hospital death. Complications included respiratory failure (2 patients) and pyothorax (1 patient). Anastomotic leakage and inominate artery rupture were not experienced. Postoperative survival was disease dependent. All patients were discharged with satisfactory oral food intake, good airway condition, and excellent cosmetic appearance. Conclusions. We suggest the use of the omentum as a simple and reliable technique in constructing mediastinal tracheostomy following total laryngoesophagectomy for cervicothoracic esophageal cancer. (Ann Thorac Surg 2001;71:409 13) 2001 by The Society of Thoracic Surgeons Advanced carcinoma of the cervicothoracic esophagus with extension to the trachea is a major therapeutic challenge. Complete removal of the tumor often requires removal of the larynx, a portion of the trachea and total esophagus, and construction of a mediastinal tracheostomy. Historically, these operations have been associated with a high operative mortality [1, 2]. Various types of myocutaneous flap have been used to construct a mediastinal tracheostomy to reduce the postoperative morbidity and mortality [2 10]. However, all of these myocutaneous flaps are troublesome and often leave disagreeable skin deformity. In this paper, we describe a method to construct a mediastinal tracheostomy, in which the omentum is used to cover the defects in the lower neck and superior mediastinum following a total laryngoesophagectomy and reconstruction with the stomach for the treatment of cervicothoracic esophageal cancer. Patients and Methods During the period between 1996 and 1999, 7 patients were operated on using this technique at Nagoya City University Hospital, Nagoya, Japan. There were 4 men and 3 Accepted for publication Aug 1, Address reprint requests to Dr Kuwabara, Department of Surgery II, Nagoya City University Medical School, 1, Kawasumi, Mizuho, Nagoya, , Japan; y.kuwa@med.nagoya-cu.ac.jp. women ranging in age from 45 to 57 years. All the patients had a cervicothoracic esophageal carcinoma that was localized in the neck and upper mediastinum with no evidence of distant metastasis. One patient had had a preoperative tracheotomy owing to airway obstruction by the carcinoma. Four patients had undergone chemotherapy, 2 patients had chemoradiation therapy, and 1 patient had radiation therapy preoperatively. Preoperative Evaluation Because of the magnitude of the operative procedure involved, each patient underwent a complete medical evaluation, including esophagoscopy, esophagograpy, bronchoscopy, computed tomography (CT), and magnetic resonance imaging (MRI). The criteria for inoperability were (1) fixation of the tumor to the prevertebral fascia, (2) inability to separate the tumor from the great vessels, (3) inability to preserve the distal part of the trachea 3 cm above the carina, (4) uncontrollable or multiple distant metastasis, and (5) performance status 2 or worse. Operative Technique Before the approach from the neck, the entire intrathoracic esophagus was mobilized through the right fifth intercostal space. The azygos vein and right bronchial artery were ligated and divided. The patient was placed 2001 by The Society of Thoracic Surgeons /01/$20.00 Published by Elsevier Science Inc PII S (00)

2 410 KUWABARA ET AL Ann Thorac Surg MEDIASTINAL TRACHEOSTOMY WITH OMENTUM 2001;71: Fig 1. Skin incision and resection of upper anterior chest wall. A large U-shaped and midline incision (single line). The medial thirds of the clavicles, medial segments of the first and second costal cartilages, and the sternum to the level of the upper edge of the third rib are removed (double line). supine, with the neck extended. A U-shaped incision was made just above the isthmus of the thyroid and a vertical midline incision was made from the bottom of the U incision to the level of the third rib (Fig 1). Sternocleidomastoid muscles were divided at their origins. The pectoralis muscles were reflected off the chest wall bilaterally to expose the ribs and their costal cartilage. With a sternal saw, the anterior thoracic breastplate was resected; medial thirds of the clavicles, medial segments of the first and second costal cartilages, and the upper third of the sternum to the upper edge of the third rib (Fig 1). The ample removal of the anterior thoracic wall allowed excellent exposure of the thoracic inlet and access to the cervicothoracic esophagus. The trachea was divided at a level that was free from the tumor. At least 3 cm of the trachea above the carina is necessary to construct a tracheostomy. The length of the distal trachea was 3 to 4 cm in 2 patients, 4 to 5 cm in 3 patients, and 5 to 6 cm in 2 patients. The oral endotracheal tube was removed, and the distal trachea was intubated. The thyrohyoid membrane was entered just above the thyroid cartilage and an incision of the laryngeal and pharyngeal mucosa was made laterally and posteriorly and the proximal esophagus was resected en bloc. One of the lobes of the thyroid gland and its adjacent parathyroid gland were preserved if this did not compromise the total resection of the tumor. After the removal of the tumor, an upper midline abdominal incision was made. The great omentum was freed from the transverse colon. At the left side of the omentum, the left gastroepiploic artery was divided as close to its origin as possible. The left gastric artery was divided at its origin. The distal esophagus attached to the stomach was pulled downward through the diaphragmatic hiatus. The gastric tube (3 to 5 cm wide) was made by sequential applications of a 5-cm gastrointestinal anastomosic stapler along the lesser curvature, leaving the first two to three branches of the right gastric artery (Fig 2). The gastric tube with the entire omentum was pulled into the neck through the posterior mediastinum. The pharyngogastric anastomosis was performed with an end-to-end anastomotic stapler (31 mm). A nasogastric tube was placed in the gastric tube (Fig 3). A feeding jejunostomy was made and the abdominal wound was closed. The trachea was transposed inferiorly and between the superior vena cava and aortic arch (Fig 4). The mobilized pectoralis muscle was sutured over the sternum to minimize the defect and cover the sharp edges of the bone. The omentum was divided in two: the lower half was placed around the trachea to separate it from the vessels; the other half was spread on the neck wound to cover the main arteries and anastomosis, and to fill up the defect (Fig 5). The end of the trachea was sutured to the skin overlying the resected sternum. Two closed suction tubes were placed under the skin. Postoperative Care The patient was managed in the intensive care unit. Mechanical ventilation was often required for 24 to 48 hours. As soon as the patient could breath spontaneously and the pulmonary function and blood gas determina- Fig 2. Gastric tube (3 to 5 cm wide) with the entire omentum attached is made by sequential applications of 5-cm gastrointestinal anastomotic stapler along the lesser curvature, leaving the first 2 to 3 branches of the right gastric artery.

3 Ann Thorac Surg KUWABARA ET AL 2001;71: MEDIASTINAL TRACHEOSTOMY WITH OMENTUM 411 tions were normal, the endotracheal tube was removed. Humidity was provided to the mediastinal trachea. Results Morbidity Two patients had respiratory failure, which required prolonged ventilatory support (6 and 7 days), and another had right pyothorax. In spite of the removal of a significant portion of the sternum, flail chest did not develop in any of the patients and the above-mentioned complication eventually resolved. Other patients experienced no major complication. Anastomotic leakage and inominate artery rupture were not experienced. Hypoparathyroidism or hypothyroidism developed postoperatively in 3 patients. They required long term calcium and vitamin D supplementation and thyroid hormone replacement. Mortality There was no hospital death. All patients were discharged with satisfactory oral food intake and good airway condition. Fig 4. The trachea is transposed inferiorly and between the superior vena cava and aortic arch. Functional Results In all patients, airway was maintained satisfactorily with the mediastinal tracheostomy. No patient demonstrated a flail chest or other compromise of pulmonary function. Stenosis of the stoma was experienced in 1 patient who had undergone preoperative radiation therapy. Stomal opening was maintained by use of a stent, which was removed after a few months. All patients were able to eat. Dilatation of the pylorus by balloon dilatater was required in 1 patient and was successful. Postprandial regurgitation during coughing, bending, or in the supine position was a common problem. However, within a few months after the operation, patients had uniformly learned how to control it. Survival Survival was disease dependent. Two patients developed distant metastases and local recurrence within a year and died. One patient had neck lymph node recurrence, which was resected. The patient is alive at 6 months postoperatively. Other patients are alive with no evidence of disease at 3, 5, 38, and 41 months postoperatively. Fig 3. This gastric tube with the entire omentum is placed into the neck through the posterior mediastinum. The pharyngogastric anastomosis is performed with an end-to-end anastomotic stapler (size 31 mm). Comment Recently, cervical exenteration with mediastinal tracheostomy has been used for the treatment of tumors in this area: recurrent carcinoma after prior laryngectomy, thyroid carcinoma invading the trachea, or cervicothoracic esophageal carcinomas [1, 2, 10]. The difficulty associated with this operation is the mediastinal tracheostomy and

4 412 KUWABARA ET AL Ann Thorac Surg MEDIASTINAL TRACHEOSTOMY WITH OMENTUM 2001;71: Fig 5. The omentum is divided in two; the lower half is placed around the trachea. The other half is spread on the neck wound to cover the main arteries and anastomosis and to fill the defect. its sometimes fatal complication. Several myoctaneous flaps for construction of a mediastinal tracheostomy [2 10] have been reported to reduce the complication, especially the erosion of the inominate artery by the trachea. In 1966, Grillo [2] described the use of a bipedicled upper thoracic apron flap, and Stell and associates [3] have reported a modification of Grillo s technique. A thoracoacrominal nipple [4] and a pectoralis major myocutaneous flap [1] and the modification of these techniques have also been reported [5 9]. By introduction of the myocutaneous flap, postoperative complication has been reduced [10]. However, these flaps require complicated procedures and a further skin graft to cover the defects. These myocutaneous flaps leave skin deformity, which sometimes is disagreeable. We decided to make use of the omentum pulled up with the gastric tube. This procedure proved to be simple and easy. It does not require an additional skin incision and a further skin graft. It also produced excellent cosmetic result (Fig 6). The omentum has many unique properties favoring its use in the construction of mediastinal trocheotomy. The omentum has not only good vascularity [11] but also an ability to induce neovascularization [12 13]. In addition, the omentum is tolerant to infection [14]. Grillo and Mathisen [15] advised mobilizing the omentum into the neck wound and interposing it between the mediastinal great vessels and the trachea to reduce the risk of innominate artery erosion. They replaced the esophagus with the colon and used the omentum, which was separately introduced retrosternally. We mobilized the omentum with the stomach and brought them up together to the neck avoiding unnecessary procedures. Procedures similar to ours have been described by Martins and coworkers [16] who used part of the omentum for covering the neck vessels after pharyngolaryngoesophagectomy. Nishimura and associates [17] have used the pectoral muscles and the omentum around the tracheostomy with minor resection of the sternum. The method we described in this paper cannot be used after gastric resection. It may also not be applicable if the patient has a history of major abdominal operation with intraabdominal adhesion. However, it should be applicable to cases in which an extensive skin defect is expected for example, those with skin involvement by the tumor because the omentum is an excellent support for a skin graft [11]. It was reported that the amount of anterior breastplate resection should be minimized because of the loss of the chest wall support [4]. In our experience, none of the patients demonstrated flail chest or other compromise of pulmonary function. Weddell and Cannon [18], and more recently, Orringer [19] reported that displacement of the trachea inferiorly and to the right of the innominate artery allows greater mobility and therefore reduce the tension of the skin. We transposed the trachea inferiorly and between the superior vena cava and aortic arch. It allowed even greater mobility than Orringer s method. The division of the azygos vein and right bronchial artery made this transposition easy. The length of the distal trachea is an important issue. Recently Orringer and associates [20] reported that 5 cm of trachea above the carina was necessary for the construction of an anterior mediastinal tracheostomy. In our experience, we had 5 patients whose distal trachea was less than 5 cm in length. However, the small size of our Fig 6. A patient 1 month after the operation using this method, showing the finished appearance of the anterior chest wall.

5 Ann Thorac Surg KUWABARA ET AL 2001;71; MEDIASTINAL TRACHEOSTOMY WITH OMENTUM 413 patients may be related to the short residual trachea and patients with thicker thoracic cage may require longer trachea for the tracheostomy. We suggest the use of the omentum is a simple and reliable technique in constructing a mediastinal tracheostomy after laryngoesophagectomy and reconstruction with gastric tube. Together with ample resection of the anterior chest wall and low placement of the tracheostomy between the superior vena cava and aortic arch, it provides ease and safety with excellent functional and cosmetic results. References 1. Sisson GA, Straehley CJ Jr, Johnson NE. Mediastinal dissection for recurrent cancer after laryngectomy. Laryngoscope 1962;72: Grillo HC. Terminal or mural tracheostomy in the anterior mediastinum. J Thorac Cardiovasc Surg 1966;51: Stell PM, Bickford BJ, Brown GA. Thoracotracheostomy after resection of the larynx and cervical trachea for cancer. J Laryngol Otol 1970;84: Conley JJ. The use of regional flaps in head and neck surgery. Ann Otol Rhinol Laryngol 1960;69: Krespi YP, Wurster CF, Sisson GA. Immediate reconstruction after total laryngopharyngoesophagectomy and mediastinal dissection. Laryngoscope 1985;95: Withers EH, Davis JL, Lynch JB. Anterior mediastinal tracheostomy with a pectoraris major musculocutaneous flap. Plast Reconstr Surg 1981;67: Gomes MN, Kroll S, Spear SL. Mediastinal tracheostomy. Ann Thorac Surg 1987;43: Maipang T, Singha S, Panjapiyakul C, Totemchokchyakarn P. Mediastinal tracheostomy. Am J Surg 1996;171: Fujita H, Kakegawa T, Yamana H, Shirouzu G, Minami T. Mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea. Surg Gynecol Obstet 1990;171: Orringer MB. Anterior mediastinal tracheostomy. Chest Surg Clin North Am 1996;6: Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Surg 1988;95: Goldsmith HS, Driffith AL, Kupferman A, Catsimpoolas N. Lipid angiogenic factor from omentum. JAMA 1984;252: Casten DF, Alday ES. Omentum transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;132: Cohen M, Silverman NA, Goldfaden DM, Levitsky S. Reconstruction of infected median sternotomy wounds. Arch Surg 1987;122: Grillo HC, Mathisen DJ. Cervical exenteration. Ann Thorac Surg 1990;49: Matins AS, Lage H, Lopes LR, Brandalise. Use of omentum pedicled graft protect great vessels in gastric transposition for pharyngoesophageal cancer. J Surg Oncol 1999;70: Nishimura Y, Ikeda T, Sakai T, et al. A case of carcinoma of esophagus involving trachea undergone anterior mediastinal tracheostomy with pedicled omental wrapping. Kyobu Geka 1991;44: Waddell WR, Cannon B. A technic for subtotal excision of the trachea and establishment of a sternal tracheostomy. Ann Surg 1959;149: Orringer MB, Sloan H. Anterior mediastinal tracheostomy: indications, techniques, and clinical experience. J Thorac Cardiovasc Surg 1979;78: Orringer MB. Anterior mediastinol tracheostomy with and without cervical exenteration. Ann Thorac Surg 1999;67:591. INVITED COMMENTARY Kuwabara and associates are to be congratulated on their outstanding results achieved in seven patients requiring mediastinal tracheostomy. The authors describe two technical modifications that are valuable contributions. They correctly identify the serious complications of this demanding surgical procedure massive hemorrhage from the innominate artery. This usually occurs because of either erosion of the trachea into the innominate artery or exposure of this vessel from wound separation. They have reduced this risk by transposing the trachea beneath the innominate artery and between the superior vena cava and aorta and using the omentum to cover, buttress, and separate the great vessels. Elective division of the innominate artery under electroencephalographic monitoring has been used to eliminate the risk of tracheal erosion and may be preferable in large patients or in cases in which less than 5 cm of trachea is available [1]. The use of the omentum either with the stomach or separately when colon bypass is the conduit of choice avoids the need for complicated muscle flaps and more easily accommodates the reconstructive demands of this procedure. The omentum can be utilized by thoracic surgeons as an adjunct to manage many complicated cardiothoracic problems [2]. The authors also recognize the need to create a tube of the stomach to reduce the bulk of the stomach and omentum to allow easy passage into the neck. Mediastinal tracheostomy is a valuable procedure that may be lifesaving in some patients and offers tremendous palliation for others. Because of the complexity of the operation, its justfication is warranted only when it can be performed safely. With a successful outcome, the functional result is the equivalent of a laryngectomy. The authors correctly identified the major pitfall of the procedure and offered useful technical alternatives that will be helpful to those who perform this demanding procedure. Douglas J. Mathisen, MD General Thoracic Surgical Unit Massachusetts General Hospital Boston, MA dmathisen@partners.org. References 1. Grillo HC, Mathisen DJ. Cervical exenteration. Ann Thorac Surg 1990;49: Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Surg 1988;95: by The Society of Thoracic Surgeons /01/$20.00 Published by Elsevier Science Inc PII S (00)