Management of a tracheal tear during laryngopharyngoesophagectomy with gastric pull-up.

Abstract

Laceration of the posterior tracheal wall is one of the risks of transhiatal esophagectomy. Various methods of repairing such lacerations have been described; many of these methods involve a thoracotomy, but some do not. We describe a case of a posterior tracheal wall tear that occurred during a laryngopharyngectomy with a gastric pull-up. The tear was repaired with the transposed stomach and did not require a thoracotomy. The transposed stomach was used to patch the tear and block communication between the environment and the mediastinum. Bedside endoscopic examination on postoperative day 5 revealed that the tear had healed. Key management considerations in such a circumstance include having the patient breathe without positive pressure ventilation postoperatively and keeping the tracheal lumen and stoma clear during the healing process in order to prevent the development of positive tracheal pressure. With these safeguards in place, the transposed stomach approach is a safe method of repairing posterior tracheal wall tears.

Introduction

Organ-sparing approaches have enjoyed wide acceptance as a treatment for advanced-stage laryngeal cancer since the publication of the Department of Veterans Affairs Laryngeal Cancer Study Group report in 1991. (1) The VA investigators compared (1) induction chemotherapy followed by radiotherapy, with salvage laryngectomy as needed, and (2) laryngectomy followed by radiotherapy. They found that cure rates in the two groups were equal and that 64% of the nonsurgical patients were able to retain their larynges. The results of numerous subsequent studies confirmed the benefits of organ-sparing approaches in head and neck cancers. (2,3)

Surgeons in a number of centers have noted that treatment of highly destructive laryngeal cancers often results in nonfunctional larynges. Many patients with nonfunctional larynges require a tracheostomy for breathing and a gastrostomy for nutrition. In such cases, removal of the larynx actually allows for a better functional outcome and high cure rates. Following laryngectomy, most patients are able to take nutrition orally, and many undergo successful speech rehabilitation with tracheoesophageal prostheses. We have adopted this approach for our patients who have large, destructive laryngeal cancers.

In patients whose cancer has extended into the esophagus, we perform a laryngopharyngoesophagectomy. This procedure is much less common in our institutions today than it once was because we now rely more on concomitant chemotherapy and radiation. However, when warranted, our current practice is to perform a cervical esophagectomy with a jejunal free-flap reconstruction. At the time of the case described in this article, we did not have the services of a reconstructive surgeon with microvascular experience, and therefore we chose to reconstruct our patient with a gastric pull-up. The complication rate associated with this approach is high (nearly 50%), including a 30-day mortality rate of 7%. (4) Prevention of adverse outcomes requires a familiarity with the possible complications of this procedure. Some reported complications include injury to the spleen, azygos vein laceration, chylothorax, recurrent laryngeal nerve paralysis, anastomotic leaks, cardiac abnormalities, pleural injury, and tears to the posterior tracheal wall.

Specific concern has been directed to the risk of tracheal tears during blind dissections of the mediastinal esophagus via the transhiatal approach. In the 1970s, experience at Memorial Sloan-Kettering Cancer Center revealed that tears of the membranous tracheal wall occurred in 62.5% of such cases. (5) Reports 2 decades later indicated that the rate of tracheal tears had fallen dramatically to less than 10% (table). (6-8) In fact, Orringer et al retrospectively reviewed 1,085 cases and reported a tear rate of less than 1%. (6)

Many surgeons prefer transhiatal esophagectomy to the transthoracic approach because it is associated with lower rates of operative mortality and postoperative morbidity. (9) In this article, we report our management of a tracheal tear that occurred during a transhiatal esophagectomy.

Case report

A 65-year-old man presented to the otolaryngology unit with complaints of respiratory distress and a 50-lb weight loss. Endoscopy revealed that a mass had filled his entire larynx and extended into the right piriform sinus. The mass had destroyed the medial sinus wall and extended into the esophageal inlet. A biopsy revealed that the lesion was a papillary squamous cell carcinoma.

The patient underwent a laryngopharyngectomy with gastric pull-up and a bilateral modified radical neck dissection. Following mobilization of the esophagus, air was seen leaking from the neck wound. When the endotracheal tube and trachea were checked, a 3-cm vertical laceration was discovered in the posterior wall of the trachea, approximately 3 to 4 cm above the carina. The tear was presumed to have occurred during the blunt, blind dissection of the trachea from the esophagus. The patient's endotracheal tube was pushed beyond the tear, and the balloon on the tube was used to block the hole and maintain ventilation. After consultation between the head and neck surgeon and the thoracic surgeon, the decision was made to continue with surgery and to evaluate the possibility that the transposed stomach could be used to tamponade the hole. If the transposed stomach was not able to adequately block the area of the tear, the patient would require a thoracotomy for either patching or direct repair of the tear.

Following transposition of the stomach without transposition of the omentum, bronchoscopy revealed that the stomach had formed a tight seal with the posterior wall of the trachea. Because of the distal position of the tear, the stomach could not be further secured without performing a thoracotomy. It was felt that the seal between the stomach and posterior tracheal wall would keep air from entering the mediastinum during normal breathing, but that positive pressure ventilation might force air into the mediastinum. These concerns were discussed with the anesthesiologist, who felt confident that the patient could continue to breathe without assistance. We felt that the tight apposition