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Tracheo-carinal reconstructions using extrathoracic muscle flaps

^a Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
^b Division of Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
^c Department of Anaesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Received 30 August 2007; received in revised form 22 October 2007; accepted 31 October 2007.

^_* Corresponding author. Address: Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudoise, 1011 Lausanne, Switzerland. Tel.: +41 21 314 24 08; fax: +41 21 314 23 58. (Email: hans-beat.ris{at}chuv.ch).

Objectives: Prospective evaluation of tracheo-carinal airway reconstructions using pedicled extrathoracic muscle flaps for closing airway defects after non-circumferential resections and after carinal resections as part of the reconstruction for alleviation of anastomotic tension. Methods: From January 1996 to June 2006, 41 patients underwent tracheo-carinal airway reconstructions using 45 extrathoracic muscle flaps (latissimus dorsi, n = 25; serratus anterior, n = 18; pectoralis major, n = 2) for closing airway defects resulting from (a) bronchopleural fistulas (BPF) with short desmoplastic bronchial stumps after right upper lobectomy (n = 1) and right-sided (pleuro) pneumonectomy (n = 13); (b) right (n = 9) and left (n = 3) associated with partial carinal resections for pre-treated centrally localised tumours; (c) partial non-circumferential tracheal resections for pre-treated tracheal tumours, tracheo-oesophageal fistulas (TEF) and chronic tracheal injury with tracheomalacia (n = 11); (d) carinal resections with the integration of a muscle patch in specific parts of the anastomotic reconstruction for alleviation of anastomotic tension (n = 4). The airway defects ranged from 2 x 1 cm to 8 x 4 cm and involved up to 50% of the airway circumference. The patients were followed by clinical examination, repeated bronchoscopy, pulmonary function testing and CT scans. The minimum follow-up time was 6 months. Results: Ninety-day mortality was 7.3% (3/41 patients). Four patients (9.7%) sustained muscle flap necrosis requiring re-operation and flap replacement without subsequent mortality, airway dehiscence or stenosis. Airway dehiscence was observed in 1/41 patients (2.4%) and airway stenosis in 1/38 surviving patients (2.6%) responding well to topical mitomycin application. Follow-up on clinical grounds, by CT scans and repeated bronchoscopy, revealed airtight, stable and epithelialised airways and no recurrence of BPF or TEF in all surviving patients. Conclusions: Tracheo-carinal airway defects can be closed by use of pedicled extrathoracic muscle flaps after non-circumferential resections and after carinal resections with the muscle patch as part of the reconstruction for alleviation of anastomotic tension.

Key Words: Tracheal resections • Carinal resections • Extrathoracic muscle flaps • Tumours • Tracheo-oesophageal fistulas • Tracheal injury

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