Interactive Cardiovascular and Thoracic Surgery 2:595-597(2003)
© 2003 European Association of Cardio-Thoracic Surgery
New ideas - Thoracic general |
Pericardial patch repair of an extensive longitudinal iatrogenic rupture of the intrathoracic membranous trachea
Christophoros N. Foroulisa,*,
Marina Simeoforidoub,
Dimitrios Michaloudisb and
Konstantinos Hatzitheofilouc
a Department of Cardio-thoracic Surgery, Larissa University Hospital, Larissa, Greece
b Department of Anesthesiology, Larissa University Hospital, Larissa, Greece
c Department of General Surgery, Larissa University Hospital, Larissa, Greece
* Corresponding author. 35 Ioustinianou Street, 41223 Larissa, Greece. Tel.: +30-241-0287-466; fax: +30-241-061-1097
foroulis{at}internet.gr
Received March 23, 2003;
received in revised form June 5, 2003;
accepted July 14, 2003
 |
Abstract
|
|---|
An iatrogenic, longitudinal rupture of the membranous trachea, which extended from the thoracic inlet to 2.0 cm above the carina, was found intra-operatively, during the thoracic stage of a three-stage esophagectomy, in a female, 80-year-old patient. Tracheal rupture was the result of tracheal intubation with a 35-F double-lumen endotracheal tube. Tracheal rupture was successfully repaired by suturing a free pericardial patch at the edges of tracheal rupture, by application of BioGlue on the external patch surface and by covering tracheal repair with a pedicled serratus anterior muscle flap. The patient had a 25-day intensive care unit stay and video-bronchoscopy performed at the 25th postoperative day showed absence of granulation tissue formation and an acceptable tracheal lumen. The overall hospital stay was 83 days because of abdominal complications; no problems concerning the tracheal repair were observed during the prolonged postoperative period.
Key Words: Trachea; Membranous trachea wall rupture; Membranous trachea wall repair; Double-lumen endotracheal tube complications; Pericardial patch
|
1. Introduction
|
|---|
Transmural trauma of the membranous trachea has occurred extremely rarely, as the result of neck and chest blunt/penetrating trauma, thoracic operations and tracheal intubation. Today, membranous trachea injury is mainly caused by intubation rather than by thoracic trauma [1,2]. Vigorous or difficult tracheal intubation is associated with an increased rate of membranous trachea rupture [3–5]. In most series concerning longitudinal membranous tracheal wall injuries, the reported way of repair is by direct closure of the rupture using fine absorbable sutures [1–6]. We report a different approach for membranous trachea repair, after an extensive longitudinal iatrogenic rupture, in a small-caliber trachea.
|
2. Technique
|
|---|
A clean, sharp-edged, longitudinal, membranous trachea rupture was discovered during the thoracic stage of a three-stage esophagectomy for esophageal cancer, located in the middle third of the esophagus. The 80-year-old, 147-cm tall, female patient was intubated with a left-sided, 35-F double-lumen endotracheal tube (Broncho-Cath Left, Mallinckrodt, Ireland). During mobilization of the intrathoracic esophagus, part of the double-lumen tube and the inflated tracheal cuff were seen to protrude through the ruptured membranous tracheal wall into the operating field, probably as the result of tracheal intubation and tracheal cuff inflation. A tracheal rupture, which extended from the thoracic inlet to 2.0 cm above the carina (5.0 cm long), was noticed. Tracheal repair was then performed at that time by tailoring and suturing an autogenous free pericardial patch to the tracheal rupture, using a running Vicryl (4.0) suture (Fig. 1). The mesothelial surface of the patch faced the tracheal lumen. The pericardial patch was harvested by incising the pericardium longitudinally, caudally to the phrenic nerve, by initiating the incision close to the superior vena cava pericardial reflection and extending it downward to the diaphragm. Thus, a pericardial patch about 10 cm long and 1.5 cm wide was harvested. No single approximation of the tracheal edges was decided upon, in order to avoid narrowing of the small caliber tracheal lumen. A thin layer of BioGlue (Cryolife International Inc., Kennesaw, GA, USA) was applied on the external pericardial tracheal patch surface, to avoid small air leaks from the suture line. The entire tracheal repair was covered with a pedicled serratus anterior muscle flap, fixed in the desired position with interrupted Vicryl (2.0) sutures in the surrounding mediastinal fat and pre-vertebral fascia. The pericardial gap, a result of pericardial patch harvesting, was left open. The main operation was completed by performing total esophagectomy and interposition of the transverse colon between the remnant cervical esophagus and the stomach, via the retrosternal way, after partial resection of the manubrium and of the right clavicle head. From the time of tracheal repair to the end of the operation, the left lung was mechanically ventilated, while a continuous positive airway pressure (CPAP) of 5 cmH2O was applied to the right lung, keeping the tracheal cuff of the double-lumen tube deflated. The patient was transferred to the intensive care unit (ICU), intubated and mechanically ventilated with a No. 7.0 single-lumen endotracheal tube, which was advanced bronchoscopically and fixed just above the carina. Bronchial toilet and the confirmation of the exact position of the endotracheal tube were succeeded by daily fiberoptic bronchoscopy. The patient had an ICU stay of 25 days (19 days on ventilator) and a cervical tracheostomy was made on the 14th postoperative day. Video-bronchoscopy, performed on the 25th postoperative day, showed absence of granulation tissue formation and an acceptable tracheal lumen, while stitches were not visible in the tracheal lumen at that time (Fig. 2). The patient had an uneventful postoperative course concerning tracheal reconstruction, and she was discharged from the hospital on the 83rd postoperative day after successful management of abdominal complications.
|
3. Comments
|
|---|
Postintubation longitudinal membranous trachea ruptures have been reported to be successfully repaired directly by continuous or interrupted, fine, absorbable sutures [1–6]. Reinforcement of the repair, by covering the suture line with a protective tissue, such as pericardium, pleura, muscle, mediastinal fat pad or azygos vein, has been suggested by some authors [1–3]. Tracheal ruptures, as the sequence of elective tracheal intubation with a double-lumen tube, are reported to occur mainly in the elderly and women (friable tracheal wall), while dissection for mobilization of the esophagus is another important risk factor for membranous laceration by the inflated tracheal cuff of the double-lumen tube, as membranous trachea looses its supportive strictures [1,3,4]. All the previous reported contributing factors for tracheal laceration were present in the case reported herein and also posed us the dilemma of how to repair the rupture, in order to avoid narrowing of the tracheal lumen. The method of pericardial patch repair, reinforced by a pedicled muscle flap, had good results in this small-caliber and -length trachea.
Good late results from direct membranous wall tracheal closure with fine sutures are reported in most series and confirmed with bronchoscopy [1–6]. We had also a good final result in our patient, where the strong tracheal repair was able to tolerate high intrapulmonary pressures and the presence of a cuffed tracheal tube during the long postoperative period on the ventilator. Pericardial patch has been used as a tracheal substitute in the past. Pericardial patch tracheoplasty for the repair of long-segmental congenital tracheal stenosis was described by Brown et al.; the authors found, in one case of postmortem pathologic examination of the repaired trachea, complete epithelization of the flap 2 years later [7]. Pericardial patch repair reinforced by synthetic material such as Marlex mesh or PTFE was reported by Moghissi [8] and Hasse [9], respectively, for the repair of tracheal defects resulting after extended pulmonary resections with partial carinal resection. In 1992 Gorenstein et al. [10] reported simple pericardial patch repair as an excellent alternative to direct closure of the membranous trachea, if narrowing of the lumen or tension closure is expected. We believe that the reinforcement of the pericardial patch repair by a pedicled thoracic muscle provides an excellent supportive stricture for the reconstructed membranous trachea and may also contribute to the revascularization of the free patch.
Pericardial patch has the disadvantage of shrinking and curling markedly after harvesting [11]. For this reason the patch should be stretched enough by the assistant during suturing, in order to place suture bites at the appropriate distance, avoiding air leakage. The application of BioGlue restricts air leakages of this source and is also supported by Marty-Ané et al. [3].
We advise pericardial patch repair supported by a pedicled muscle flap for extensive longitudinal membranous trachea ruptures in small body-sized patients, with small tracheal caliber, as the ideal way of repair, capable of supporting a long postoperative period with prolonged mechanical ventilation and of avoiding late tracheal stenosis.
doi:10.1016/S1569-9293(03)00142-7
|
References
|
|---|
- Hoffamnn HS, Retting G, Radke J, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg. 2002;21:649–652[Abstract/Free Full Text]
- Gabor S, Renner S, Pinter H, Sankin O, Maier A, Tomaselli F, Smolle Juttner FM. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg. 2001;20:399–404[Abstract/Free Full Text]
- Marty-Ané C-H, Picard E, Jonquet O, Mary H. Membranous tracheal wall rupture after endotracheal intubation. Ann Thorac Surg. 1995;60:1367–1371[Abstract/Free Full Text]
- Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. A report of ten cases. Eur J Cardiothorac Surg. 1997;12:98–100[Abstract]
- Kaloud H, Smolle-Juettner F-M, Prause G, Franz List W. Iatrogenic ruptures of the tracheobronchial tree. Chest. 1997;112:774–778[Abstract/Free Full Text]
- Mussi A, Ambrogi MC, Mencomi G, Ribechini A, Angeletti CA. Surgical approaches to membranous tracheal wall lacerations. J Thorac Cardiovasc Surg. 2000;120:115–118[Abstract/Free Full Text]
- Brown JW, Bando K, Sun K, Turrentine MW. Surgical management of congenital tracheal stenosis. Chest Surg Clin North Am. 1996;6:837–852[Medline]
- Moghissi K. Tracheal reconstruction with a prosthesis of marlex mesh and pericardium. J Thorac Cardiovasc Surg. 1975;69:499–506[Abstract]
- Hasse J. Patch closure of tracheal defects with pericardium/PTFE. A new technique in extended pneumonectomy with carinal resection. Eur J Cardiothorac Surg. 1990;4:412–416[Abstract]
- Gorenstein LA, Abel JG, Patterson GA. Pericardial repair of a tracheal laceration during transhiatal esophagectomy. Ann Thorac Surg. 1992;54:784–786[Abstract]
- Rendina EA. CTS net expert's techniques. Bronchial and pulmonary arterial sleeve resection. www.ctsnet.org/doc/6197.
This article has been cited by other articles:
|
|
|
|
 
C. N. Foroulis
eComment: Autologous or bovine pericardial patch for the repair of membranous tracheal wall lacerations?
Interactive CardioVascular and Thoracic Surgery,
October 1, 2008;
7(5):
868 - 868.
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction
