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Interact CardioVasc Thorac Surg 2009;9:347-349. doi:10.1510/icvts.2009.203471 © 2009 European Association of Cardio-Thoracic Surgery
A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy
a Departments of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Received 23 January 2009; received in revised form 30 April 2009; accepted 1 May 2009
*Corresponding author. Tel.: +91-172-2756645, 2591552/Cell no. +91-9872041120, +91-9914209645; fax: +91-172-2744401.
Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45–60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity.
Key Words: Esophagectomy; Trachea; Injury; Repair; Technique; Laceration; Trauma; Transhiatal
Transhiatal esophagectomy (THE) is widely performed for benign and malignant conditions of the esophagus [1]. The close proximity of trachea to esophagus makes it vulnerable for injury during mediastinal dissection [1–3]. Tracheal laceration is a life threatening condition and demands immediate attention to ventilate the patient [2, 3]. Repair of the laceration is warranted once the patient is well ventilated [2, 3]. Conventionally, tracheal laceration is approached via thoracotomy [3, 4]. A variety of technical modifications has been described to tackle airway injury during esophagectomy [2, 5–8]. In another report we have described 1.30% incidence of tracheal injury during THE, and various strategies in the management of this complication [2]. The aim of the present report is to describe the technique of repair of tracheal laceration through the cervical incision used to expose the alimentary canal in the neck.
From January 2003 to December 2007, we managed three thin and lean male patients, age range 33–62 years, with lacreration of the membranous thoracic trachea, through neck incision at a tertiary care center. All the patients underwent trans-hiatal esophagectomy – for esophageal malignancy in two and achalasia with end stage esophageal disease in one. 2.1. Injury recognition and immediate management Injury to the membranous thoracic trachea occurred during the mediastinal phase of esophageal dissection. The injury was recognized immediately by loss of airway resistance in an attempt to ventilate the patient. The endotracheal tube was advanced into the right bronchus to establish adequate ventilation. Esophageal dissection was completed subsequently. The rent in the trachea was assessed by surgeon's finger and direct visualization. 2.2.1. Approach and exposureLongitudinal incision along the anterior border of sternocleidomastoid in left neck was extended up to the superior border of manubrium. The neck was hyperextended with a pillow between the shoulder blades and rotated towards left (position for THE). The surgeon positioned himself along the head end of the patient so as to visualize the retro-tracheal space. A head light was worn so as to illuminate the area of interest. Trachea was retracted medially and anteriorly, sternocleidomastoid laterally and maubrium anteriorly. The cervical esophageal stump was retracted cranially. This could widen the retro-tracheal space (Figs. 1 and 2).
2.2.2. Repair The tracheal rent was sutured with interrupted polyprolene (4.0) suture using long instruments from distal to proximal. The sutures were buttressed with muscle and fascial pledget. Care was taken not to take suture bite from the cuff of the endotracheal tube. Entire laceration was sutured in this fashion. At the end of tracheal repair the endotracheal tube was withdrawn so as to ensure that there was no inadvertent suturing of the airway tube. The gastric tube was advanced into the neck and was anastomosed to the esophageal stump. Bilateral intercostal tubes were placed and the procedure was completed. All the patients were ventilated for a period of 24–48 h. Deep breathing exercises were encouraged. Enteral nutrition was instituted through a jejunostomy tube within 24 h of surgery. Integrity of esophageal anastomosis was checked after a week before the resumption of oral diet.
The laceration ranged from 3.5 to 5 cm in length, one of which was extending up to the right bronchus. Balloon of the endotracheal tube got ruptured in two and aspiration of blood occurred in one. The operative procedure lasted for 45–60 min. All the patients were ventilated for 24–72 h postoperatively. One patient developed permanent left recurrent laryngeal nerve palsy requiring medialization of the cord, while another developed bronchopneumonia. There was no mortality. Two patients with malignancy remained stable until 15 and 24 months after surgery, when they succumbed to recurrent disease. One patient with benign disease is well at a follow-up of more than one year.
Tracheal injury is a rare, dreaded and potentially fatal complication of esophagectomy [1–3]. Although blunt mediastinal dissection during THE is thought to cause more damage to vital structures, but the incidence of tracheal injury was found to be similar in two large reports comparing the former with open thoracic approach [2, 3]. Management of major airway injury during THE is challenging as there is no direct access to membranous trachea during the procedure. This invariably entails the performance of thoracotomy or an anterior sternal split in order to facilitate repair, which add to the morbidity [3, 4]. A variety of technical modifications to avoid thoracotomy have been described to manage iatrogenic tracheal lacerations [2, 4–8]. Use of transposed stomach to patch the lacerations is suitable for small tears [2]. Longer lacerations often require suturing [2, 3]. Management of tracheal laceration through the neck wound has been well described in trauma [4, 5]. Gorenstein et al. [7] described the successful repair of membranous trachea at the level of carina through a cervical incision in a patient undergoing THE. Patient positioning, appropriate retraction and proper illumination are the key points for adequate exposure and visualization of the posterior laceration. Harney et al. [8] described the successful use of laparoscopic instruments to repair iatrogenic tracheal injury extending up to the carina. We have also emphasized the use of long instruments. Reinforcement of the repair using a variety of synthetic and autologous tissues has been described [6, 7]. We used autologous muscle pledgets to reinforce the repair. Concluding, management of injury to membranous trachea during transhiatal esophagectomy is challenging. Injuries as low as reaching up to the carina and beyond can be successfully managed through the cervical incision with the technique described without adding much to the morbidity. Thus this technical modification can avoid the need of an urgent thoracotomy/sternal split.
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Abstract
1. Introduction
