Advertisement

Mediastinal Tracheostomy With Vessel Transposition and Minimally Invasive Transhiatal Esophagectomy

Open ArchivePublished:October 27, 2016DOI:https://doi.org/10.1053/j.optechstcvs.2016.10.004
      As surgical outcomes and survival of patients with cancer improves, in particular patients with head and neck cancer would often develop multiple primaries. The limitations of radiation for repeated local therapy leave radical surgery as the only local option for some of these patients. Given the complexity of the issues at hand, these patients should be evaluated by a multidisciplinary team with expertise in otolaryngology, radiation oncology, medical oncology, and thoracic surgery. Mediastinal tracheostomy is rarely used, but it can be a useful tool in the management of these complex patients. When esophagectomy is performed in combination with pharyngolaryngectomy, a minimally invasive transhiatal approach can be used. Transhiatal esophageal mobilization is technically feasible with laparoscopy, and it obviates the need for thoracic incisions and patient repositioning in this already complex morbid procedure. Additionally, for cervical esophageal tumors, neither margins nor completeness of lymphadenectomy are sacrificed. We describe several critical steps of mediastinal tracheostomy and minimally invasive transhiatal esophagectomy for the management of these complex patients.

      Keywords

      Introduction

      The surgical care of large and invasive proximal esophageal and upper airway tumors has evolved significantly over the last half century. Although beyond the scope of this article, a comprehensive review of early techniques for reconstruction of the laryngopharynx and cervical esophagus was published by Fabian.
      • Fabian R.L.
      Reconstruction of the laryngopharynx and cervical esophagus.
      It offers a historical perspective and a logical timeline from the first survivable esophageal surgery and the early use of prosthetics through attempts at autografts and mucosal flaps, and finally the introduction of free tissue grafting. At that time, the 5-year survival rate for resection and reconstruction of the cervical esophagus and upper airway was 24%. The most complex lesions involving both trachea and esophagus, once thought inoperable, are now resected with good oncologic outcome followed by any of several well-accepted reconstruction options. These techniques include but are not limited to jejunal free flaps, pedicled local muscle flaps, and free anterolateral thigh flaps.
      • Ghali S.
      • Chang E.I.
      • Rice D.C.
      • et al.
      Microsurgical reconstruction of combined tracheal and total esophageal defects.
      Mediastinal tracheostomy is indicated in cases of extensive laryngotracheal resection where the residual trachea is too short to accommodate a cervical tracheostomy. This complex operation carries with it high morbidity rates between 20% and 70%, and mortality rate of up to 18%.
      • Martinod Emmanuel
      • Guillaume Jean-Yves
      • Radu Dana M.
      • et al.
      A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea.
      We describe mediastinal tracheostomy with vessel transposition and minimally invasive transhiatal esophagectomy. These procedures are useful for the thoracic surgeon in the treatment of both primary tracheal pathologies and secondary tracheal involvement as in the case of locally advanced head and neck cancers.
      • Kamiyama R.
      • Mitani H.
      • Yonekawa H.
      • et al.
      A clinical study of pharyngolaryngectomy with total esophagectomy: Postoperative complications, countermeasures, and prognoses.
      • Zhong Z.
      • Zhao E.
      • Xiao S.
      • et al.
      Surgical treatment for cervicothoracic esophageal carcinoma with tracheal involvement.
      • Conti M.
      • Benhamed L.
      • Mortuaire G.
      • et al.
      Indications and results of anterior mediastinal tracheostomy for malignancies.
      • Orringer M.B.
      As originally published in 1992: Anterior mediastinal tracheostomy with and without cervical exenteration.
      The rate of secondary head and neck malignancies after radiation treatment to neck is not trivial. In cases where the second tumor is ineligible for additional neck radiation, this procedure provides a definitive or palliative solution. The technique may also prove useful in the resection and reconstruction of tracheal anatomy for inoperable tumors. Mediastinal tracheostomy can be placed de novo during initial laryngotracheal resection, and it is also easily applied to the patient with a pre-existing tracheostomy in situ.
      Careful multidisciplinary operative planning and informed consent are one of the keys to the success of these complex operations. Head and neck surgeons, medical oncologists, radiation oncologists, speech pathologists, and respiratory therapists are among the multidisciplinary team that would assist the thoracic surgeon. Intraoperatively, the team approach is also of paramount importance in decreasing operative time and minimizing morbidity related to positioning and airway control.

      Operative Technique

      Part I: Transhiatal esophagectomy

      Patient positioning is of critical importance, particularly when multiple operative fields are active simultaneously. As described in the first part of this article, the patient is positioned supine, with arms tucked to facilitate the neck dissection. The legs are placed in split leg positioners; A 4-6-cm (depending on the size of the surgeon׳s hand) upper midline incision is made starting 1 cm distal to the xiphoid, and the gel hand port placed. A 5-mm supraumbilical trocar allows camera access, and a liver retractor is placed through a second 5-mm trocar in the anterior axillary line at or above the level of the umbilicus. Two additional working ports are placed in the left upper quadrant. After insufflation, abdominal exploration is undertaken. Although the authors prefer a hand-assisted approach, an entirely laparoscopic approach is a safe alternative. A fifth trocar would be placed in lieu of the hand port. Typically, we use a 30°, 5-mm camera (Fig. 1).
      The stomach is pulled inferiorly and to the patient׳s left, exposing the lesser curvature. A bipolar energy device is used to open the gastrohepatic ligament. Inspection and palpation of the translucent gastrohepatic ligament may reveal an accessory or replaced left hepatic artery (inset). Replaced left hepatic arteries should be spared.
      • Ghali S.
      • Chang E.I.
      • Rice D.C.
      • et al.
      Microsurgical reconstruction of combined tracheal and total esophageal defects.
      Accessory hepatic arteries can be transected. If unclear, temporary clamping of the vessel to assess for ischemia can help in deciphering the anatomy before dividing. When available, careful review of a contrast computed tomography scan would reveal this anatomical variant. The dissection is continued cephalad along the edge of the right crus. The phrenoesophageal ligament is divided across the esophageal hiatus to the left crus.
      The operation then proceeds by dissecting along the greater curvature and fundus of the stomach 1-2 cm away from the gastroepiploic vessels. Division of the second layer of the gastrocolic ligament allows entry into the lesser sac, which improves exposure by allowing the surgeon to manually elevate the stomach toward the field. The short gastric vessels are divided by continuing this dissection cephalad along the greater curvature toward the left crus until the spleen falls away from the field. The dissection of the left crus is performed with a hook cautery to complete circumferential exposure of the lower esophagus (Figure 2, Figure 3).
      Figure 3
      Figure 3Inset to 2: Gastrohepatic ligament with replaced left hepatic artery.
      The stomach is grasped along the greater curvature and reflected cephalad. Short, avascular attachments to the retroperitoneum and pancreas are divided sharply or with hook cautery, revealing the lesser curvature and the left gastric pedicle from the underside. The pedicle is encircled allowing for continual palpation while the artery and vein are skeletonized with a combination of bipolar cautery and finger fracture dissection and ultimately divided. Bulky pedicles can alternatively be divided using a vascular load of the endovascular stapling device, although sealing devices work quite well for these vessels (Fig. 4).
      An extensive kocherization is important for a tension-free, well-vascularized gastric conduit. The dissection of the distal lesser curvature is resumed at the previously opened gastrohepatic ligament and proceeds caudad. The right gastric pedicle is divided in the process, and the dissection proceeds along the duodenum where the Kocher maneuver is performed. Typically, we incise the peritoneum with hook cautery and then use blunt dissection for mobilization of the duodenum. In a similar fashion, the dissection along the greater curvature is taken caudad, being careful to remain at least 1-2 cm off the edge of stomach to preserve the right gastroepiploic pedicle. Palpation of the pulse through a hand port is advantageous here (Fig. 5).
      The esophagus is encircled loosely with a 1/4-in. Penrose drain (Medline, Mundelein, IL). With the Penrose elevated, circumferential dissection of the lower esophagus is undertaken using a bipolar energy device. Care is taken to avoid avulsion of direct arterial branches from the aorta by using gentle retraction of the esophagus. An assistant providing countertraction on the crus also significantly improves exposure during this important step. This dissection is continued circumferentially as high as possible, ideally to at least the level of the azygos vein. Here again, the presence of the hand port allows for a more traditional direct palpation of the mediastinal attachments during mobilization of the intrathoracic esophagus. Blunt dissection should be employed liberally in the anterior and lateral dissections to help define planes before dividing tissues, particularly after neoadjuvant radiation. Care is taken to not enter the pleural spaces. In obese or very tall patients, extra long laparoscopic instruments can improve visualization and dissection in this small space (Fig. 6).
      The gastric conduit is fashioned using a laparoscopic stapler. The first transection starts at the angular notch of the lesser curvature just proximal to the incisura and aiming 45° toward the greater curvature. The subsequent firings head toward the mid fundus, essentially dividing the stomach in half (Fig. 7).
      For cases of cervical esophageal cancer where the necessary gastric margin is small, the esophagus can be transected at the gastroesophageal junction and the stomach extracorporealized. The conduit can then be fashioned such that the lesser curvature is used as an additional (and the most proximal) portion of the gastric conduit providing the additional length, albeit ischemic, to reach the posterior pharynx. These typically will heal (Fig. 8).

      Part II: Mediastinal tracheostomy

      A midline upper sternal incision starts at the sternal notch and is carried down past the sternomanubrial junction and onto the sternum to the level of the second rib. Skin flaps are created on each side and the soft tissues in the midline are divided down to the bony sternum and manubrium. Periosteal elevators are used to clear the soft tissue off the anterior surface of the manubrium and heads of clavicles bilaterally. The retromanubrial and retrosternal spaces are bluntly developed and then temporarily packed with sponges to protect the vessels that lay just beneath. The clavicular heads are circumferentially dissected and transected using an oscillating or Gigli saw. A U-shaped portion of manubrium is resected also with the oscillating saw. The sternum is divided just medial to the insertion of the second rib using the sagittal saw. This dissection can be taken further inferiorly if the pathology so necessitates; by dividing the sternum medial at the costal insertions, the internal mammary vessels can be spared (Fig. 9).
      A limited thymectomy allows for increased visualization of the innominate vessels. Dissection is carried down to the left innominate vein, which is dissected circumferentially and controlled with a vessel loop. The innominate artery is controlled in a similar manner. Skeletonization of the innominate vessels is critical to the next steps (Fig. 10).
      Figure 10
      Figure 10Post sternotomy anatomy and innominate vessel dissection.
      The patient is ventilated to 100% oxygen saturation. The tracheal balloon is deflated, and the endotracheal tube pulled back. The trachea is transected several tracheal rings distal to the tumor or the cervical tracheostomy if one is in place. After transection of the anterior half of the trachea, stay sutures are placed on each side at 9 and 3-o׳clock positions. The tracheal transection is completed while pulling forward on the stay sutures and an over-the-field ringed endotracheal tube is placed into the distal trachea and the balloon reinflated (Fig. 11).
      Figure 11
      Figure 11Tracheal transection and transposition.
      When the trachea is short, the innominate vessels are elevated, and the trachea is passed underneath using the stay sutures, allowing a more direct route to the anterior chest (inset).
      The trachea is sutured to the dermis circumferentially with interrupted absorbable sutures such as 2-0 Vicryl. Given the thickness of the sternum, the bony edges can be tailored to adjust the step-off between the skin surface and the tracheal edge for a more cosmetic skin closure. The midline chest incision is then closed in 2 layers (Fig. 12).
      Figure 12
      Figure 12Inset of transposed trachea (partially sutured).
      After completion of the pharyngolaryngectomy, the transected pharynx is retracted anteriorly allowing better access to the esophagus. In cases of large masses or malignant tumors where the structures are fused together, this resection is performed en bloc so that the anterior wall of the esophagus is not dissected free of the pharynx, larynx, and posterior trachea. The esophageal dissection is approached laterally from each side working toward the spine. All nodal tissues are removed en bloc with the specimen. Transection of the recurrent laryngeal nerves is not of concern in this case given that the upper airway is being removed, so a more liberal dissection allows improved oncologic clearance. Once dissected off the spine, the dissection of the upper thoracic esophagus is undertaken. A combination of blunt dissection and sealing device for the vessels are used to continue the distal dissection of the esophagus until it meets with the dissection from the transhiatal approach. The esophagus is then transected with a stapler at the gastroesophageal junction and the specimen delivered en block from the neck. If the esophageal and tracheolaryngeal specimens are separable, the delivery of the esophageal specimen can be approached through the abdomen. Either way, when removing the esophagus from its mediastinal position, tying or suturing an umbilical tape to the specimen before removal facilitates later delivery of the conduit through the mediastinum. The tubularized stomach is then passed anatomically through the posterior mediastinum to the neck using an attached umbilical tape, or by grasping with a blunt clamp passed from the neck to the abdomen. A long, curved ring forceps typically works well for this maneuver. Once in the neck, excess conduit is resected and the esophageal anastomosis is performed with interrupted 3-0 Vicryl sutures. We typically perform a 2-layered anastomosis (Fig. 13).
      Figure 13
      Figure 13Esophageal dissection and anastomosis.
      Flap closure is encouraged given the large dead space in the neck after this dissection. Drains are used liberally to avoid postoperative fluid collections necessitating additional procedures. We suggest closed suction drains in subcutaneous spaces bilaterally, and along the anastomosis. These drains are removed sequentially, with the perianastomotic drain remaining until oral intake is resumed. The chest incisions are closed. With a drain left beneath the closure (Fig. 14).

      Summary

      We describe a rare and complex procedure: resection and reconstruction of advanced cervical esophageal cancer in patients who are not candidates for the traditional therapeutic option of definitive chemotherapy and radiation. The successful undertaking of this operation requires open and direct communication between the members of the multidisciplinary team. Following the operation, the arduous recovery process requires a motivated patient and a skilled team familiar with the postoperative pitfalls.
      Airway management is of foremost importance. The patient may be liberated from the ventilator immediately after the operation, or, depending on operative length and circumstances, shortly thereafter. The authors suggest an early postoperative chest radiograph to rule out pneumothorax in cases where the pleura was knowingly or inadvertently injured. Once off the ventilator, oxygen or room air should be delivered through a humidifier, and ultimately through a heat and moisture exchanger valve.
      Pulmonary toilet with physical chest percussion, mucolytic nebulizers, and frequent suctioning would prevent mucous plugging. The patient and caregivers must be aware of positioning restrictions given the now obligate chest breather.
      Drains are monitored for changes in volume and character to rule out chylothorax or deep space infections, and are removed sequentially once the output decreases. The perianastomotic drain is left in place until esophagram rules out a leak. The authors perform esophagrams on postoperative day 7, or day 14 in the previously irradiated neck.
      Broad-spectrum perioperative antibiotic coverage is mandatory given obligate entry into the airway and gastrointestinal tract. In particular, when the entire gastric conduit is used, a longer antibiotic course may be warranted given the increased risk of ischemia and leak in the neck. Mitigating a mediastinal infection is paramount, but it must be weighed against the drawbacks of lengthy antibiotic use as well.
      Given the lengthy procedure and the oncologic diagnosis, early prophylaxis for venous thromboembolism is encouraged. However, we consider this on a day-by-day basis as typically the postoperative hemoglobin levels in an esophagectomy patients would drift down. We have a high threshold for blood transfusions given the association with decreased survival in oncologic patients.
      • Satomoto M.
      • Suzuki A.
      • Uchida T.
      • et al.
      Potential influence of pre and intraoperative factors on postoperative recurrence and survival in patients undergoing radical resection of esophageal cancer.
      The confined space of the neck and position of the drains should help in early identification of an unlikely event of a bleeding complication.
      Complications can extend far outside the immediate postoperative period. These patients would require careful long-term follow-up and multispecialty care regardless of the primary disease for which the resection was performed. In one case series prospectively collected over 9 years,
      • Bagheri R.
      • Rahim M.B.
      • Majidi M.
      • et al.
      Anterior mediastinal tracheostomy for malignancy: Analysis of 12 cases.
      12 patients underwent anterior mediastinal tracheostomy for recurrent tracheal disease, primary tracheal carcinomas with subglottic extension, or carcinoma of the tracheal esophagus (3/12). They were followed up for at least 1 year; the procedure was highly successful, with complete tumor excision in all patients, however, the morbidity rate was high; postoperative complications included atelectasis (3/10), stomal necrosis (1/10), and anastomotic leak (1/10), with a 16.6% in hospital mortality.
      Complications were similar in a group of 10 patients with primary esophageal cancers who underwent total laryngopharyngoesophaectomy with gastric pull-up over a 10-year period. In all, 7 of 10 patients had preoperative radiotherapy. The most common complications were tracheal necrosis (60%) and anastomotic leakage in the neck (30%). Postoperative hemorrhage (20%) and anastomotic stricture (10%) were less common.
      • Homma A.
      • Nakamaru Y.
      • Hatakeyama H.
      • et al.
      Early and long-term morbidity after minimally invasive total laryngo-pharyngo-esophagectomy with gastric pull-up reconstruction via thoracoscopy, laparoscopy and cervical incision.
      Monitoring patients in the long term for further complications such as stricture of the tracheal stoma and tracheoinnominate fistula.
      Finally, quality of life is a major consideration. A total of 29 patients who underwent pharyngolaryngoesophagectomy with pharyngogastric anastomosis for upper aerodigestive tract tumors completed questionnaires. All respondents were able to complete activities of daily living, and 70% reported acceptable voice rehabilitation.
      • Affleck D.G.
      • Karwande S.V.
      • Bull D.A.
      • et al.
      Functional outcome and survival after pharyngolaryngoesophagectomy for cancer.
      Treatment goals and patient expectations should weigh heavily in the decision to offer this complex operation, and they should be discussed at length preoperatively.

      References

        • Fabian R.L.
        Reconstruction of the laryngopharynx and cervical esophagus.
        Laryngoscope. 1984; 94: 1334-1350
        • Ghali S.
        • Chang E.I.
        • Rice D.C.
        • et al.
        Microsurgical reconstruction of combined tracheal and total esophageal defects.
        J Thorac Cardiovasc Surg. 2015; 150: 1261-1266
        • Martinod Emmanuel
        • Guillaume Jean-Yves
        • Radu Dana M.
        • et al.
        A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea.
        Interact Cardiovasc Thorac Surg. 2011; 12: 672-675
        • Kamiyama R.
        • Mitani H.
        • Yonekawa H.
        • et al.
        A clinical study of pharyngolaryngectomy with total esophagectomy: Postoperative complications, countermeasures, and prognoses.
        Otolaryngol Head Neck Surg. 2015; 153: 392-399
        • Zhong Z.
        • Zhao E.
        • Xiao S.
        • et al.
        Surgical treatment for cervicothoracic esophageal carcinoma with tracheal involvement.
        Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2014; 49: 31-34
        • Conti M.
        • Benhamed L.
        • Mortuaire G.
        • et al.
        Indications and results of anterior mediastinal tracheostomy for malignancies.
        Ann Thorac Surg. 2010; 89: 1588-1595
        • Orringer M.B.
        As originally published in 1992: Anterior mediastinal tracheostomy with and without cervical exenteration.
        Ann Thorac Surg. 1999; 67 ([Updated in 1998]): 591
        • Satomoto M.
        • Suzuki A.
        • Uchida T.
        • et al.
        Potential influence of pre and intraoperative factors on postoperative recurrence and survival in patients undergoing radical resection of esophageal cancer.
        Masui. 2014; 63: 1344-1349
        • Bagheri R.
        • Rahim M.B.
        • Majidi M.
        • et al.
        Anterior mediastinal tracheostomy for malignancy: Analysis of 12 cases.
        Asian Cardiovasc Thorac Ann. 2013; 21: 187-192
        • Homma A.
        • Nakamaru Y.
        • Hatakeyama H.
        • et al.
        Early and long-term morbidity after minimally invasive total laryngo-pharyngo-esophagectomy with gastric pull-up reconstruction via thoracoscopy, laparoscopy and cervical incision.
        Eur Arch Otorhinolaryngol. 2015; 272: 3551-3556
        • Affleck D.G.
        • Karwande S.V.
        • Bull D.A.
        • et al.
        Functional outcome and survival after pharyngolaryngoesophagectomy for cancer.
        Am J Surg. 2000; 180: 546-550