Anterior mediastinal tracheostomy as salvage operation

This study aimed to assess early and long-term results after anterior mediastinal tracheostomy (AMT) as a salvage operation for recurrent neck malignancies.

Between October 2006 and February 2013, 12 patients (mean age, 57 years) underwent AMT. All patients had experienced stomal recurrence, with or without esophageal involvement, after laryngectomy. All patients had undergone previous radiotherapy (50.3 ± 6.2 [43-60] Gy) and previous surgical treatment: total laryngectomy (n = 11) and thyroidectomy (n = 2).

The mean length of resected trachea was 3.7 ± 2.7 (2.5-6) cm. Resection was complete in 10 patients. All patients required relocation of the remaining trachea below the innominate artery and myocutaneous flap for coverage/stoma construction. AMT was associated with esophagectomy (n = 4) and supraaortic trunk resection (innominate artery, n = 2; carotid artery, n = 3). Seven patients required resection of the pharyngoesophageal region, and 4 patients underwent reconstruction, including primary closure of a pharyngeal remnant (n = 1) and gastric pull-up (n = 3). There was 1 operative death (8.3%) resulting from an infectious process leading to bypass fistulization. Major complications were partial tracheal necrosis (n = 3), pharyngeal fistula (n = 1), pneumonia (n = 4), and flap dehiscence (n = 2). Length of hospital stay was 30 ± 22.8 (13-86) days. Actuarial overall 5-year survival was 58.3%, and median estimated disease-free survival was 53 (31-75) months.

Our experience with AMT as salvage therapy has shown acceptable long-term results if complete resection is achieved. This procedure is not risk free, and very careful patient selection is required because of a tortuous postoperative course, especially in combined pharyngeal-esophageal and vascular reconstruction.