A novel technique for securing tracheal blood supply in salvage anterior mediastinal tracheostomy

The only way for complete cure of advanced esophageal cancer with invasion to the mid-trachea is anterior mediastinal tracheostomy (AMT), which has a significantly high risk of fatal complications. The shorter tracheal stump is beneficial for good blood supply, but complicates to create a tracheostomy.

A 71-year-old patient with a history of advanced cervical esophageal cancer who was treated with definitive chemoradiotherapy 3 years earlier had local recurrence on the left side of the trachea despite salvage lymphadenectomy for solitary left paratracheal lymph node recurrence 1 year earlier. AMT involving a resection of nearly the whole trachea was needded for complete resection. However, the recurrenced tumor was localized on the tracheal left side. We designed the new surgical procedure to preserve a longer segment of the unaffected right tracheal wall by diagonal cut (3.6cm longer than on the left side) while maintaining adequate blood flow by preserving the right lateral vascular pedicle in a state of connecting with the right lobe of the thyroid gland and the right tracheal stump. The postoperative course was uneventful, and at 1 year postoperatively, no tumor recurrence has been detected.

Preservation of the lateral vascular pedicle enables a longer tracheal stump by securing sufficient blood supply and a longer tracheal stump in AMT, even when unilateral, enables to create tracheostomy more surely, preventing fatal complications.

This novel procedure should be considered in cases with tumor invasion extending into the lower mid-trachea that is limited to one side.