experiences with prosthetic reconstruction trachea and ... · a54yearold manwith progressive...

Thorax 1985;40:32-37

Experiences with prosthetic reconstruction of thetrachea and bifurcationH TOOMES, G MICKISCH, I VOGT-MOYKOPF

From the Department of Thoracic Surgery, Rohrbach Hospital, Clinic for Thoracic Medicine, Heildelberg,West Germany

ABSTRAcr Extensive tracheal resections were performed to avoid imminent asphyxia in ninepatients. Airway continuity was restored with either a straight or a bifurcated Neville prosthesis.One patient had progressive perichondritis and the remaining eight had advanced malignancy.Three patients died of complications due to the prosthesis, 15 days, seven months, and 10 monthsafter operation. Five patients from their underlying disease and one patient is alive 13 monthsafter reconstruction.For more than 30 years various materials have beenused for prosthetic reconstruction of the trachea andbifurcation, in animal studies and subsequently inman (table 1).1-38 The frequent changing of materi-als, combined with the short survival of the patientsafter reconstruction, reflects the unsolved problem

of synthetic substitution. For good prosthetic recon-struction of the trachea there are five essentialconditions-namely, airproof sealing, flexibility toavoid erosion of major blood vessels, good tissuetolerance with minimal reaction, resistance toincrustation and bacterial invasion, and the possibil-

Table 1 Materials used for prosthetic tracheal reconstruction with references to published papers

Ist author and date ofpaper

Vitallium Daniel'Glass Daniel'Stainless steel Daniel'

Cotton4Lucide Longmire'Polyethylene Clagett'

Craig"Biocarbone Hoffmann"Tantalum Ferguson'2

Knothe'4Stainless steel Bucher"Tantalum with fascia lata, pleura, skin

19481948194819521948194819531980195019681951

Rob'" 1949Ravitch'9 1951

Stainless steel with fascia, skin, pericardiumRob'7 1949Belsey22 1950

Marlex mesh Greenberg23 1962Ellis25 1962

Ivalon Taber21 1958Nylon Holle21 1953Dacron Parhofer30 1965Teflon Ekestrom3' 1959

Atamanyuk33 1962Silicone rubber with dacron nrng

Grazianoe 1967Demos's 1973

Marlex mesh with autogenous fibrous cartilage, omentum,mucosa, pericardium

Poticha36 1966Greenberg23 1962Moghissi3" 1975

Holmes2

Jarvis3

Michelson6Pressman8Morfit'°

Kiriluk"

Keshian'6

Carter'8Edgerton20

Gebauer2'Bucher"Beall24Pearson26Michelson6Bornemisza2'

Dramish32

1950

1950

196119531955

1953

1956

19501954

195019511960196819611961

1961

Neville353' 1972, 1976Vogt-Moykopf40 1980

tracheal

Pearson"7 1974

Address for reprint requests: Dr Heikki Toomes, Rohrbach Hospi-tal, Amalienstrasse 5, D-6900 Heildelberg, West Germany.Accepted 29 August 1984

32

Material

Hard material

Metal netting

Metal nettingand tissue

Plastic

Plastic with tissue

on February 4, 2020 by guest. P

rotected by copyright.http://thorax.bm

j.com/

Thorax: first published as 10.1136/thx.40.1.32 on 1 January 1985. D

ownloaded from

http://thorax.bmj.com/

Experiences with prosthetic reconstruction of the trachea and bifurcation

ity of epithelialisation.In practice, most of the materials used do not fulfil

these requirements and have to be regarded as ofonly historical interest. The silicone rubber pros-thesis, however described by Neville,"' with a non-terminal dacron ring (fig 1) and telescopic sinking ofthe prosthesis into the tracheal lumen is almost idealexcept for epithelialisation. It has been of clinicalimportance since 1967 and experiences with it havebeen reported during this period.39-4'

Fig 2 Diagrammatic representation oftrachealreplacement showing a straight Neville prosthesis.

Fig 1 Straight and bifurcated Neville prosthesis (scale incentimetres).

Patients and methods

Since 1979 we have performed nine resections ofthe trachea or bifurcation with reconstruction of theairway with a straight or bifurcated Neville pros-thesis (figs 2 and 3), using the surgical techniquewhich was originally described.3" Eight patients hadmalignant disease of the trachea and one sufferedfrom progressive perichondritis; clinical details are

summarised in table 2. In three cases ( 1, 3, and 5)the approach was through a collar incision, while theremaining six underwent a right thoracotomy. Venti-lation was maintained across the operative field inall cases and extracorporeal oxygenation was notrequired.

All patients were operated on because of extremedyspnoea and life threatening asphyxia. The deci-sion to use prosthetic reconstruction was made only

at operation when it was found impossible to per-form end to end anastomosis, because of the lengthof tracheal resection required.

Case reports

A 49 year old man was referred with an extensivesquamous carcinoma of the middle third of thetrachea. When admitted to us he had severe

respiratory distress that required immediate endo-

t' ' _X .1

Fig 3 Diagrammatic representation ofcarinal replacementusing a bifurcated Neville prosthesis.

tracheal intubation. Bronchoscopically the tumourwas causing a 4 cm stenosis of the trachea andappeared to be resectable. Operation was per-formed through a collar incision but it showed thatthe tumour had invaded the thyroid gland and theconnective tissue on both sides of the trachea. Apalliative resection of the tumour together with 7 cmof the trachea was performed with reconstructionusing a straight Neville prosthesis. The postopera-tive course was uncomplicated and three weeks laterradiotherapy was commenced. Two months afteroperation the patient died suddenly with heart fail-ure.

CASE 2

A 29 year old woman who had had a malignantmelanoma removed from the occipital region nineyears previously was referred with haemoptysis anddyspnoea. Bronchoscopy showed a mass of tumourin the distal trachea and bifurcation. At operationthe extent of the tumour required resection of the

.0t

ti++

t.i4

. ' (

33

4



j.com/


ownloaded from


Table 2 Clinical data on nine patients treated with a Neville prosthesis

Patient Age Sex Pathology Location Operadon Survival Complications due Cause ofno tme to prosthesis death

1 49 M Squamous cell Middle Resection 7 cm, 2 m Tumourcarcinoma

2 29 F Malignantmelanomametastasis

3 55 M C cellthyroidcarcinoma

4 55 F Malacia(previouslymphosarcoma)

5 55 M Cylindroma

6 54 M

thirdDistal

trachea andbifurcation

Upper andmiddlethirds

Middlethird

Upper and-12 1middle thirds

Progressive Upper andperichondritis middle thirds

straight prosthesisCarinal resection,

bifurcatedprosthesis

Resection 9 cm,caval patch,bifurcatedprosthesis

Resection 6 cmstraight prosthesis



7 58 M Squamous cell Right main Pneumonectomy,carcinoma bronchus and carinal resection,

carina straight prosthesis8 50 M Cylindroma Bifurcation Carinal resection,

bifurcatedprosthesis

9 63 M Squamous cell Right upper Carinal resection,carcinoma lobe and bifurcated

carina prosthesis

carina together with the distal end of the trachea.Reconstruction was by means of a bifurcated Nevilleprosthesis. Three weeks later the patient developeda left vocal cord paralysis and stridor due to a newmetastasis. This was removed by laryngotomy, atwhich time a Montgomery tube42 was inserted toavoid difficulties with retention of sputum. Thepatient subsequently learned to conduct suctionthrough the Montgomery tube herself and was dis-charged. Four months later she died from furtherdissemination of her tumour.

CASE 3A 55 year old man had resection of 9 cm of thetrachea through a collar incision, for an extensivethyroid carcinoma with dyspnoea and stridor. In thecourse of removal of lymph node metastases severevenous bleeding occurred. A right thoracotomyshowed that the superior vena cava was invaded bytumour and this was tangentially resected and closedwith a patch from the azygos vein. Airway continuitywas restored with a straight Neville prosthesis, butthe patient did not recover from this procedure anddied 10 days later in the intensive care unit.

CASE 4A 55 year old woman was admitted with severerespiratory distress two years after radiotherapy tothe mediastinum for a lymphosarcoma. Bronchos-

4 m Sputum retention

10d

15 d Erosion haemorrhage

7m

lom

4m

13 m(alive)

8 d

Loosening ofprosthesis

Sputum retention,loosening ofchanging ofprosthesis

Granulation tissue,laser coagulation

Sputum retention

Tumour

Cardio-respiratoryinsufficiency

Erosionhaemorrhage

Septicaemia

Erosionhaemorrhage

Tumour

Cardio-respiratoryinsufficiency

copy reveal extensive malacia of the middle third ofthe trachea. At operation 6 cm of the trachea had tobe resected. Despite extensive mobilisation of theremaining trachea an end to end anastomosis wasnot possible owing to a loss of flexibility from theprevious irradiation. A straight prosthesis wasinserted and wrapped in a soft Gore-Tex patch toprevent erosion of the innominate artery. Despitethis, however, a fatal haemorrhage occurred on the15th postoperative day. At postmortem examina-tion the patch was found to be folded and stiffened,with resulting damage to the artery. Since then wehave abandoned this technique.

CASE 5A 55 year old man was referred with a cylindroma(fig 4) of the upper trachea. Through a collar inci-sion 5 cm of the trachea was resected, but frozensections showed the margins to be affected bytumour and the resection had to be extended to 8cm. Despite mobilisation end to end anastomosiscould not be performed and a straight Neville pros-thesis was inserted. The postoperative course wasuneventful, and endoscopy after four monthsshowed the prosthesis still in position and in goodcondition. Seven months after operation the patientwas readmitted with an acute mediastinitis and rightsided empyema due to detachment of the prosthesisat its distal end. Despite immediate operation andresuture of the prosthesis the patient died from sep-ticaemia.

34 Toomes, Mickisch, Vogt-Moykopf



j.com/


ownloaded from


Experiences with prosthetic reconstruction of the trachea and bifurcation

Fig 5 Operative photograph showing insertion ofastraight Neville prosthesis over the endotracheal tube.

.,.....................j./..../hS.

Fig 4 Operative specimen (case 5) showing cylindroma ofthe trachea with longitudinial extensioni (scale incentimetres).

(ASE 6A 54 year old man with progressive perichondritis ofthe upper and middle thirds of the trachea hadrequired a tracheal cannula for some two years. Inthe past two weeks repeated life threatening cyano-

tic attacks had occurred despite the use of differenttypes of tracheal tube. Because of severe malacia ofthe trachea a 6 cm resection was required but scartissue, presumably from a mediastinitis, preventedend to end anastomosis and a straight prosthesis wasinserted. His postoperative recovery was compli-cated by sputum retention. Six weeks after opera-tion the prosthesis became loose and partiallyblocked the tracheal lumen. Reoperation was per-formed and a new prosthesis inserted (fig 5), com-bined with a NIontgomery tube for sputum control.The patient then made a good recovery and wasdischarged from hospital after two months. Tenmonths after operation he died suddenly at homefrom an erosion haemorrhage.

( ASE 7

A 58 year old man was referred with respiratory

distress due to a squamous carcinoma of the rightmain bronchus affecting the carina. Pneumonec-tomy with resection of the bifurcation of the tracheawas performed and the airway reconstructed with astraight prosthesis. Staging showed the tumour to beT3N2MO. The postoperative course was uneventfuland the patient was discharged. Four and a halfmonths later he died from recurrence of the tumourwith occlusion of the remaining left main bronchus.

CASE 8A 50 year old man was admitted with atelectasis ofthe right lower lobe and dyspnoea due to recurrenceof a cylindroma of the lower trachea. This had beenirradiated nine years previously and for the past fouryears he had required several endoscopic lasercoagulations for tumour recurrence. At bronchos-copy the tumour appeared to be resectable andreconstruction of the bifurcation was planned. Hisprevious irradiation prevented mobilisation of thetrachea and a bifurcated prosthesis was inserted.After operation he developed sputum retention buteventually his condition improved and he was dis-charged after two months. Six and 11 months afteroperation granulation tissue had to be removed bylaser coagulation at the anastomosis with the rightmain bronchus, but 13 months after operation theprosthesis is in good position and the patient is well.

CASE 9A 63 year old man was referred with a bronchialcarcinoma of the right upper lobe affecting thebifurcation of the trachea. The upper lobe and bifur-cation were resected and reconstruction was per-formed with a bifurcated prosthesis. Three weeksafter operation the patient had severe sputum reten-tion and bronchoscopy revealed necrosis of theupper anastomosis. Reoperation was performed,when the right pneumonectomy was completed and

35



j.com/


ownloaded from


36

airway continuity reestablished with two joinedstraight prostheses. The patient, however, did notrecover and died on the eighth day from cardiores-piratory insufficiency.

In this series two patients (3 and 9) died after opera-tion and three (4, 5, and 6) died subsequently fromcomplications related to the prosthesis. One diedtwo months and two others four months after opera-tion from their underlying disease but with the pros-thesis functioning satisfactorily. The remainingpatient is alive and well at 13 months.

After operation all patients remained in the inten-sive care unit for at least four days for control ofsputum. Bronchoscopic suction was performed asnecessary and bronchoscopy was also performedbetween four and six weeks to assess the state andposition of the prostheses. Retention of sputumwas an important problem in three patients. In twothis was controlled by the insertion of a Montgom-ery tube while the third recovered with the use ofregular mucus solvents.

Discussion

As a palliative measure severe airway obstructionmay be treated by the insertion of different tubes, asdescribed by Montgomery,42 Clarke,43 and Westabyet al.44 Definitive treatment, however, requiresresection of the obstruction and whenever possiblethis should be followed by end to end anastomosis ofthe trachea to restore the continuity of the airway, ifnecessary with the addition of a laryngeal release.45Prosthetic reconstruction of the trachea should beconsidered only when anastomosis is not possible,but it may be required if there is extensive scarringwhich prevents mobilisation (for example, from pre-vious mediastinitis or irradiation), or if an extensivetracheal resection is required.

In 1973 Demos et a146 reported on animal experi-ments with a silicone prosthesis, followed by its usein a single patient with no follow up. In 1976 Nevilleand Bolanwski reported on 26 patients with recon-struction of the trachea using a silicone rubber pros-thesis and dacron sewing ring.39 Eight patients had abifurcated prosthesis and 18 a straight prosthesis. Ofthe 18 patients with a straight prosthesis, the first 13did not have the prosthesis telescoped into thelumen and six developed suture granulomas. Onedeath resulted from a complication of the prosthesiswith erosion of the innominate artery. Survival of upto five years has been reported.The problems of granulation tissue and late suture

adhesions appear to have been resolved buthaemorrhage from erosion of the great vessels canstill occur and Neville has recommended protection

Toomes, Mickisch, Vogt-Moykopfof the vessels with a double flap of pericardium.Alternative methods which have been suggested forthis purpose include the use of the pedicled greateromentum or division of the innominate artery"' orthe use of de-epithelialised dermal flaps or muscularflaps taken from the sternomastoid muscle.48 On thebasis of our experience we believe that prostheticreconstruction does have a place in the managementof tracheal obstruction and can give good long termresults. Nevertheless the method does have impor-tant complications and should be reserved for casesin which direct anastomosis is definitely impossible.

References

1 Daniel RA jun. The regeneration of defects of thetrachea and bronchi: An experimental study. J ThoracSurg 1948; 17:335-49.

2 Holmes CL. In discussion of Gebauer P. Dermal graftsfor tracheobronchial reconstruction. J Thorac Surg1950;20:650.

3 Jarvis FJ. In discussion of Gebauer P. Dermal graftsfrom tracheobronchial reconstruction. J Thorac Surg1950;20:649.

4 Cotton BH, Penido JRJ. Resection of the trachea forcarcinoma: Report of two cases. J Thorac Surg1952;24:231-42.

5 Longmire WP jun. Tracheal wounds and injuries,repair of large defects. Ann Otol Rhinol Laryngol1948; 572: 875-83.

6 Michelson E, Solomon R, Mann L, Romire J. Experi-ments in tracheal reconstruction. J Thorac CardiovascSurg 1961;41:748-59.

7 Clagget OR, Grindlay JH, Moersch HJ. Resection ofthe trachea: An experimental study and a report of acase. Arch Surg 1948;57:253-66.

8 Pressman JJ. Experimental tracheal implants. AnnOtol Rhinol Laryngol 1953;62:791-802.

9 Craig RL, Holmes GW, Shabart EJ. Resection andreplacement with prosthesis. J Thorac Surg1953;25:384-96.

10 Morfit HM and others. Sleeve resections (including useof polyethylene tube). Experimental studies onregenerative capacity and principles of reconstructionand repair. Arch Surg 1955;70:654-61.

11 Hoffmann TH, Randell HT. Comparison of lobectomyand wedge resection for carcinoma of the lung. JThorac Surg 1980;79:211-7.

12 Ferguson DJ, Wild JJ, Wangensteen OH. Experimen-tal resection of the trachea. Surgery 1959;28: 597-603.

13 Kiriluk LB, Richer WA jun, Merendino KA. Experi-mental evaluation in dog of bronchial transplantation,bronchial, tracheal and tracheobronchial resection withreconstruction. Ann Surg 1953; 137:490-503.

14 Knothe W. Bronchiektasen und Lungenabszesse.Thoraxchirurgie 1967; 15:488-98.

15 Bucher RM, Burnett E, Rosemond GP. Experimentalreconstruction of the trachea and bronchial defectswith stainless steel wire mesh. J Thorac Surg1951;21:572-83.

16 Keshishian JM, Blades B, Beattie EJ jun. Trachealreconstruction. J Thorac Surg 1956;32:707-25.



j.com/


ownloaded from


Experiences with prosthetic reconstruction of the trachea and bifurcation17 Rob CG, Bateman GH. Reconstruction of the trachea

and cervical esophagus: Preliminary report. Br J Surg1949;37: 202-5.

18 Carter MG, Strieder JW. Resection of trachea andbronchi: Experimental study. J Thorac Surg1950;20:613-27.

19 Ravitch M. In discussion of Gebauer P. Reconstructivesurgery of the trachea and bronchi: late results withdermal grafts. J Thorac Surg 1951; 21:568. .

20 Edgerton MT, Zorchian A. Reconstruction of thetrachea and infraglottic larynx. Plast Reconstr Surg1954; 13:167-92.

21 Gebauer PW. Further experiences with dermal graftsfor healed stenosis of bronchi and trachea. J ThoracSurg 1950;20:628-47.

22 Belsey R. Resection and reconstruction of theintrathoracic trachea. Br J Surg 1950;38:200-5.

23 Greenberg SD, Wilms RK. Tracheal prosthesis: Anexperimental study in dogs. Arch Otolaryngol1962;75:335-71.

24 Beall AC jun, Harrington OB, Greenberg SD, MorrisGC Jr, Usher FC. Tracheal replacement with heavyMarlex mesh. Arch Surg (Chicago) 1962;87:390-6.

25 Ellis PR, Harrington OB, Beall AC Jr, De Bakey ME.The use of heavy Marlex mesh for tracheal reconstruc-tion following resection for malignancy. J Thorac Car-diovasc Surg 1962;44: 520-7.

26 Pearson FG. Henderson RB, Gross AE, Ginsberg RJ,Stone RM. The reconstruction of circumferentialtracheal defects with a porous prosthesis. J ThoracCardiovasc Surg 1968;55:605-16.

27 Taber RE, Tomatis R. Experimental and clinical util-ization of prostheses for replacement of the trachea.AMA Arch Surg 1958;77:576-83.

28 Holle F. Healing conditions of tracheobronchial treeand its plastic reconstruction. Experimental study.Arch Klin Chir 1953;277:1-35.

29 Bomemisza G. Experimental substitution of trachealdefects with the aid of auto-alloplastic methods. BrunsBeitr Klin Chir 1961;202:368-76.

30 Parhofer R. Experimentelle Untersuchungen zurUberbruckung von Tracheadefekten mit Kunststoff-prothesen. Thoraxchirurgie 1965; 13:17-28.

31 Ekestrom S. Experimental reconstruction ofintrathoracic trachea. Acta Chir Scand 1956;110:367-72.

32 Kramish D, Morfit HM. The use of Teflon prosthesis tobridge complete sleeve defects in the human trachea.Am J Surg 1963; 106:704-8.

33 Atamanyuk MY, Melrose DG. The treatment of cir-

cumferential defects of the trachea. Br J Surg1962; 52: 59-62.

34 Graziano JL, Spinazzola A, Neville WE. Prostheticreplacement of the tracheal carina. Ann Thorac Surg1967;4: 1-11.

35 Neville WE, Hamouda F, Anderson J, Dwan FM.Replacement of the intrathoracic trachea and bothstem bronchi with a molded silatic prosthesis. J ThoracCardiovasc Surg 1972;63:569-76.

36 Poticha SM, Lewis FJ. Experimental replacement ofthe trachea. J Thorac Cardiovasc Surg 1966;52:61-7.

37 Pearson FG, Thompson DW, Weissberg D, SimpsonWJK, Kergin FG. Adenoid cystic carcinoma oftrachea. Experience with 16 patients managed bytracheal resection. Ann Thorac Surg 1974; 18:16-29.

38 Moghissi K. Tracheal reconstruction with prosthesis ofMarlex mesh and pericardium. J Thorac CardiovascSurg 1975;69:499-506.

39 Neville WE, Bolanwski PJP. Prosthetic reconstructionof the trachea and carina. J Thorac Carviovasc Surg1976;72:525-38.

40 Vogt-Moykopf I, Lullig H, Toomes H, Weidauer H.Tracheaersatz am Menschen, kombinierte Eingriffe anBronchien und Gefaessen der Lunge. LangenbecksArch Chir 1980;352:285-9.

41 Weidauer H, Vogt-Moykopf I, Toomes H. Derprothetische Trachealersatz mit Kunststoff. LaryngolRhinol 1981;6:29-32.

42 Montgomery WW. Silicone tracheal T-tube. Ann OtolRhinol Laryngol 1974;83:71-5.

43 Clarke DB. Palliative intubation of the trachea andmain bronchi. J Thorac Cardiovasc Surg1980;80:736-41.

44 Westaby SB, Jackson JW, Pearson FG. A bifurcatedsilicone rubber stent for relief of tracheobronchial obs-truction. J Thorac Cardiovasc Surg 1982;83:414-7.

45 Dedo HH, Fishmann NH. Laryngeal release and sleeveresection for tracheal stenosis. Ann Otol RhinolLaryngol 1969;78: 285-96.

46 Demos NJ, Kutnick H, McCally D, Feinberg F,McKeon J, Timmes JJ. Tracheal regeneration in long-term survivors with silicone prosthesis. Ann ThoracSurg 1973; 16:293-300.

47 Grillo HC. Surgical treatment of postintubationtracheal injuries. J Thorac Cardiovasc Surg1979; 78: 860-75.

48 Denecke HJ. Fehler und Gefahren bei derTracheotomie. Verhand d Deutsch Gesellsch fHNO-Heilk Kopf-u-Hals Chirurg XLII JahresversReichenhall 1971:391-402.

37



j.com/


ownloaded from


experiences with prosthetic reconstruction trachea and ... · a54yearold manwith progressive...

Documents