Anterior mediastinal tracheostomy: Indications, techniques, and clinical experience

Abstract

Anterior mediastinal tracheostomy has wider clinical application than its initially described use for treatment of stomal recurrences following laryngectomy for carcinoma. This procedure provides access to the cervicothoracic esophagus and thereby permits resection and reconstruction in an area traditionally regarded as “no-man’s land.” This report reviews our experience with 17 patients who have undergone anterior mediastinal tracheostomy for cervicothoracic esophageal carcinoma (11); pharyngeal carcinoma following previous laryngectomy (two); stomal stenosis following laryngectomy and radiation therapy for carcinoma (two); stomal recurrence following laryngectomy (one); and extensive thyroid carcinoma (one). Ten patients underwent concomitant laryngopharyngectomy, 12 blunt transmediastinal esophagectomy, and 13 visceral esophageal substitution using either stomach (pharyngogastrostomy in eight) or colon (pharyngocolostomy in five). A bipedicled upper thoracic apron flap was used to construct the mediastinal tracheostomy in 13 patients; four patients required a thoracoacromial rotational flap because of the need to resurface the anterior neck following resection of skin involved with tumor. Three deaths occurring within 30 days of operation resulted from innominate artery rupture (one), acute myocardial infarction (one), and respiratory insufficiency (one). Two late hospital deaths followed a cerebrovascular accident (one) and hepatorenal syndrome (one). Iatrogenic hypoparathyroidism and hypothyroidism occurred in six patients. After a period of follow-up ranging from 2 to 36 months (average 12 months), satisfactory airways and swallowing have been restored in the surviving 12 patients. Two of the survivors now have mild stomal stenoses which are easily dilated.