Circumferential Tracheal Replacement: Do the Benefits Warrant the Risks?

Abstract

Fabre and colleagues [1Fabre D. Kolb F. Fadel E. et al.Successful tracheal replacement in humans using autologous tissues: an 8-year experience.Ann Thorac Surg. 2013; 96: 1146-1155Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] recently reported their experience of both lateral and circumferential tracheal repair with special reference to the already described use of cartilage-reinforced forearm free flaps [2Olias J. Millán G. da Costa D. Circumferential tracheal reconstruction for the functional treatment of airway compromise.Laryngoscope. 2005; 115: 159-161Crossref PubMed Scopus (29) Google Scholar]. Of 12 patients, 2 underwent lateral repair of esophagotracheal fistula, 4 salvage operations, and 6 tracheal/carinal replacement for adenoid cystic carcinoma (ACC) (n = 5) or malacia (n = 1). Although flap-wrapped aortic allografts have proved useful in elective central airway replacement [3Wurtz A. Porte H. Conti M. et al.Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland-type carcinoma.J Thorac Cardiovasc Surg. 2010; 140: 387-393Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar], and recently in the emergency setting [4McGiffin D. Wille K. Young K. Leon K. Salvaging the dehisced lung transplant bronchial anastomosis with homograft aorta.Interact Cardiovac Thorac Surg. 2011; 13: 666-668Crossref PubMed Scopus (10) Google Scholar], Fabre and colleagues claim that “we believe this technique, with a mortality of about 50%, should not be used.” Therefore, we take the opportunity to briefly compare the patient data of their six tracheal/carinal replacements with the data from our study [3Wurtz A. Porte H. Conti M. et al.Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland-type carcinoma.J Thorac Cardiovasc Surg. 2010; 140: 387-393Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar] (enrollment from 2005 to 2007) of 6 patients undergoing tracheal resection involving the carinal region in four cases, followed by repair with aortic allografts, for ACC (n = 5) or mucoepidermoid tumor (n = 1): (1) In-hospital mortality, 2/6 versus zero; (2) pathology (ACC patients), 4/5 R1 resection versus 5/5 R0 resection; (3) mean survival time, 25 months versus 64 months (of our 6 patients, 3 died at 26, 45, and 77 months, and the 3 survivors at 72, 76, and 87 months are currently in full-time employment). According to the 100% efficacy of chemoradiation in locally advanced ACC of the trachea reported by Allen and colleagues [5Allen A.M. Rabin M.S. Reilly J.J. Mentzer S.J. Unresectable adenoid cystic carcinoma of the trachea treated with chemoradiation.J Clin Oncol. 2007; 25: 5521-5523Crossref PubMed Scopus (39) Google Scholar] and recently confirmed through electronic communication with the authors, we decided, however, not to include further patients in our study. The results of Fabre and colleagues reporting severe mortality and morbidity (mainly adult respiratory distress syndrome and arterial rupture), and poor quality of life (mucus plugging and 66% of definitive tracheostomy) after implantation of their neoconduit also pleads in favor of chemoradiation as an alternative therapy. By contrast, the successes obtained in esophagotracheal fistula operations demonstrate the relevance of fasciocutaneous flaps in the setting of lateral tracheal repair [1Fabre D. Kolb F. Fadel E. et al.Successful tracheal replacement in humans using autologous tissues: an 8-year experience.Ann Thorac Surg. 2013; 96: 1146-1155Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar]. Successful Tracheal Replacement in Humans Using Autologous Tissues: An 8-Year ExperienceThe Annals of Thoracic SurgeryVol. 96Issue 4PreviewFifty years of surgical research using synthetic materials and heterologous tissues failed to find a good, durable replacement for the trachea. We investigated autologous tracheal substitution (ATS) without synthetic material or immunosuppression. Full-Text PDF