Tracheal reconstruction with a free vascularized myofascial flap: preclinical investigation in a porcine model to human clinical application

Won Shik Kim,Gina Na,Woo Soon Jang,Yoon Woo Koh,Jung Min Kim,Da Hee Kim,Hak-Joon Sung,Seung Ho Shin,Se-Heon Kim,Hyung Kwon Byeon,Jae Won Chang,Eun Chang Choi,Jae Hong Park,Mi-Lan Kang,Hong Koo Baik,Myung Jin Ban,Young Joon Seo

doi:10.1038/s41598-017-10733-z

Abstract

Although there are various methods for tracheal reconstruction, such as a simple approximation with suturing and coverage with adjacent soft tissue or muscle, large defects >50% of the tracheal length still present a clinical challenge. Tissue engineering, a recent promising way to possibly resolve this problem, requires a long preparatory period for stem cell seeding on a scaffold and relatively invasive procedures for stem cell harvesting. As an alternative, we used a vascularized myofascial flap for tracheal reconstruction. In four porcine models, the deep inferior epigastric perforator (DIEP) was used in two and the superior epigastric artery perforator (SEAP) in two. Transformation of the surface of the transplanted myofascial flap was analyzed in the airway environment. The flaps failed in the DIEP group due to venous congestion. At 12 weeks postoperatively, none of SEAP group showed any signs of respiratory distress; the inner surface of the implant exhibited stratified squamous epithelium with sparse cilia. In the clinical setting, a patient who underwent a tracheal reconstruction with a vascularized myofascial flap and 2-year follow-up was in good health with no respiratory distress symptoms.

Highlights

There are various methods for tracheal reconstruction, such as a simple approximation with suturing and coverage with adjacent soft tissue or muscle, large defects >50% of the tracheal length still present a clinical challenge
We investigated the feasibility of tracheal reconstruction with a vascularized myofascial flap, using a deep inferior epigastric perforator (DIEP) or superior epigastric artery perforator (SEAP) flap in a preclinical porcine model with a partial tracheal defect
We previously provided a preliminary report of a human case in which we applied the technique using a vascularized muscle fascia from an anterolateral thigh (ALT) flap to reconstruct a partial tracheal defect that developed during the surgical management of papillary thyroid cancer (PTC) invading the trachea[9]

Summary

Introduction

There are various methods for tracheal reconstruction, such as a simple approximation with suturing and coverage with adjacent soft tissue or muscle, large defects >50% of the tracheal length still present a clinical challenge. In 2005, Delaere et al reported their management for restenosis following anastomosis after segmental resection of the trachea[6] They used a buccal mucosal-lined fascial flap for a partial tracheal defect that developed after a longitudinal incision of the trachea for widening the tracheal lumen diameter. The patient underwent intermittent bronchoscopic interventions and required repeated endoluminal stenting for progressive cicatricial stenosis, according to the 5-year follow-up results[8] Their method required long preparatory work, including the search for a suitable donor, harvesting of autologous cells, and assembling these materials using a bioreactor. We investigated the feasibility of tracheal reconstruction with a vascularized myofascial flap, using a deep inferior epigastric perforator (DIEP) or superior epigastric artery perforator (SEAP) flap in a preclinical porcine model with a partial tracheal defect. This study establishes a theoretical foundation for the feasibility of tracheal reconstruction using a vascularized myofascial flap

Methods

Results

Conclusion