Tracheal Flap Research Articles

Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae.

To evaluate surgical options of treatment in combined tracheo-esophageal injuries and their sequelae and elaborate new ones. The overlooked diagnosis of combined tracheo-esophageal injury would lead to severe stenosis of the esophagus and trachea with tracheo-esophageal fistula. This condition requires a complex surgical intervention to be performed with non-standard procedure in every single case. Forty patients with combined tracheo-esophageal injuries were treated in our institution. Nine patients were urgently operated while others were transferred to us from other hospitals with chronic sequelae of the initial trauma. In the majority of cases the cause of the injury was penetrating (17 patients) or iatrogenic (13 patients) trauma followed by blunt neck and chest trauma (six patients) and caustic burn (four patients). Three patients had total cut off of the esophagus and trachea, which were repaired with end-to-end anastomoses. Another six patients had tracheal and esophageal disruptions within one-half to three-quarters of circumference. In these cases both the trachea and esophagus were mobilized within wall laceration and sutured by interrupted Vicryl 4/0. One of them died due to pre-existing disease. Thirty-one patients with sequelae of the trauma were also operated on. In spite of the complexity and extent of the tracheo-esophageal stenosis and fistula the surgical treatment was aimed to one-stage reconstruction of both the esophagus and trachea. For this purpose we performed an originally developed surgical intervention, which was to be modified in accordance with patients diagnosis. The main point of the procedure is that after mobilization of the trachea and esophagus we resect an involved part of the trachea, but preserve a pedicled flap fashioned from the tracheal membrane. Then we remove the mucosa from the flap, resect an involved esophageal wall, repair esophageal mucosa and replace the defect of the muscular layer of the esophagus with the tracheal flap. Then a tracheal or laryngo-tracheal anastomosis is established. There were no postoperative mortality and complications among patients with the sequelae. Combined tracheo-esophageal injury requires the precise preoperative diagnosis and well organized plan of surgical treatment, which may be unique for every single patient. The main purpose of the treatment is to restore the continuity of both the esophagus and trachea in one-stage intervention.

Further experience with tracheojejunal shunt speech after pharyngolaryngoesophagectomy.

Over the past 10 years, 16 patients have undergone the tracheojejunal shunt operation for voice reconstruction after undergoing pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. For the purpose of voice reconstruction, a 2-cm inferiorly based tracheal flap is obtained from the membranous part of the trachea by removing 4 cartilaginous tracheal rings. After the establishment of digestive continuity with the jejunal graft, a side-to-side anastomosis is created by approximating the incised margin of the jejunal mucosa to that of the tracheal flap. The tracheal flap is tubed to construct the tracheojejunal shunt. In addition, the incised margin of the jejunal serosa is sutured to the lateral wall of the shunt to reinforce the approximation of the shunt to the jejunal graft. Thirteen of the 16 patients (81%) were initially capable of voice production. The length of time during which tracheojejunal speech has been used ranges from 18 to 122 months, with a mean of 55 months. During follow-up, 12 of the 13 patients (92%) have been able to swallow without aspiration.

Management of the posterior commissure and thyrotracheal anastomosis

Posterior glottic stenosis continues to be a challenge for otolaryngologists. Endotracheal intubation continues to be the most common reason for this condition. The presence of stenosis at other sites is not uncommon. The subglottis may also be involved, along with the posterior glottis. Assessment by radiological imaging and endoscopic evaluation is required to best determine the site and severity of the injury. Treatment may be either endoscopic or open. Synchronous injuries of the posterior glottis and subglottis are best treated by cricotracheal resection, excision of posterior glottic scar, and advancement of a membranous posterior tracheal mucosal flap.

Speech rehabilitation after laryngectomy with the amatsu tracheoesophageal shunt

The Amatsu vocal rehabilitation technique is a tracheoesophageal shunt using a posterior tracheal flap associated with a sphincter made of esophageal muscular wall. Since march 1991 the procedure was done in 33 men and 2 women, ages ranging from 30 to 78 years. Previous radiotherapy, hypopharynx lesions, need for postoperative radiotherapy or use of myocutaneous flap were not considered contraindications. Vocalization was achieved in 76% of our patients and the quality was considered superior than that obtained by the esophageal voice. In only one case the shunt had to be closed surgically because of aspiration. In conclusion, the Amatsu tracheoesophageal shunt is an inexpensive technique that obtain a good quality of vocal rehabilitation in a high percentage of patients, it has few complications and it should be considered for all candidates to a laryngectomy, mainly for those with a good prognosis and a desire to return to their social environment.

Extraction of a large tracheal foreign body through a tracheotomy

Foreign body aspiration is not uncommon in children and is a significant cause of childhood morbidity and mortality. Laryngotracheal foreign bodies, although less common than bronchial foreign bodies, are potentially more dangerous and require urgent recognition and treatment. Most of the aspirated foreign bodies are removed with the use of classic instruments like rigid bronchoscope and foreign body forceps, or more rarely with flexible fiberoptic bronchoscope, but sometimes we fail to remove them. We present a large nonasphyxiating, aspirated foreign body lodged in the subglottis of a a-year-old child, which was removed through a tracheotomy under bronchoscopic control, followed by primary suture and closure of the tracheotomy site. Under general anesthesia, bronchoscopy demonstrated a hollow conic-shaped plastic piece of a toy (Fig 2). Repeated attempts to extract the foreign body through the larynx failed because of the size of the foreign body, the fact that its larger diameter was upward, and the anatomic shape of the subglottic region. An attempt at rotation of the foreign body failed too, because of its length. The foreign body was therefore pushed to the right mainstem bronchus, and a tracheotomy was performed over the ventilating Stotz-Hopkins bronchoscope, using a superiorly based tracheal flap (Fig 3). The foreign body was then manipulated endoscopically to the stoma and removed without difficulty. The bronchoscope was replaced by an endotracheal tube, and the flap was returned to its original position and sutured to the tracheal wall.

Tracheal advancement flap for postlaryngectomy stomal stenosis.

Tracheal stenosis can be a troubling consequence of laryngectomy. Some revision techniques disturb the posterior stoma site of a current or planned tracheoesophageal puncture (TEP). A revision technique which advances the trachea out of the stoma, divides the anterior tracheal wall, and leaves the posterior tracheal wall undisturbed was designed. The paper describes the technique in detail. "Success" was defined as producing a stable, trouble-free stoma requiring no stenting; "partial success" as an improved stoma requiring some stenting; and "failure" as no improvement and continuous stenting. Fifteen patients underwent the procedure. Median time from laryngectomy to revision was 10 months. Preoperative to postoperative median stoma size increased from 63 mm2 to 135 mm2. Seven patients were classified as successful, six patients were partially successful, and two patients had no improvement. The tracheal advancement flap is a safe technique for the laryngectomy patient who has undergone or might undergo voice restoration.

An analysis of the inferior based tracheal flap for pediatric tracheotomy

In the past, various tracheotomy incisions have been used at the Children's Hospital of Michigan with the occurrence of complications related to accidental decannulation and immediate recannulation. Since that time the inferior based tracheal cartilage flap has been used to minimize early complications. A retrospective study of 126 pediatric tracheotomies performed at the Children's Hospital of Michigan from June 1986 to January 1991 was reviewed. Only tracheotomies performed by a staff otolaryngologist utilizing the inferior based tracheal cartilage flaps were reviewed. This study includes patients with a 6 month to 5 year follow up. The early complication rate was 4%, while the late was 50%. Stomal granulation tissue was comparatively increased in this series of patients but did not hinder decannulation. We consider the use of the inferior based tracheal cartilage flap in the pediatric population a safe and effective technique without increasing the morbidity of long-term tracheotomy.

喉摘後の音声再建-TEシャントの新しい展開-

During the past 14 years the tracheoesophageal (TE) shunt capability has been performed on 207 patients for primary voice restoration following total laryngectomy, and 172 patients (83%) retained fluent and intelligible speech with TE shunt. On the basis of successful results of postlaryngectomy speech with the TE shunt operation, the acquirement of both TE and esophageal speech, the primary tracheojejunal (TJ) shunt operation following pharyngolaryngoesophagectomy and the TE puncture operation for primary or secondary voice restoration reported by Singer and Blom were performed.Out of 172 patients who had TE speech, 8 obtained voice capability with esophageal speech and the vibratory source during phonation with esophageal voice was located at the hypopharynx as well as with TE speech. These indicated that the TE speakers could acquire the esophageal voice.The primary TJ shunt operation was performed on 6 patients for voice restoration following pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. A fistula was created between the membraneous tracheal flap and the lower part of the transplanted jejunum. The membraneous part of the trachea was tubed to construct the TJ shunt. Out of 6 patients, 5 retained phonatory function. No leakage was seen at all during deglutition and a swallowing function was obtained in all 6 patients.A total of 29 patients underwent the TE puncture operation. Seventeen and twelve were performed for primary and secondary voice restoration after total laryngectomy, respectively. Out of 29 patients, 24 acquired fluent speech with voice prosthesis.

Tracheal flap for primary reconstruction of subglottic stenosis. An experimental study

Tracheal flap for primary reconstruction of subglottic stenosis. An experimental study

Tracheal flap for primary reconstruction of subglottic stenosis

The management of subglottic stenosis in children remains a controversial issue. This study aimed to develop a reproducible, single-stage, curative procedure for primary reconstruction of the trachea in subglottic stenosis that would be applicable in the newborn period. A method of resection of the subglottic portion of the trachea with reconstruction by primary anastomosis utilizing an anterior tracheal flap is described. Thirty young rats were operated upon according to this method, utilizing a microsurgical technique. There were 2 deaths, of which 1 was unrelated to the operation. Following surgery all the surviving rats had slight stridor due to mild postoperative oedema lasting some 3–4 days. Subsequently there were no further respiratory symptoms. The experiments were terminated 3 months following surgery when the rats had attained full adult size. Macro- and microscopical assessment of the tracheas was carried out. The study showed that in an animal model it is possible to carry out primary reconstruction of the subglottic area of a very small-calibre trachea without a diversionary tracheostomy and that the procedure is followed by good primary healing with minimal scarring, no stricturing, and no impairment of growth.

喉摘と音声再建外科

Over the past three decades a variety of surgical techniques have been developed for voice restoration following laryngectomy. The underlying principle of these procedures is to divert pulmonary air into the gullet where vibrations of the tissue creates the sound used for speech production. To achieve successful surgical voice restoration voice production must be compatible with normal deglutition. Many of the surgical techniques resulting in good voice production report frequent problems with aspiration indicating they have not been equally successful in achieving normal deglutition. The current paper presents a simple primary surgical technique that provides a new sound source and normal deglutition. This primary surgical technique uses a membraneous tracheal flap for voice restoration combined with bilateral esophageal muscle flaps to avoid problems with aspiration.

Primary tracheoesophageal shunt operation for postlaryngectomy speech with sphincter mechanism.

This paper describes a primary voice restoration technique designed to eliminate the problem of aspiration commonly encountered in rehabilitation procedures following laryngectomy. This technique, utilized in 16 patients, consists of a unique combination of tracheal flap for voice production and bilateral esophageal constrictor muscle flaps to prevent aspiration. Fourteen patients developed satisfactory tracheoesophageal speech; of them 12 had normal deglutition without problems of aspiration. On radiographic examination, the bilateral esophageal muscle flaps, in combination with the dilatation and elevation of the cervical esophagus, provide a sphincter mechanism that prevents tracheal reflux during deglutition.

A new operation for construction of a neo-larynx

A new operation for constructing a neo-larynx has been devised using the upper parts of the trachea and oesophagus without using any extraneous inert material, following total laryngectomy. A full-thickness tongue-shape flap is raised from the posterior tracheal wall and is passed through a transverse slit in the anterior oesophageal wall into the oesophageal lumen. The newly created transverse cleft between the antero-inferior mucosa-lined surface of the tracheal flap above and inferior margin of the oesophageal slit with the incorporated cartilage bar below acts as the neo-glottis’. Because of the presence of mucosa on the free margins of the lips of the ‘neo-glottis’, chances of stenosis of the neo-glottis’ is minimised. The tracheal flap acts as the neo-epiglottis’.

Superiorly based tracheostomal flap to counteract tracheal stenosis: experimental study.

A superiorly based tracheal flap raised from the anterior tracheal wall was rotated anteriorly and superiorly to be sutured to the subcutaneous tissues. A series of 16 tracheostomies were performed on mongrel dogs. The stenosing effects of conventionally performed operations were compared to those of the new method. Autopsy sections of the post-tracheostomy sites demonstrated a significant loss of anteroposterior diameter averaging 16.5% as compared to the original unoperated-on luminae. No signs of tracheal stenosis were found whenever the proposed new technique was employed. This technique seems applicable to patients in whom assisted ventilation is contemplated.

Management of the Flap Tracheostomy: An Experimental Study

The flap tracheostomy was studied in 25 adult canines to further investigate its best management. Tracheostomies were performed by employing the inverted U flap incision in the trachea. After decannulation, the flap was either formally resewn to the trachea, bluntly dissected from the surrounding soft tissues, or left in place. The time required for epidermal closure over the tracheostomy site was measured, along with fixation of skin to soft tissues in the area. Histologic examinations were made, and tracheal dimensions were calculated on sections through the stomal area. More rapid skin closure and less soft tissue fixation occurred in animals that underwent resuturing or release of the tracheal flap. In all groups, cartilage viability and regrowth were noted. Tracheal diameters were maintained in all groups, but smoother contouring was seen with resuturing. Additional support for the flap tracheostomy is provided from this animal experimentation.

VOCAL REHABILITATION AFTER TOTAL LARYNGECTOMY

In order for achieving a permanent tracheo-esophageal shunt for the post operative vocal function, the following requirements should be satisfied. 1) technically easy and safe, 2) applicable to almost all cases, 3) one-stage operation, 4) leakage of saliva and/or fluid from the esophagus into the trachea is negligible, and 5) the obtained speech function should at least be equivalent or even exceeding the speech obtained by nonsurgical methods. A new surgical technique reported herein satisfies most of the requirements mentioned above. Techniques 1) Skin Incision and Tracheostomy: A U-shaped or I-shaped incision is made and a spindleshaped opening is made at the level of the third and fourth tacheal ring. An endotracheal tube for general anesthesia is inserted through this opening. 2) Laryngectomy: An attention should be paid in order not to separate the posterior wall of the trachea from the anterior wall of the esophagus. The larynx is removed juat above the first tracheal ring. If there is no suspicious growth to the subglottis, a removal just above the cricoid arch using a pair of angulated heavy scissors is preferrable. Otherwise, laryngectomy is performed in an ordinary fashion. 3) Creation of Tracheal Flap and Lower Half of the Tracheostoma: The anterior two thirds of the tracheal wall above the fourth ring is cut off, thus a tracheal flap, measuring 2.5 X 4 cm based inferioly, is obtained. The remainder of the tracheal and the cricoid cartilages on both sides is carefully removed subperichondrally using a pair of small scissors. The lower half of tracheostoma is formed after this procedure. 4) Creation of Side-to-Side Anastomosis and Closure of the Hypopharynx: A 7mm midline vertical incision is made starting 5 mm below the superior margin of the flap to reach the esophageal lumen. A single layer of mucosal inter- rupted 4-0 catgut sutures is used to create a sideto-side anastomosis between the incised margins of the tracheal flap and the esophagus. Closure of the hypopharynx is done in an ordinary fashion. 5) Creation of the Tracheo-Esophageal Shunt: A 5-0 Nelation catheter is inserted through this anastomosed opening into the esophagus before completing the T-E shunt. A single layer of submucosal interrupted 4-0 catgut sutures is made to approximate the both lateral margins of the tracheal flap starting from above or below. Thus a 3 cm mucosal tunnel connecting the esophagus and the tracheostoma is constructed. 6) Creation of Upper Half of the Tracheostoma and Closure of the Skin Incision: After suction drains are inserted on each side and fixed on the chest wall, the upper half of the tracheostoma, the center of which is formed by lower end of the mucosal tunnel, is created starting from midline using 3-0 nylon. After 12-20 days, the inserted Nelation catheter is removed. Voice can be produced after the removal of the Nllation catheter by closing the stoma with a finger and giving an expiratory effort. Results Eleven patients so far underwent this procedure and all of them were able to speak 12-52

Modified tracheotomy technique after Tapia Acuna

Decanulation problems have been handled with modified Tapia-Acuna tracheal fenestration. Two cases of them were reported.Two months male having dispnea since birth was found to have hypopharyngeal edema and tracheotomy was performed. U-shaped flap of trachea at the level of 2nd and 3nd tracheal ring was sutured and attached to the skin flap and after 40 days tracheostoma was closed without any troubles.Twelve months male. Tracheotomy in U-shape Tapia method was performed because of severe dyspnea after removal of foreign body of left main bronchus. Tracheal flap was sutural to skin and tracheostoma was created and remained untill 5 days later when stoma was closed.The authors prefer the tracheal flap formation to the midline incision and round shaped tracheotomies for rather long lasting tracheostoma.