General Thoracic Surgery Department, Hospital Clinic, Universidad de Barcelona, Barcelona, Spain; Department of Thoracic Surgery, University Hospital- U1046, INSERM-Montpellier, France.
Department of Neck Surgery, University Hospital, Montpellier, France.
Ann Thorac Surg. 2014 Sep;98(3):1026-33. doi: 10.1016/j.athoracsur.2014.04.103. Epub 2014 Jul 16.
This study aimed to assess early and long-term results after anterior mediastinal tracheostomy (AMT) as a salvage operation for recurrent neck malignancies.
Between October 2006 and February 2013, 12 patients (mean age, 57 years) underwent AMT. All patients had experienced stomal recurrence, with or without esophageal involvement, after laryngectomy. All patients had undergone previous radiotherapy (50.3 ± 6.2 [43-60] Gy) and previous surgical treatment: total laryngectomy (n = 11) and thyroidectomy (n = 2).
The mean length of resected trachea was 3.7 ± 2.7 (2.5-6) cm. Resection was complete in 10 patients. All patients required relocation of the remaining trachea below the innominate artery and myocutaneous flap for coverage/stoma construction. AMT was associated with esophagectomy (n = 4) and supraaortic trunk resection (innominate artery, n = 2; carotid artery, n = 3). Seven patients required resection of the pharyngoesophageal region, and 4 patients underwent reconstruction, including primary closure of a pharyngeal remnant (n = 1) and gastric pull-up (n = 3). There was 1 operative death (8.3%) resulting from an infectious process leading to bypass fistulization. Major complications were partial tracheal necrosis (n = 3), pharyngeal fistula (n = 1), pneumonia (n = 4), and flap dehiscence (n = 2). Length of hospital stay was 30 ± 22.8 (13-86) days. Actuarial overall 5-year survival was 58.3%, and median estimated disease-free survival was 53 (31-75) months.
Our experience with AMT as salvage therapy has shown acceptable long-term results if complete resection is achieved. This procedure is not risk free, and very careful patient selection is required because of a tortuous postoperative course, especially in combined pharyngeal-esophageal and vascular reconstruction.
本研究旨在评估前纵隔气管切开术（AMT）作为复发性颈部恶性肿瘤挽救性手术的近期和远期结果。
2006 年 10 月至 2013 年 2 月，12 例患者（平均年龄 57 岁）接受了 AMT。所有患者在喉切除术后均经历过吻合口复发，且伴有或不伴有食管受累。所有患者均接受过放疗（50.3±6.2[43-60]Gy）和先前的手术治疗：全喉切除术（n=11）和甲状腺切除术（n=2）。
切除的气管平均长度为 3.7±2.7（2.5-6）cm。10 例患者的切除为完全性。所有患者均需要将剩余的气管向下重新定位至无名动脉，并使用肌皮瓣覆盖/造瘘口。AMT 与食管切除术（n=4）和主动脉上干切除术（无名动脉，n=2；颈总动脉，n=3）相关。7 例患者需要切除咽食管区域，4 例患者接受重建，包括咽残留的一期闭合（n=1）和胃上提（n=3）。1 例患者因感染导致旁路瘘化而死亡（8.3%）。主要并发症为部分气管坏死（n=3）、咽瘘（n=1）、肺炎（n=4）和皮瓣裂开（n=2）。住院时间为 30±22.8（13-86）天。总 5 年生存率的估计值为 58.3%，中位无疾病生存时间为 53（31-75）个月。
如果能够达到完全切除，我们采用 AMT 作为挽救性治疗的经验显示出可接受的长期结果。但该手术并非没有风险，需要非常仔细地选择患者，因为术后过程曲折，特别是在联合咽食管和血管重建时。
