Despite progress in tracheal surgery over the past 60 years, to date, there is no suitable substitute for the trachea to bridge long gaps after resection. The adult trachea is usually approximately 9 to 13 cm long. Currently, approximately half of the adult trachea can be removed surgically and reanastomosed with various tracheal release and mobilization maneuvers. More extensive tracheal resections are limited by the lack of dependable and predictable replacements. This limitation is quite apparent by the occasional necessity of creating an anterior mediastinal tracheostomy (MT) in palliative, curative, or sometimes emergent or “bail out” procedures.
An anterior MT involves the construction of a tracheostomy stoma on the anterior chest wall using the intrathoracic trachea when there is insufficient length to reanastomose the remaining trachea or to bring the trachea out of the superior mediastinum for a standard suprasternal stoma. The procedure involves laryngectomy (if not done previously) and resection of the upper sternum, the medial third of the clavicles, and the first and usually second ribs. This provides access to the intrathoracic trachea with excellent exposure of the superior mediastinum and brings the chest wall down to the remaining shortened trachea to avoid tension on the stoma. The primary indications for this operation are mostly limited to advanced cervicothoracic neoplasms in the superior mediastinum, although it is done occasionally for benign disease. The indications for this procedure have become less common with the refinement of radiation therapy and tracheal surgery and are confined to very selected clinical scenarios. Tumors in this location that are amenable to resection are quite rare.
Few thoracic surgeons or institutions have any extensive experience with this procedure. MT is a complex procedure that is performed in a difficult, unfamiliar anatomic location and is associated with very high morbidity and mortality. However, as described in multiple series in the literature, curative and palliative resections of advanced or recurrent carcinomas in this region can be accomplished with acceptable outcomes. Often the patient will experience a prolonged recovery with a high risk of associated serious complications. MT requires dedicated postoperative care delivered by experienced medical and nursing teams. With a successful outcome, however, the functional result is the equivalent of laryngectomy.1 When undertaking this radical procedure, one must show good clinical judgment in patient and case selection. Also, it is imperative to determine whether the procedure is being done for cure or palliation because 1 or 2 cm of length can change the complexion of the procedure.
Patient Characteristics, Indications, and Oncologic Principles
Patients must be selected carefully, and the surgeon's preoperative preparation should be meticulous. The typical patient requiring an anterior MT usually is afflicted with an advanced cervicothoracic malignancy involving either the thyroid, larynx, pharynx, trachea, or esophagus that often invades adjacent structures (Fig. 65-1). It also can be a recurrent tumor at the ...