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Mentions: A 52-year-old man was referred for a tracheal mass. He had dyspnea for the past 10 months. The dyspnea had become aggravated 2 weeks earlier, and blood-tinged sputum developed simultaneously. Computed tomography revealed about a 4.5-cm mid-tracheal mass obstructing 80% of the tracheal lumen (Fig. 1). Infiltration to the adjacent tissue was suspected. However, there was no enlarged regional lymph node. The mass showed mild FDG uptake on positron emission tomography. On fiber-optic bronchoscopy, a protruding mass with an irregular surface was found at the mid-trachea. The mass was hypervascular and fragile. A biopsy was omitted due to the risk of bleeding and respiratory insufficiency. The clinical impression was adenoid cystic carcinoma of the trachea. In the operating room, an endotracheal tube was positioned proximally to the mass through the nasopharyngeal route by a bronchoscopic guide in deep sedation status with spontaneous breathing. The neck was hyper-extended, and a collar incision was made after local anesthesia. The trachea was exposed and the distal margin of the mass was confirmed by bronchoscopy. After initiation of general anesthesia, the trachea was opened beyond the distal margin of the mass and another armored endotracheal tube was inserted to the distal trachea for mechanical ventilation. We found an irregularly shaped mass originating from the right posterior membranous wall. However, the longitudinal mucosal extension was much longer than expected, especially at the right posterolateral wall. To achieve complete resection and preserve the trachea as much as possible, the trachea was resected obliquely at both ends. The longest length of the resected tracheal segment was 6.5 cm at the right posterolateral wall and the shortest length was 5.0 cm at the left anterolateral wall. In order to approximate both ends of trachea and minimize the tension of anastomosis, a proximal tracheal release was performed on the cricoid cartilage, and bilateral main bronchial release was performed under video-assisted mediastinoscopy (VAM). After dissection of the anterior and posterior wall of the trachea to the carina under direct vision, the anterior and posterior walls of both main bronchi were dissected under VAM. The bronchi were released to the proximal part of the intermediate bronchus on the right and to the origin of the upper lobe bronchus on the left. The subcarinal lymph nodes were sampled. Both bronchial arteries were preserved. End-to-end anastomosis was performed by rotating the distal end 90 degrees counter-clockwise and the proximal end 90 degrees clockwise. The pathologic diagnosis was adenoid cystic carcinoma. Both resection margins were clear. The mass had infiltrated into the paratracheal fibroadipose tissues. Cervical flexion was maintained for 10 days. Fiberoptic bronchoscopy on the 8th day revealed intact anastomosis. Computed tomography taken 12 months later revealed an approximately 3-cm elevation of the carina (Fig. 2). Fiber-optic bronchscopy revealed mild anastomotic stenosis at the cranial portion 5 cm from the carina (Fig. 3). Postoperative radiotherapy was performed because of the close radial margin. The patient has been disease-free for 18 months.
Mediastinoscopic Bilateral Bronchial Release for Long Segmental Resection and Anastomosis of the Trachea
Bottom Line: The extent of resection and release of the trachea is important for successful anastomosis.Bilateral bronchial dissection is one of the release techniques for resection of the lower trachea.We present the experience of cervical video-assisted mediastinoscopic bilateral bronchial release for long segmental resection and anastomosis of the lower trachea.
Affiliation: Department of Chest Surgery, Heymin General Hospital, Korea.
The extent of resection and release of the trachea is important for successful anastomosis. Bilateral bronchial dissection is one of the release techniques for resection of the lower trachea. We present the experience of cervical video-assisted mediastinoscopic bilateral bronchial release for long segmental resection and anastomosis of the lower trachea.