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

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 site where the trachea or larynx was resected previously, such as a recurrence at the site of the tracheal stoma.

An important consideration is whether the patient will need to have restoration of alimentary continuity (Table 65-1) because this adds substantially to the duration, complexity, and stress of the operation. The general condition of the patient should be good enough to tolerate this radical procedure. A thorough history, physical examination, and clinical workup should focus on the following: preoperative nutritional status, weight loss, cardiac and respiratory function, smoking status, and a history of diabetes or steroid dependence. All these conditions should be optimized, and the patient should cease smoking several weeks before surgery. The patient also should undergo preoperative respiratory conditioning, including incentive spirometry and respiratory physical therapy. Other important details include a history of prior abdominal surgery (important to know the esophageal substitution), laryngectomy, tracheal resection, chemotherapy, and radiation therapy. A prior history of radiation therapy will make the neck structures, including the great vessels, more fixed. In addition, tracheal blood supply may be compromised, increasing the risk of ischemic breakdown and delayed healing. Finally, and perhaps most important, it is the surgeon’s job to make sure that the patient is psychologically prepared for the morbidity of this procedure (including loss of speech) and a potentially long recovery.

Indications

MT, whether for palliation or for cure, is indicated after tracheal resection, laryngectomy, or laryngopharyngectomy in cases where there is insufficient length of intrathoracic trachea to either reanastomose it superiorly or bring it out suprasternally (Fig. 65-2). This determination depends on various factors, including the patient’s anteroposterior diameter (one needs more length in a barrel chest), the effectiveness of tracheal mobilization, and the malleability of the remaining trachea. Some surgeons suggest that the optimal length for MT is greater than 5 cm from the carina.² The procedure also may be indicated in some patients with a cervicothoracic malignancy and “impending airway obstruction.” However, if the disease is unresectable or the patient has significant comorbidities, an airway stent may be more appropriate.

Oncologic Principles

Upper aerodigestive system malignancies severely affect quality of life, and careful consideration must be given not only to cure but also to palliation. The most important oncologic principle is to understand clearly if the goal is cure or palliation. One or two centimeters can change the approach to the procedure. That is, if palliation is the goal, clear margins are not critical, and the additional preserved length may facilitate the procedure. On the other hand, if the procedure is being performed for cure, one must not sacrifice oncologic margin for the sake of tracheal length. Most important, in either case, this procedure must be completed without tension on the anastomosis. Otherwise, neither palliation nor cure may be achieved. Instead, the patient will be at severe risk of complications such as innominate artery rupture or stomal breakdown with mediastinitis.

Preoperative bronchoscopy, esophagogastroduodenoscopy, computed tomography, and magnetic resonance imaging should be done to assess if the operation is technically possible. The surgeon should assess the length of tumor-free trachea distal to the lesion and the involvement of adjacent vital structures. A metastatic workup is necessary and may include a whole-body positron emission tomography scan, bone scan, and head imaging. MT is not contraindicated in patients with metastatic disease if the goal is palliation. However, with metastatic disease, other therapies, such as airway stents or radiation therapy, may be considered. If there are plans to divide the innominate artery, a preoperative arteriogram assessing the patient’s cranial perfusion is important. A visceral arteriogram also may be useful in evaluating the blood supply to the colon as an esophageal substitute. In this case, a barium enema and colonoscopy are recommended to assess the colon as an appropriate conduit. Finally, a bowel preparation should be performed if there is any possibility of esophageal substitution.