A novel technique for securing tracheal blood supply in salvage anterior mediastinal tracheostomy

• This is the first report of the novel surgical procedure to maintain the tracheal blood supply in anterior mediastinal tracheostomy.
• The longer tracheal stump makes easier to create a tracheostomy, but has a disadvantage for its blood supply.
• The unaffected-sided tracheal sheath was preserved in a state of connecting with the ipsilateral lobe of the thyroid gland and the tracheal stump.
• The trachea was cut diagonally, leaving the unaffected tracheal wall longer.
• This technique enables to secure the blood supply of the tracheal stump and to prevent postoperative fatal complications.

IntroductionThe only way for complete cure of advanced esophageal cancer with invasion to the mid-trachea is anterior mediastinal tracheostomy (AMT), which has a significantly high risk of fatal complications. The shorter tracheal stump is beneficial for good blood supply, but complicates to create a tracheostomy.Presentation of caseA 71-year-old patient with a history of advanced cervical esophageal cancer who was treated with definitive chemoradiotherapy 3 years earlier had local recurrence on the left side of the trachea despite salvage lymphadenectomy for solitary left paratracheal lymph node recurrence 1 year earlier. AMT involving a resection of nearly the whole trachea was needded for complete resection. However, the recurrenced tumor was localized on the tracheal left side. We designed the new surgical procedure to preserve a longer segment of the unaffected right tracheal wall by diagonal cut (3.6 cm longer than on the left side) while maintaining adequate blood flow by preserving the right lateral vascular pedicle in a state of connecting with the right lobe of the thyroid gland and the right tracheal stump. The postoperative course was uneventful, and at 1 year postoperatively, no tumor recurrence has been detected.DiscussionPreservation of the lateral vascular pedicle enables a longer tracheal stump by securing sufficient blood supply and a longer tracheal stump in AMT, even when unilateral, enables to create tracheostomy more surely, preventing fatal complications.ConclusionThis novel procedure should be considered in cases with tumor invasion extending into the lower mid-trachea that is limited to one side.