Tracheal Resection and Reconstruction for Malignant Tumor
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CASE REPORT
Tracheal Resection and Reconstruction for Malignant Tumor Sanjeev Parshad 1 & Shekhar Gogna 2
&
Vikas Saroha 1 & Shamsher Singh Lohchab 3 & Rajender Kumar Karwasra 1
Received: 23 December 2019 / Accepted: 2 June 2020 # Indian Association of Surgical Oncology 2020
Introduction
Case 1
The incidence of tracheal malignancies is about 0.1 in every 100,000 persons per year. It constitutes approximately 0.2% of all tumors of the respiratory tract [1]. Tracheal tumors are rare so there are no dedicated guidelines on their management. In adult patients, these tumors have more malignant potential, with squamous cell carcinomas (SCCs); being commonest with 85–90% of cases and adenoid cystic carcinomas (ACCs) as the second most common variety, accounting for approximately 10 to 15% of cases [2]. Surgical resection is the definitive mode of treatment in resectable cases. The 4 basic challenges in surgical resection of tracheal tumors are the following: type and access for anesthesia, dissection around the trachea, type of tracheal resection, and restoration of continuity of the trachea. We hereby report two cases of malignant tracheal tumors describing the different surgical techniques employed and review of literature of this rare disease.
Patient I is a 38-year-old male, a heavy smoker, complaining of severe wheeze and dyspnea on exertion associated with cough, for approximately 6 months. The patient was being treated by an internist for asthma with bronchodilators and anti-allergy medication but without any relief. Over this time, he had developed stridor and presented to ED. Surgery consult was sought and flexible bronchoscopy revealed a mass obliterating > 90% of tracheal lumen at the junction of upper and middle trachea; the scope was not negotiable (Fig. 1a). The CECT thorax and abdomen revealed a 6-cm segment of proximal intrathoracic trachea involved with the tumor (Fig. 1b). There was no mediastinal lymphadenopathy. After a multimodality tumor board meeting, we decided to plan the surgical resection of the tracheal tumor and subsequent radiotherapy (RT). During preoperative anesthesia evaluation, it was deemed that endotracheal intubation may not be successful and any attempt may be hazardous to the patient’s life as it may lead to bleeding or injury to the trachea. Tracheostomy was also not possible because the tumor involved the upper mediastinal trachea. Anesthesia was induced after cardiopulmonary bypass under local anesthesia. Surgical procedure began by gaining the access to upper and middle trachea by right thoracotomy. The rationale was to assess operability intraoperatively. The dissection started in posterior mediastinum preserving bilateral recurrent laryngeal nerves and bilateral vagus nerves. We took meticulous care not to peel off the loose fascial layer over the trachea to completely deprive of its blood supply. The trachea was divided 1-cm distal to the tumor. Flexometalic endotracheal (ET) tube was then passed per operatively in the distal cut end of trachea and ventilation was sta
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