Cervical exenteration

Abstract

Cervical exenteration is a radical procedure for the treatment of locally invasive cancers of the trachea, esophagus, or thyroid, as well as recurrent tumors at the site of a tracheal stoma, and occasionally for benign disease. Exenteration involves removal of the larynx, pharynx, esophagus, and trachea, as well as associated lymphatic tissue. The tracheal stump is brought up as a cervical or mediastinal tracheostomy, depending on the length and the location of the distal resection site. The alimentary tract can be reconstructed with several types of conduits, but most commonly the stomach or left colon are used. Tension on the innominate artery must be avoided when repositioning the trachea to prevent innominate artery erosion. Tension on the artery can be addressed by either dividing the vessel or by transposing the trachea inferior and lateral to the innominate artery and vein. Overall, cervical exenteration is associated with a significant risk of morbidity, including anastomotic leak, innominate artery erosion, and tracheostomy dehiscence with subsequent mediastinitis, as well as the potential for postoperative death. Nevertheless, in highly selected patients, it can provide an unparalleled opportunity for either cure or palliation, with functional results equivalent to that of total laryngectomy.

Keywords: Mediastinal tracheostomy; aortic homograft; conduit; reconstruction; skin flap.

Figure 1

Incisions for cervical exenteration. The superior incision allows access to the neck and mediastinum. The inframammary incision is used to create a bipedicled advancement flap, according to the technique described by Grillo et al. A midline laparotomy allows preparation of the conduit, usually stomach or colon, and placement of a jejunostomy tube for enteral feeding postoperatively. With permission from Grillo and Mathisen, 1990.

Figure 2

Dissection and resection of the anterior breast plate. The manubrium is split to facilitate mediastinal exploration and dissection. Both clavicular heads are removed along with 4 cm of the medial clavicles. The first and second costal cartilages are resected, along with the first intercostal muscle. With permission from Grillo and Mathisen, 1990.

Figure 3

Esophageal reconstruction. The conduit (here, colonic) is brought into the mediastinum to the left of the tracheal stump and anastomosed to the base of the tongue in two layers. With permission from Grillo and Mathisen, 1990.

Figure 4

Tracheal resection. The diseased portion of the trachea is resected, and the innominate artery is divided (dashed line) if tension exists between the artery and the distal tracheal stump (A). Prior to maturing the tracheostomy, the tracheal stump is wrapped with omentum to protect the innominate artery from potential erosion (B). With permission from Grillo and Mathisen, 1990.

Figure 5

Creation of the anterior mediastinal tracheostomy using a bipedicled skin flap. The tracheostomy is brought out through the flap below the cervical incision site (A). The tracheal stump is sutured to the skin flap with interrupted vicryl sutures. With permission from Grillo and Mathisen, 1990.

Figure 6

Transposition of the tracheal stump. To avoid tension between the tracheal stump and the innominate artery, the trachea can be transposed laterally and inferior to the innominate vessels. Modified with permission from Orringer, 1992.

Figure 7

Thoracoacromial skin flap. This flap can be used when the tracheal stump has been repositioned below and laterally to the innominate vessels. The inframammary wound is covered with a split thickness skin graft. Modified with permission from Orringer, 1992.

Figure 8

Cervical resection with esophageal reconstruction using aortic homograft. Anterior (A) and posterior (B) views of a resection specimen including the larynx and cervical trachea and the anterior esophagus. The anterior esophageal defect included over 50% of the circumference (C). This esophageal defect was reconstructed with cryopreserved aortic homograft sewn in place over a silicone tube (D).

Video

Cervical exenteration.