From the clavicle to the windpipe: Tracheal window resections reconstructed with calcifying periosteum in thyroid cancer

Abstract

Objectives: We aimed to evaluate the outcomes of tracheal window resection and reconstruction using a vascularized periosteal flap (intended for calcification) harvested from the medial clavicle. This is one of several surgical techniques for tracheal resection and reconstruction used for patients with thyroid carcinoma invading the trachea. Importantly, in partial tracheal resection postoperative dynamic airway collapse must be prevented. Reconstruction of the tracheal defect with a vascularized periosteal flap is one method of achieving a stable airway.

Methods: Twelve patients with locally advanced thyroid carcinoma who underwent tracheal resection and reconstruction at Oslo University Hospital from 2004 to 2017 were studied retrospectively. The primary outcome was a stable airway not requiring airway stenting. The secondary outcomes were the time to decannulation, morbidity, and survival.

Results: Eleven of 12 patients did not require airway stenting postoperatively after a median of 111 days. Seven patients developed postoperative complications. The median observation time was 74.8 months (range 10.5-153.5) for all patients. The median disease-free survival was 40 months (range 0-147). By February 1, 2020, seven patients were alive, of whom five showed no evidence of disease.

Conclusions: Tracheal reconstruction with a vascularized periosteal flap yielded good results in terms of establishing a stable airway. This procedure is a viable reconstructive option that allows for decannulation by preventing airway collapse, thereby potentially mitigating the need for end-to-end (ETE) anastomosis or sleeve resections. For selected patients, this procedure may prevent local fatal complications from thyroid cancer invading the trachea.

Level of evidence: Level 4.

Keywords: thyroid neoplasms/surgery; thyroidectomy/methods; tracheal resection; treatment outcome.

FIGURE 1

Window resection of the trachea. Tumor is shown with arrow. Ventilation switched to Jet‐ventilation

FIGURE 2

Harvest of myoperiosteal flap from the clavicle and manubrium. (1) sternal head of sternocleidomastoid muscle, (2) clavicular head of sternocleidomastoid muscle, (3) periosteum, (4) sternoclavicular joint capsule, (5) manubrium

FIGURE 3

Partially closed tracheal resection with T‐tube. Myoperiosteal flap and harvest‐area marked by hatched fields

FIGURE 4

After the repositioning of the myoperiosteal flap, muscle is seen to the right. Note a tight fit around the T‐tube

FIGURE 5

On the left, T1‐weighted contrast enhanced image MRI preoperatively. Tumor infiltration in the trachea indicated by arrowheads. On the right, postoperative CT of the same patient 7.5 years later. Arrowheads indicate the calcified periosteal flap

FIGURE 6

Preoperative images on the left, postoperative images (respectively 5, 0.5, and 8 years) after surgery on the right