Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland–type carcinoma Alain Wurtz, MD, Henri Porte,

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Presentation transcript:

Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland–type carcinoma Alain Wurtz, MD, Henri Porte, MD, PhD, Massimo Conti, MD, Catherine Dusson, MD, Jacques Desbordes, MD, Marie-Christine Copin, MD, PhD, Charles-Hugo Marquette, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 140, Issue 2, Pages 387-393.e2 (August 2010) DOI: 10.1016/j.jtcvs.2010.01.043 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Gross tumor extension, proximal and distal sections of the airway, in patients 1 to 6 (double arrows). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Main steps of the procedure, in patient 1. A, Orotracheal intubation and ventilation; circumferential tumor dissection (large arrow); removal of the gross tumor extension (double arrows). B, Withdrawal of the endotracheal tube and cross-field left main bronchus cannulation; distal sections after frozen section analysis (double arrows). C, Carinal restitution by suturing the right and left main bronchi together; end-to-end anastomosis between the proximal trachea and aortic allograft. D, Orotracheal intubation with a rigid bronchoscope; the folded stent was pulled with a forceps introduced through the bronchoscope. E, Jet ventilation was applied through the bronchoscope; the bifurcated stent was gently pushed caudally with a forceps. F, The anterior distal anastomosis was completed and the patient was conventionally reintubated. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Partial wrap. Pectoral muscle flap interposed between the splinted aortic allograft and the large vessels (patients 1 to 4). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Complete wrap. “Thymopericardial fat flap” with its right internal thoracic pedicle, on the right and posterior face of graft, and the right pectoral muscle flap interposed between the graft and large vessels (patients 5 and 6). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

A, Carinal restitution in patient 1 A, Carinal restitution in patient 1. RMB, Right main bronchus; LMB, left main bronchus. B, Operative view of the tracheal reconstruction with the fresh aortic allograft in place, in patient 1. IA, Innominate artery; AA, aortic allograft. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Operative view of interposition of the pectoral muscle flap between the graft and large vessels, in patient 1. IA, Innominate artery; AO, aorta. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

A, Chest computed tomographic scan in patient 2 A, Chest computed tomographic scan in patient 2. The arrows show the upper and lower limits of the tumor. B, Tracheal and carinal resection specimen including the stapled bronchial stump of the right upper lobe. RUB, Right upper lobe bronchus, LMB, left main bronchus. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

A, Normal respiratory epithelium and basement membrane lining the graft (arrow), in patient 1 (hematoxylin–eosin stain ×100). B, Persistence of islet of elastic fibers (arrows) within a dense inflammatory infiltrate in patient 1 (hematoxylin–eosin stain ×400). The Journal of Thoracic and Cardiovascular Surgery 2010 140, 387-393.e2DOI: (10.1016/j.jtcvs.2010.01.043) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions