19 Hemicricolaryngectomy with Tracheal Autotransplantation

10.1055/b-0039-170475

19 Hemicricolaryngectomy with Tracheal Autotransplantation

Pierre R. Delaere, Vincent Vander Poorten

Abstract

Tracheal autotransplantation is a reconstructive technique that allows for organ-sparing treatment of selected patients with advanced cricoid cartilage chondrosarcoma and T2 or T3 laryngeal squamous cell carcinoma (SCC; unilateral T2 with impaired vocal fold mobility; T3 with subglottic extension and/or arytenoid cartilage fixation). For this particular group of patients, our tracheal autotransplantation technique provides excellent functional results for respiration, speech, and swallowing without compromising the oncologic outcome. This is particularly true for patients younger than 65 years and for those with cricoid chondrosarcoma.

19.1 Case Report

A 54-year-old male patient presented with a T3N0 unilateral glottic squamous cell carcinoma (SCC) with involvement of the arytenoid and with infraglottic tumor extension. The lesion did not extend to the ventricle. Two years earlier, he received radiation therapy for a T1N0 glottic SCC. His pulmonary function test was within the normal range. The patient had no other comorbidities.

An extended hemicricolaryngectomy with tracheal autotransplantation was performed in this patient. An overview of the tumor extent and the amount of resection is depicted in Fig. 19‑1 .

**Fig. 19.1** Preoperative CT scan. Overview on CT scan of laryngeal tumor (*dotted line*) and the planned resection (*white contour lines*). **(a)** Coronal reformatted CT scan. The extended hemilaryngectomy defect involving up to one half of the cricoid cartilage will be reconstructed with the top 4 cm of the cervical trachea (*double arrow*). **(b)** Axial sections. b1, supraglottic level; b2, glottic level; b3, subglottic level.

19.1.1 First Operation

The operation began with a lateral selective neck dissection (levels II–IV) ¹ with inclusion of one an ipsilateral thyroidectomy. A hemilaryngectomy with inclusion of half of the cricoid cartilage was performed ( Fig. 19‑2).

**Fig. 19.2** Tumor resection for a right glottis squamous cell carcinoma with subglottic extension. **(a)** Artist’s representation of resection on a coronal sectional view. **(b)** Endoscopic view. The anterior commissure was included in the resection because the squamous cell carcinoma reached the anterior commissure. The aryepiglottic fold remains preserved. **(c)** Resection specimen. Lateralized cancer with subglottic extension.

After tumor resecting the cancer, the cervical trachea was wrapped with the radial forearm subcutaneous tissue and fascia with the aim of fabricating a transplantable tracheal patch, axially vascularized by the radial forearm flap (RFF) pedicle. The hemilaryngeal defect was repaired temporarily with the radial forearm skin paddle. A tracheostomy was necessary for respiration ( Fig. 19‑3).

**Fig. 19.3** Tracheal revascularization and temporary reconstruction. **(a–c)** Endoscopic representation after tumor resection and after closure (*arrows*; **a,b**) of the lateral gap between aryepiglottic fold and epiglottis. **(c)** Endoscopic representation after temporary reconstruction with forearm skin. **(d–f)** The radial forearm flap is designed with a paddle consisting of fascia and a paddle consisting of skin. The fascial paddle will serve for revascularization of the cervical trachea and the skin paddle will serve as temporary closure for the hemilaryngectomy defect. The forearm fascia **(d)** is wrapped around the 4-cm segment of cervical trachea **(e,f)**. The superior surface of the forearm fascia lies against the tracheal wall. The hemilaryngectomy defect is covered as a temporary measure until step 2 of the procedure using the cutaneous part of the revascularized free flap from the forearm. The first lateral site of the skin flap is sutured to the posterior laryngeal section margin of the cricoid cartilage from inferior (*black dot*) to superior. The second lateral side of the skin paddle is sutured to the anterior laryngeal section line from superior (*asterisk*) to the inferior (*triangle*) aspect. The lower edge (*triangle*) is not sutured into the laryngeal defect. An opening is left that served as a tracheostomy. The radial blood vessels are sutured to the neck vessels. The superior thyroid artery (end to end) and the internal jugular vein (end to side) are mostly used. A Gore-Tex membrane (*asterisk*; Preclude Pericardial Membrane, 0.1 mm, W.L. Gore and Associates, Inc. Flagstaff, AZ) is applied over the fascial-enwrapped trachea.

The sphincteric function after resection was restored by closing the gap between preserved aryepiglottic fold and epiglottis at the side of resection and by using the skin paddle of the RFF as a buttress for apposition ( Fig. 19‑3 a). The aryepiglottic fold allowed for a posterior midline reconstruction at the glottic and supraglottic level. After this intervention, the patient could close the glottic chink during speech and swallowing. A CT scan after 2 weeks illustrates the first step in the reconstruction process ( Fig. 19‑4).

**Fig. 19.4** CT scan after first operation. Overview on CT scan of tracheal revascularization and temporary larynx reconstruction. **(a)** Coronal reformatted CT scan. Levels of axial sections. *Arrow* indicates entrance of recurrent nerve. Double arrow indicates amount of cervical trachea to be used for larynx reconstruction. **(b)** Glottic level. A complete obliteration of the laryngeal lumen is visible at the glottic level. **(c)** Upper tracheal level. The double arrow shows a 1-cm segment of cervical trachea near the recurrent nerve (*position indicated with arrow*) that is not included in the autotransplant. Inset shows the amount of cartilaginous trachea that will be included in the autotransplant. **(d)**. Lower tracheal level. Inset: At the lower tracheal level, the full amount of cartilaginous trachea will be included in the autotransplant.

At this point, the tracheostomy remains necessary for respiration. In the immediate postoperative period, first the nurses and after a few days the patient aspirated his own secretions using the bedside hospital suction system. Frequent suctioning through the tracheostomy tube was indicated to evacuate pulmonary secretions. Oral alimentation was begun after 1 week.

The histopathological report confirmed a T3N0 SCC. Resection margins were tumor free.

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