Reconstruction of the (Crico)trachea for malignancy in the virgin and irradiated neck

Background: Reconstruction of the trachea following resection for malignancy is challenging. We present our experience over a 5-year period, and a reconstruction algorithm with particular emphasis on minimising complications associated with radiotherapy. Methods: A maximum of six tracheal rings can be resected and anastomosed primarily with acceptable tension. A more conservative approach is required in an irradiated trachea. For a limited defect localised anteriorly or laterally, a tracheal flap can be fashioned. As for more eccentric defects, an option is to convert the defect into an asymmetrical segmental defect, and to primarily anastomose the trachea with rotation of the distal stump. Our workhorse loco-regional flaps for patch reconstruction or suture line reinforcement include the sternocleidomastoid, internal mammary artery perforator and pectoralis major myocutaneous flaps. For extensive defects, a radial forearm free flap (RFFF) with rib cartilage struts for rigidity provides a good solution. Results: Fifteen patients (M:F = 4:11, median age 69 years) were identified. Six cases were locally aggressive papillary thyroid cancer. Mean follow-up was 17 months. Five and two patients had had radiotherapy prior to and following tracheal resection, respectively. Nine patients were extubated at the end of surgery, two were successfully decannulated from their T tube subsequently, and one from his tracheostomy. The two surgical complications included a partial RFFF dehiscence causing minor air leak, and major haemorrhage that warranted urgent operation and pectoralis major flap reconstruction. Conclusion: Reconstruction of the trachea requires individualised techniques suited to the patient's body habitus, co-morbidity, previous treatment and the configuration of the defect.