Successful conservative treatment for massive tracheal necrosis after lung segmentectomy

BACKGROUND

Tracheal necrosis, which is rare because the trachea has rich in blood supply, can be a serious condition. Herein, we report the case of extensive tracheal necrosis that developed after right apical segmentectomy for a metastatic lung tumor of esophageal cancer.

CASE PRESENTATION

A 74-year-old man who had undergone thoracoscopic subtotal esophagectomy and gastric tube reconstruction via the posterior sternal route for esophageal adenocarcinoma 2 years previously was referred to our department with an enlarging nodal lesion in the right upper lung lobe. Computed tomography revealed a 30-mm tumor in the right apical segment with no lymph node enhancement, suggesting primary lung cancer or a metastatic lung tumor. The patient underwent right apical segmentectomy. The upper lobe was adherent to the chest wall and mediastinal fat from the apex of the lung to the dorsal side, with particularly strong adhesion at the esophagectomy site. After dissecting the adhesions, right apical segmentectomy was performed via complete video-assisted thoracic surgery. The patient was discharged on the 9th day after surgery without any complications. Pathologic findings revealed a metastatic lung tumor originating from the patient's esophageal cancer. On the 26th day after surgery, the patient returned with dyspnea and increased sputum. Computed tomography images revealed that the posterior wall of the trachea was missing an area of 16 × 42 mm and was connected to the dead space after the right apical segmentectomy, with no effusion. We diagnosed extensive tracheal necrosis. Considering that the patient's status was very well despite the extensive tracheal necrosis, we chose conservative treatment. After receiving 12 days of intravenous antibiotic treatment, his symptoms improved, and he was discharged on day 26 after admission.

CONCLUSIONS

Right upper lung lobe resection after esophagectomy has a risk of tracheal necrosis. Conservative treatment is one approach to manage massive tracheal necrosis in patients with stable respiratory conditions.

Tracheal necrosis following thyroid radiofrequency ablation

INTRODUCTION

Radiofrequency ablation for benign thyroid nodules has a low rate of complications in experienced hands for selected indications, but tracheal necrosis is a major complication.

CASE REPORT

A 60 year-old female patient underwent percutaneous radiofrequency ablation of an unesthetic benign isthmic thyroid nodule. The procedure was performed with a cooled electrode, using the "moving shot" technique on a trans-isthmic approach, under general anesthesia. Postoperative course was complicated by dysphonia and cervical pain implicating a third-degree skin burn of the medial cervical region progressing to severe soft-tissue and cervical tracheal necrosis.

DISCUSSION

Risk factors in the present case included the general anesthesia, isthmic location and thyroid nodule volume. To avoid this kind of complication, the procedure should be performed under local anesthesia, using cooled dextrose solution hydrodissection between trachea, thyroid and skin. Ahead of radiofrequency ablation, patients should be informed of possible major complications, especially if the indication is cosmetic.

Closing a Tracheal Defect with an Omental Pedicled Gastric Flap; A Technical Note

Due to an adenocarcinoma of the right upper lobe with infiltration of the main bronchus a 49-years-old female patient underwent an upper bilobectomy with sleeve resection. After two completed chemotherapy bouts and signs of sepsis another thoracotomy was inevitable.  As a complicating factor a supracarinal, necrotic and perforating lesion of the trachea appeared. The defect can be initially repaired with a suture and covered with azygos vein material. However surgical revision showed an enlargement of the tracheal necrosis. Then the lesion was occluded with a diaphragmatic pedicled flap. Nevertheless after the operation a tracheal insufficiency with massive ventilation leakage was observed. It was generated by the death of the diaphragmatic flap. As an ultimate therapeutic measure a transplantation of a pedicled omental gastric flap was performed, which in case of a failure of the conventional operative techniques, is an additional option in closing tracheal defects caused by infections. Especially in cases of massive infected thoracic cavity and tracheal necrosis omentum majus is, compared to muscle flaps, the better biological tissue to close and heal the tracheal defect. This case report firstly describes a successfully closure of a tracheal defect using the technique mentioned above.

Risk factors for complications after pharyngolaryngectomy with total esophagectomy

BACKGROUND

Pharyngolaryngectomy with total esophagectomy (PLTE) is an effective surgical treatment for synchronous or metachronous hypopharyngeal or laryngeal cancer and thoracic esophageal cancer, although it is more invasive than esophagectomy and total pharyngolaryngectomy. The aim of this study was to identify risk factors for complications after PLTE.

METHODS

From November 2002 to December 2014, a total of 8 patients underwent PLTE at the Shizuoka Cancer Center Hospital, Shizuoka, Japan. We investigated the clinicopathological characteristics, surgical procedures, and postoperative complications of these patients.

RESULTS

Of the 8 patients, 5 underwent one-stage PLTE and 3 underwent staged PLTE. There was no mortality in this study. Two cases of tracheal necrosis, two of anastomotic leakage, and one of ileus were observed as postoperative complications. Two patients who underwent one-stage PLTE with standard mediastinal lymph node dissection developed tracheal necrosis and severe anastomotic leakage.

CONCLUSION

One-stage PLTE and standard mediastinal lymph node dissection were identified as the risk factors for severe postoperative complications. Staged PLTE or transhiatal esophagectomy should be considered when PLTE is performed and standard mediastinal lymph node dissection should be avoided when one-stage PLTE is performed with transthoracic esophagectomy.