Manubrial resection and anterior mediastinal tracheostomy: friend or Foe?

OBJECTIVES/HYPOTHESIS To review our experience with manubrial resection and anterior mediastinal tracheostomy and formulate operative guidelines to improve the surgical outcome. STUDY DESIGN Retrospective study. METHODS Between January 1980 and June 2010, we performed 38 manubrial resections. The indications of the procedure, reconstructive methods, and operative outcomes were analyzed. RESULTS Fourteen patients had tumors of the hypopharynx/cervical esophagus, eight had parastomal recurrences of laryngeal tumor, four had recurrent esophageal tumors, four had postirradiation sarcoma, four suffered from subglottic/upper tracheal tumors, three had thyroid malignancy, and the remaining patient had tumor recurrence at the previous tracheostomy site. The hospital mortality rate was 5.3% due to bleeding from major vessel erosion. The mean length of the tracheal stump was 5.4 cm, of which 81.6% required relocation inferior to the innominate artery for construction of the mediastinal tracheostomy. Among the different reconstructive methods for the pharyngoesophageal defects, the anastomotic leakage rate was 17.6%, the majority of which required exteriorization followed by second stage reconstruction. The long-term tracheostomy stenosis rate was 47.4%, the risk of which was significantly increased by anastomotic leakage and necrosis of distal trachea. The use of a pectoralis major flap was shown to protect against this complication. The overall survival was 80.6% at 1 year and 55.6% at 5 years after surgery. CONCLUSIONS With attention to operative details, manubrial resection and anterior mediastinal tracheostomy is a safe procedure with acceptable outcome. It should be performed when indicated to facilitate tumor resection in the cervicothoracic region.