Surgical management of combined cervical tracheo‐esophageal defects

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Abstract
Three rather complicated cervical tracheo‐esophageal problems and their appropriate management, are described. In each case, a tracheal defect required repair. In one case, fascia lata was used to close a defect in the posterior tracheal wall. In another, this type of repair was unsuccessful in one‐stage closure of a large tracheo‐esophageal fistula. A 7 cm defect of esophagus in heavily irradiated tissues was successfully reconstituted with transposed colon. The co‐existing postirradiation tracheo‐esophageal fistula was repaired at an earlier stage to ensure that the patient's recovery from the laparotomy would not be complicated by aspiration pneumonitis. Thoracotomy was not required, but resection of the clavicular head and mobilization of the origin of the sternomastoid were used to improve the transcervical exposure of the superior mediastinum.In the second case, a tracheal defect that involved the tracheal cartilage was repaired by sleeve resection and end‐to‐end anastomosis. In revision surgery of chronic cervical tracheal and subglottic stenosis, one can anticipate massive local scar formation. The densely fibrosed common wall between the trachea and the esophagus should be left completely with the esophagus and only the lateral and anterior remnants of the trachea excised to avoid iatrogenic recurrent nerve paralysis or inadvertent perforation into a traction diverticulum of the esophagus. One should anticipate the use of the laryngeal drop procedure to make up the tracheal defect. The suprathyroid tissues will be virgin, whereas the previous tracheal procedures will have reduced the length attainable below from tracheal remobilization. Suturing the chin toward the chest is an effective and well‐tolerated prophylactic measure that prevents both extension of the neck after the operation and undue tension on the tracheal anastomosis.In the third case, closure of a vertical tracheal‐esophageal fistula and repair of a tracheal defect were undertaken simultaneously. The procedure involved mobilizing the larynx from its hyoid attachments, dropping the larynx, and bringing the margins of the esophageal defect together transversely, as in a pyloroplasty. This application of the laryngeal drop procedure, not previously described, was effective.

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