RECONSTRUCTIVE AIRWAY OPERATION AFTER IRRADIATION

After a patient died of anastomotic necrosis following a tracheal rese ction for the management of recurrent thyroid cancer invading the trac hea, which had been treated 6 years previously by thyroid lobectomy an d 4,800 cGy of radiation to control known residual disease, we explore d methods to promote the healing of tissues damaged by irradiation. Be tween 1979 and 1992, 22 patients underwent major airway resection and reconstruction after receiving large doses of radiation. The average d ose was 4,979 +/- 1,113 cGy (range, 3,150 to 6,840 cGy); the number of fractions, 20 to 38; and the average dose per fraction, 180 cGy (rang e, 150 to 200 cGy). The interval between irradiation and surgical trea tment was 42 +/- 105 months (range, 1 to 480 months). Seven cervical, eight midtracheal, and five carinal resections were performed, as well as two mainstem sleeve resections. Omentum was used to protect the an astomosis in 15 patients (68%), a pericardial fat pad was used in 2, a nd pleura was used in 2. In 3 patients, sternohyoid muscle was placed between the anastomosis and a major vascular structure, but without a tissue wrap. Two patients (9.0%) died postoperatively. Anastomotic deh iscence was the cause of death in a patient treated for lymphoma, and adult respiratory distress syndrome was the cause in the other patient ; this patient had undergone carinal pneumonectomy. Complications deve loped in 8 patients (36%). Two cervical dehiscences were treated by T- tube placement, 2 patients suffered wound infection, and 1 patient eac h suffered a myocardial infarction, dysphagia, hemoptysis, and bronchi tis. Major airway surgical procedures can be performed despite prior i rradiation given remote in time, but the likelihood of complication is increased in this setting. The use of vascularized tissue naps, prefe rably omentum, to enhance the blood supply and promote fibroplasia see ms beneficial.