ORIGINAL
MANAGEMENT OF A TRACHEAL TEAR DURING ARTICLE
LARYNGOPHARYNGOESOPHAGECTOMY WITH GASTRIC PULL-UP
Management of a tracheal tear during
laryngopharyngoesophagectomy with
gastric pull-up
Sandra Koterski, MD; Norman Snow, MD; Mike Yao, MD
Abstract
Laceration of the posterior tracheal wall is one of the
risks of transhiatal esophagectomy. Various methods of
repairing such lacerations have been described; many of
these methods involve a thoracotomy, but some do not.
We describe a case of a posterior tracheal wall tear that
occurred during a laryngopharyngectomy with a gastric
pull-up.The tear was repaired with the transposed stomach
and did not require a thoracotomy. The transposed stom-
ach was used to patch the tear and block communication
between the environment and the mediastinum. Bedside
endoscopic examination on postoperative day 5 revealed
that the tear had healed. Key management considerations
in such a circumstance include having the patient breathe
without positive pressure ventilation postoperatively and
keeping the tracheal lumen and stoma clear during the
healing process in order to prevent the development of
positive tracheal pressure. With these safeguards in place,
the transposed stomach approach is a safe method of
repairing posterior tracheal wall tears.
Introduction
Organ-sparing approaches have enjoyed wide acceptance
as a treatment for advanced-stage laryngeal cancer since
the publication of the Department of Veterans Affairs
Laryngeal Cancer Study Group report in 1991.1 The VA
investigators compared (1) induction chemotherapy fol-
lowed by radiotherapy, with salvage laryngectomy as
needed, and (2) laryngectomy followed by radiotherapy.
They found that cure rates in the two groups were equal
From the Department of OtolaryngologyHead and Neck Surgery,
Northwestern University Feinberg School of Medicine, Chicago (Dr.
Koterski); the Division of Cardiothoracic Surgery, Department of
Surgery (Dr. Snow); and the Department of OtolaryngologyHead
and Neck Surgery (Dr. Yao), University of Illinois at Chicago
College of Medicine.
Reprint requests: Mike Yao, MD, Eye and Ear Infirmary, Department of
OtolaryngologyHead and Neck Surgery, University of Illinois at
Chicago, 1855 W. Taylor St., M/C 648, Chicago, IL 60657. Phone:
(312) 413-4240; fax: (312) 413-2010; e-mail: myao@uic.edu
Volume 85, Number 4 271
and that 64% of the nonsurgical patients were able to retain
their larynges. The results of numerous subsequent stud-
ies confirmed the benefits of organ-sparing approaches in
head and neck cancers.2,3
Surgeons in a number of centers have noted that treat-
ment of highly destructive laryngeal cancers often results
in nonfunctional larynges. Many patients with nonfunc-
tional larynges require a tracheostomy for breathing and
a gastrostomy for nutrition. In such cases, removal of the
larynx actually allows for a better functional outcome and
high cure rates. Following laryngectomy, most patients are
able to take nutrition orally, and many undergo successful
speech rehabilitation with tracheoesophageal prostheses.
We have adopted this approach for our patients who have
large, destructive laryngeal cancers.
In patients whose cancer has extended into the esopha-
gus, we perform a laryngopharyngoesophagectomy. This
procedure is much less common in our institutions today
than it once was because we now rely more on concomitant
chemotherapy and radiation. However, when warranted,
ourcurrentpracticeistoperformacervicalesophagectomy
with a jejunal free-flap reconstruction. At the time of the
case described in this article, we did not have the services
of a reconstructive surgeon with microvascular experience,
and therefore we chose to reconstruct our patient with a
gastric pull-up. The complication rate associated with this
approach is high (nearly 50%), including a 30-day mortality
rate of 7%.4 Prevention of adverse outcomes requires a fa-
miliarity with the possible complications of this procedure.
Some reported complications include injury to the spleen,
azygos vein laceration, chylothorax, recurrent laryngeal
nerve paralysis, anastomotic leaks, cardiac abnormalities,
pleural injury, and tears to the posterior tracheal wall.
Specific concern has been directed to the risk of tracheal
tearsduringblinddissectionsofthemediastinalesophagus
via the transhiatal approach. In the 1970s, experience at
Memorial Sloan-Kettering Cancer Center revealed that
tears of the membranous tracheal wall occurred in 62.5% of
such cases.5 Reports 2 decades later indicated that the rate
of tracheal tears had fallen dramatically to less than 10%
 KOTERSKI, SNOW, YAO

(table).6-8 In fact, Orringer et al retrospectively reviewed and posterior tracheal wall would keep air from entering
1,085 cases and reported a tear rate of less than 1%.6 themediastinumduringnormalbreathing,butthatpositive
Many surgeons prefer transhiatal esophagectomy to the pressure ventilation might force air into the mediastinum.
transthoracic approach because it is associated with lower These concerns were discussed with the anesthesiologist,
rates of operative mortality and postoperative morbidity.9 whofeltconfidentthatthepatientcouldcontinuetobreathe
In this article, we report our management of a tracheal tear without assistance. We felt that the tight apposition of the
that occurred during a transhiatal esophagectomy. stomach to the posterior tracheal wall was adequate to seal
off the mediastinum from the environment, and therefore
Case report we did not pursue any further intervention.
A 65-year-old man presented to the otolaryngology unit Prior to our leaving the operating room, a right-sided
with complaints of respiratory distress and a 50-lb weight pneumothorax was noted on the chest x-ray, and a chest
loss. Endoscopy revealed that a mass had filled his entire tube was placed to re-expand the right lung. The patient
larynx and extended into the right piriform sinus.The mass was allowed to awaken and breathe spontaneously. No
had destroyed the medial sinus wall and extended into the air leak from the chest tube was noted. The patient was
esophageal inlet. A biopsy revealed that the lesion was a then extubated and outfitted with a mist tracheostomy
papillary squamous cell carcinoma. collar with oxygen. The stoma was widely patent, and no
The patient underwent a laryngopharyngectomy with tracheostomytubewasplaced.Thepatientwastransported
gastric pull-up and a bilateral modified radical neck dis- to the surgical intensive care unit.
section. Following mobilization of the esophagus, air was On postoperative day 5, bedside flexible endoscopy
seen leaking from the neck wound.When the endotracheal of the posterior tracheal wall revealed that the tear had
tube and trachea were checked, a 3-cm vertical laceration healed completely; in fact, the original site could not be
was discovered in the posterior wall of the trachea, approxi- identified.Onpostoperativeday8,amegluminediatrizoate
mately 3 to 4 cm above the carina. The tear was presumed (Gastrografin) swallow study demonstrated no evidence
to have occurred during the blunt, blind dissection of the of extravasation, and oral feedings were begun without
trachea from the esophagus. The patients endotracheal complication. The patient was discharged home on post-
tube was pushed beyond the tear, and the balloon on the operative day 18. At the 3-year follow-up, his posterior
tube was used to block the hole and maintain ventilation. tracheal wall remained intact and he had not experienced
Afterconsultationbetweentheheadandnecksurgeonand any related difficulties.
the thoracic surgeon, the decision was made to continue
with surgery and to evaluate the possibility that the trans- Discussion
posed stomach could be used to tamponade the hole. If the Asmentioned,earlystudiesofthecomplicationsoftranshia-
transposed stomach was not able to adequately block the tal esophagectomy revealed a high rate of tracheal tears.5,10
area of the tear, the patient would require a thoracotomy Patientswhohadundergonepreviousirradiationandthose
for either patching or direct repair of the tear. whose tumors had eroded through the esophagus were at
Following transposition of the stomach without trans- particularly high risk. Management in these cases did not
position of the omentum, bronchoscopy revealed that the requireformaltrachealrepairbecauseanadequatesealhad
stomach had formed a tight seal with the posterior wall of been created with the transposed stomach. More recently,
the trachea. Because of the distal position of the tear, the tracheal injuries during transhiatal esophagectomy have
stomachcouldnotbefurthersecuredwithoutperforminga beenmanagedbythoracotomyandrepairwithpericardium
thoracotomy. It was felt that the seal between the stomach or pleura.4,8 Again, in many cases, the thoracotomy is un-
necessarybecauseanexcellentseal
Table. Reported rates of tracheal tears during transhiatal esophagectomy can be created with the transposed
stomach.
Authors Type of study No. pts. Rate Animportantconsiderationwhen
Bains and Spiro, 1979
5
Retrospective 16 63% using the stomach to tamponade a
Spiro et al, 1983
10
Retrospective 63 16% tracheal tearistherespiratorystatus
Hankins et al, 1987
11
Retrospective 26 8% of the patient. If the air pressure in
Spiro et al, 1991
12
Retrospective 120 18% the trachea is significantly higher
Deshmane et al, 1993
13
Retrospective 174 4% than that in the thoracic cavity, air
Katariya et al, 1994
4
Review of 23 articles 1,353 0.7% might leak from the trachea into the
Orringer et al,6 1999 Retrospective 1,085 <1% mediastinum. Air leaks delay the
Kannan and Mahajan, 1999
7
Retrospective 50 6% healing of a tear, and they provide
Hulscher et al, 2000
8
Prospective 383 1.8% a vector by which bacteria from
the trachea can contaminate the

272 ENT-Ear, Nose & Throat Journal April 2006

 MANAGEMENT OF A TRACHEAL TEAR DURING LARYNGOPHARYNGOESOPHAGECTOMY WITH GASTRIC PULL-UP

mediastinum. The two most common causes of elevated 6. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagec-
intratracheal pressure are positive pressure ventilation tomy: Clinical experience and refinements. Ann Surg 1999;230:392-
400; discussion 400-3.
and expiration against a closed glottis (as occurs during 7. Kannan RR, Mahajan V. Tracheal injury during transhiatal mobi-
speaking or coughing). Positive pressure ventilation can lization of the esophagus. J Surg Oncol 1999;71:186-8.
be avoided by allowing the patient to breathe spontane- 8. Hulscher JB, ter Hofstede E, Kloek J, et al. Injury to the major
ously, while expiration against a closed glottis is not a airways during subtotal esophagectomy: Incidence, management,
and sequelae. J Thorac Cardiovasc Surg 2000;120:1093-6.
factor in laryngectomy patients because the glottis has 9. Bolton JS, Sardi A, Bowen JC, Ellis JK. Transhiatal and transtho-
been removed. Another possible cause of significant in- racic esophagectomy: A comparative study. J Surg Oncol 1992;51:
tratracheal pressure elevation is obstruction of the stoma, 249-53.
but this can be avoided by frequent suctioning and the 10. Spiro RH, Shah JP, Strong EW, et al. Gastric transposition in head
and neck surgery. Indications, complications, and expectations.
humidification of inspired air. With an open conduit into Am J Surg 1983;146:483-7.
the trachea at all times, intratracheal pressures remain 11. Hankins JR, Miller JE, Attar S, McLaughlin JS. Transhiatal
very close to the atmospheric pressure. Free flow of air esophagectomy for carcinoma of the esophagus: Experience with
into the trachea minimizes the pressure gradient between 26 patients. Ann Thorac Surg 1987;44:123-7.
12. Spiro RH, Bains MS, Shah JP, Strong EW. Gastric transposition
the trachea and mediastinum. This pressure gradient is for head and neck cancer: A critical update. Am J Surg 1991;162:
the driving force for air passage from the trachea into the 348-52.
mediastinum. By minimizing the gradient, the likelihood 13. Deshmane VH, Divatia JV, Dasgupta D, et al. Tracheal tear during
of an air leak is decreased. laryngopharyngectomy with gastric transposition. J Surg Oncol
1993;54:219-22.
Thevastmajorityofourpatientswithadvancedlaryngeal
or hypopharyngeal cancer are treated with concomitant
chemotherapy and radiation therapy. As a result of our
extensive use of these protocols, the frequency of laryn-
gectomyorlaryngopharyngoesophagectomyinourpractice
has decreased substantially. However, a small population
of patients does have a need for these procedures, and
surgeons who care for these patients must be familiar with
the management of complications. This case report serves
as a reminder that tracheal tears, be they distal or proxi-
mal, can often be successfully sealed with the transposed
stomach.Avoidingthoracotomydecreasesthepotentialfor
further morbidity or mortality. Our patient recovered from
surgery without additional morbidity, and his tear healed
within 5 days. We believe that repair with the transposed
stomach should always be considered and that it should
be attempted, when appropriate, before more complex
approaches are tried. The keys to minimizing air leak are
to have the patient breathe spontaneously and to keep the
trachea and stoma clear of obstruction.

References
1. The Department of Veterans Affairs Laryngeal Cancer Study Group.
Inductionchemotherapyplusradiationcomparedwithsurgeryplus
radiation in patients with advanced laryngeal cancer. N Engl J Med
1991;324:1685-90.
2. Wolf GT. Commentary: Phase III trial to preserve the larynx:
Induction chemotherapy and radiotherapy versus concurrent che-
motherapy and radiotherapy versus radiotherapyIntergroup trial
R91-11. J Clin Oncol 2001;19(18 suppl):28S-31S.
3. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy
and radiotherapy for organ preservation in advanced laryngeal
cancer. N Engl J Med 2003;349:2091-8.
4. Katariya K, Harvey JC, Pina E, Beattie EJ. Complications of
transhiatal esophagectomy. J Surg Oncol 1994;57:157-63.
5. Bains MS, Spiro RH. Pharyngolaryngectomy, total extrathoracic
esophagectomy and gastric transposition. Surg Gynecol Obstet
1979;149:693-6.

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