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Long Segment Tracheal Reconstruction With A Composite Cervical Skin Flap Buttressed With Costal Cartilage Provides A Novel Approach For Tracheal Substitute
D. Fabre, F. Kolbe, E. Fadel, P. G. Dartevelle. Marie Lannelongue Hospital, Le Plessis Robinson, France,
Objective:
Tracheal replacement after long segment resection for airway tumors remains a challenging procedure due to inadequate substitute conduits. An ideal airway conduit should be well vascularized, rigid and autologous to avoid infections, free from airway stenosis and not require imunosuppression. We report a novel autologous tracheal substitute that provides excellent long term results.
Methods:
A six centimeter tracheal resection (60% of total length) was performed in 12 adult pigs and reconstructed using a rotational cervical skin flap. Costal cartilage strips measuring 6 cm in length and 2 mm in were harvested from the chest wall on the same animal and inserted at regular 0.5 centimeter intervals between the dermal layers of the cervical skin flap. The neo-trachea was then constructed by rotating the flap around a silicone stent of 6 cm of length and 1.4 cm of diameter. An end to end anastomosis was performed between this tube and the native trachea at each edge and the skin closed using a double-Z plasty. Animals were sacrificed and studied at 1 week (group I, n=4), 2 weeks (group II, n=4) and 5 weeks (group III, n=4). In group III, the stent was removed one week prior to being sacrificed. The neo-trachea was assessed by monitoring weight gain, daily flexible bronchoscopy and histologic autopsy examination.
Results:
There were no animal deaths during the study period. Weight gain was appropriate in all animals. On bronchoscopy there were no evidence of suture line dehiscence but a symptomatic distal granuloma was removed in 5 cases using rigid bronchoscopy. In group III, three animals tolerated the stent removal at 4 weeks. One animal required stent re-insertion due to respiratory distress secondary to tracheomalacia. On histology, all flaps and cartilages were viable.
Conclusion:
Long segment tracheal replacement with autologous cervical skin conduit scaffolded with costal cartilages is a simple and reproducible model in a large animal trial. This preliminary study demonstrated good results in terms of respiratory function and tracheal substitute strength. Cervical skin flaps buttressed with costal cartilage is a promising solution for long segment tracheal replacement 
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