Tracheal Replacement Techniques and Associated Mortality: A Systematic Review.

OBJECTIVE: Tracheal replacement is a crucial operation to enhance the quality of life for patients with extensive tracheal lesions. The most suitable surgical techniques for different clinical conditions remain a topic of debate. Through a reviewing of the relevant literature, this study investigated the association between surgical techniques and mortality rate. DATA SOURCES: Studies were collected from PubMed, Embase, the Web of Science, the Cochrane Center Register of Controlled Trials, and ClinicalTrials.gov. METHODS: This systematic review encompassed literature from the inception of each database to May 10, 2023, focusing on tracheal replacement for patients who underwent circumferential resection of the trachea or partial resection with preservation of the posterior membranous wall. Non-human and non-clinical studies were excluded. RESULTS: About 31 studies were included in the assessment comprising a combination of case reports and case series, and 118 patients underwent tracheal replacement through four underlying methodologies, including tracheal allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, or tissue engineering surgery. Each modality exhibits unique advantages and disadvantages, leading to variable outcomes in clinical application. CONCLUSION: Tracheal replacement is challenging due to the absence of an ideal substitution or graft material. Despite limited clinical successes observed across various modalities, we believe autologous tissue reconstruction for tracheal replacement has the advantage of broadest indications, low rejection rate, and avoidance of immunosuppressive agents. Future research should focus on achieving tracheal replacement that preserves mucociliary clearance, lateral rigidity, and longitudinal flexibility. LEVEL OF EVIDENCE: NA Laryngoscope, 134:1517-1522, 2024.

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major-latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction.

BACKGROUND: The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options. METHODS: This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n = 24) and free extended ALT (n = 20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis. RESULTS: The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm2 , and the mean flap size was 150.0 (8*12-15*15) cm2 and 205.0 (8*15-10*25) cm2 in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm2 , and the mean flap size was 285.2 (9*30-12*25) cm2 . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p = .048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p = .030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p = .044) than the free extended ALT myocutaneous flap. CONCLUSION: The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.