Long term results of tracheal replacement with aortic allografts for locally advanced carcinoma

Objective. To assess the anatomical and oncological results of tracheal replacement with aortic allografts for locally advanced carcinoma. Methods. From March 2005 to October 2007, six patients ranging in age from 17 to 52 years with advanced muco-epidermoid (n=1) or adenoid cystic (n=5) carcinomas underwent a large (mean, 9.6 cm-long) tracheal replacement with silicone-stented aortic allograft. The grafts were wrapped using a pectoralis major muscle flap in the first four patients, with an additional ''thymopericardial fat flap'' in the last two. No immunosuppressive therapy was administered. Results. All grafts transformed into well-vascularized conduits, focally lined with respiratory epithelium. The first four patients developed, however, a silent esophageal (n=3) or mediastinal (n=1) fistula, which required a reoperation (n=3) at 6, 12 and 24 months, respectively. The last two showed an uneventful course. Long-term follow-up showed progressive contraction of the graft (up to 66%), with no evidence of tracheal cartilage regeneration. Consequently, stent withdrawal was not attempted in any patient. In contrast, TR ensured a local control of the disease in all patients. With a mean follow-up time of 58 months, the last four patients are still alive and disease free, and three of them have returned to full-time employment. Conclusion. To our knowledge, no other technique allowed for such extensive TR for tumor, with no postoperative mortality. To avoid the constraints of prolonged stenting, we are currently studying the construction of a revascularized tracheal substitute using an aortic allograft and additional tracheal rings in the rabbit model.