Median sternotomy provides superior surgical exposure in intrathoracic tracheal malignancies: A 15-year retrospective analysis

Background: Tracheal resection and reconstruction is a complex thoracic surgery procedure. Posterolateral thoracotomy (PLT) is the standard approach for intrathoracic tracheal resection; however, research on the median sternotomy (MST) approach is limited. This study evaluated the surgical outcomes of MST in treating intrathoracic tracheal malignancies.

Methods: A 15-year retrospective analysis of the data of patients with primary intrathoracic tracheal malignancies who underwent “trachea + carina” resection and reconstruction at a single center was conducted.

Results: A total of 62 patients were included in the analysis. Among the patients, 27 (43.55%) underwent tracheal resection only, while 35 (56.45%) underwent combined carinal and main bronchial resection. The mean length of the resected tracheal segment was 35.00±8.15 mm, and 13 (20.97%) patients had a resection length of at least 40 mm. Negative surgical margins were achieved in 33 patients (53.23%), unilateral positive margins in 15 patients (24.19%), and bilateral positive margins in 14 patients (22.58%). The logistic regression analysis identified adenoid cystic carcinoma (ACC) pathology and extraluminal tumor growth as independent risk factors for positive surgical margins. No postoperative sternotomy site infection case was observed, and postoperative pain was generally well tolerated. Complications requiring medical intervention occurred in 16 patients (25.8%), including excessive granulation tissue formation at the anastomosis in 14 patients (22.58%) and an anastomotic fistula in 2 patients (3.23%). Notably, no instances of recurrent laryngeal nerve injury were reported.

Conclusions: The MST approach offers several advantages in the management of tracheal tumors, including better exposure, blood supply preservation, and left recurrent laryngeal nerve protection. Thus, it should be the preferred approach for long-segment resection and reconstruction.

Keywords: Tracheal malignancies; tracheal resection and reconstruction; median sternotomy (MST); complications


 

Highlight box

Key findings

• This study used the largest single-center dataset to evaluate the perioperative outcomes of median sternotomy (MST) in treating intrathoracic tracheal malignancies. The MST approach was safe and feasible in a retrospective analysis of 62 patients with complex “trachea + carina” malignancies. No postoperative infections or extensive complications were observed, and pain was well tolerated. Notably, the superior surgical visibility provided by MST preserved vascular integrity, protected the left recurrent laryngeal nerve, and achieved a longer resectable tracheal length.

What is known, and what is new?

• Surgery remains the primary treatment for tracheal malignancies, but resection and reconstruction, particularly of the long-segment intrathoracic segment, are technically challenging. Posterolateral thoracotomy (PLT) is the most commonly used approach in these scenarios. Despite its prevalence, data on the use of MST in malignant tracheal resection and reconstruction remain limited.

• The MST approach is advantageous for patients requiring extensive tracheal resections—an area not extensively addressed in previous research.

What is the implication, and what should change now?

• Our findings significantly contribute to the existing body of knowledge by demonstrating that MST is a viable alternative to PLT that provides superior surgical exposure and results in fewer complications in long-segment tracheal resections. This evidence supports the use of MST for more complex cases and may influence future surgical strategies for managing tracheal malignancies. Incorporating these findings into clinical practice could improve patient outcomes, particularly those requiring extensive resections and reconstructions.