Stomaplasty-anterior advancement flap and lateral splaying of trachea, a simple and effective techniqueNP Trivedi, D Patel, K Thankappan, S Iyer, MA Kuriakose
Head and Neck Institute, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.39185
Source of Support: None, Conflict of Interest: None
Background: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. Aim: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. Settings and Design: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. Materials and Methods: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. Statistical Analysis: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. Results: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. Conclusions: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.
Keywords: Laryngectomy, stomal stenosis, stomaplasty, tracheo-esophageal-prosthesis
Stomal stenosis after laryngectomy is a common and distressing problem. The reported incidence ranges from 4 to 34%. , Various contributing factors for stomal stenosis such as female sex, infection, fistula formation and improper mucocutaneous approximation have already been identified. ,,,
Stomal stenosis results in difficulty in maintaining an adequate airway, inability to clear secretions and inability to use tracheo-esophageal-prosthesis (TEP). Various treatment modalities ranging from repeated dilatations to different revision surgeries have been described for this condition. Repeated dilatation and stenting is not useful in long term as it has problems like bleeding and excoriation, retained secretions and inability to use TEP. Many stomaplasty techniques have been described. Most of these advocate circumferential dissection for improved airway patency and avoidance of re-stenosis. ,,, However, this may result in excision of the scar tissue in the posterior region where TEP is sited resulting in the need for removal of the prosthesis.
In this we report a modified advancement flap and splaying of trachea for stomaplasty, which gives a wide stoma and prevents restenosis. This technique also avoids the posterior excision-avoiding disturbance of the TEP site.
The patient with stomal stenosis is initially submitted to dilatation and stenting with tracheostomy tube for a minimum of 2 months period. The patient who does not respond to this is considered for surgery.
The patient is placed supine with a shoulder bag in place. General anaesthesia is induced and maintained using a small (#5 or 6) endotracheal tube. An inferiorly based skin flap is developed in a subfascial plane on the manubrium [Figure - 1]. Scar tissue from the anterior two-third of trachea is excised for about 3-4 mm width including a part of skin; leaving posterior part of TEP site untouched. [Figure - 2]. Anterior two-thirds of the trachea is freed exposing the top one or two rings of the cartilage. The dissection is carried out in a paratracheal plane to avoid injury to the innominate vessels. Anteriorly trachea is incised vertically in the midline for up to one to two rings [Figure - 2]. Tip of the triangular skin flap is sutured with 2'0 prolene stitch to apex of tracheal incision [Figure - 3]. The superficial cut end of trachea is sutured to the periosteum of clavicular head resulting in lateral spaying of the trachea [Figure - 4]. To assist this further, medial one-third of sternocleidomastoid muscle is cut. Lateral and posterolateral wall of trachea is sutured to freshened skin margin, which brings trachea out further and splays it laterally [Figure - 5]. No tracheostomy tube is used during the postoperative period. Stitches are removed after 10 days. Patients are followed up on a monthly basis for up to 6 months. Stoma retains adequate diameter in longer follow-up [Figure - 6] with TEP in situ .
Eight patients underwent modified stomaplasty procedure in our institution from January 2004 to October 2006. After approval from the institutional review board a retrospective review of results was carried out. Charts of all patients who underwent modified stomaplasty were reviewed and serial measurement of vertical and horizontal diameter was recorded from charts. Patients who completed 1-year follow-up were included for analysis.
The median time from laryngectomy to stoma revision surgery was 7 months (range 3-14 months). Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally [Table - 1]. The patient in figure had preprocedure diameter of 8 × 5 mm 2 , which could be, increased up to 20 × 16 mm 2 at 1-year follow-up [Patient 4 in [Table - 1]].
All patients had a trial with stenting with tracheostomy tube for at least 2 months but failed to improve. Six patients had primary TEP (Bloom-Singer prosthesis). None of these patients were able to use TEP due to the stomal stenosis and the use of tracheostomy tube. One of the eight patients has to use stent during night even after the stoma revision procedure, as his stoma has a tendency to contract again due to scar formation. Only intermittent stenting at night is adequate to maintain adequate size stoma and this does not interfere with speech production during daytime. Six of these patients (Patient 1-5 and 8), who already had indwelling TEP placed, have been successfully producing TEP speech after stoma revision. Other two patients (Patients 6 and 7), in whom non-indwelling valve were inserted simultaneously with stomaplasty, had later on developed peri-TEP leak due to puncture hole gradually getting bigger with repeated insertion-removal of valve (Duckbill type prosthesis by Siddham Diagnostics, Nagpur, India). This was unrelated to stomaplasty procedure and TEP had to be removed later [Table - 2].
Wound healing was uneventful in all but one patient, who developed dehiscence of the inferior flap. This patient underwent stomaplasty within 3 months of completion of adjuvant chemoradiation. He required a second local flap reconstruction.
An adequate stoma is one, which is large enough not to require permanent stent, allows adequate clearance of secretion and provides enough space to clean TEP. Failure to meet these criteria is defined as stomal stenosis.  Montgomery attempted to classify tracheostomal stenosis according to the shape of the stoma.  He described three type of stenosis: vertical slit (due to compression from the sternal heads of the sternocleidomastoid muscle), concentric (due to scar contraction) and inferior shelf (due to redundant skin folds). In clinical practice, most of them are of concentric types.
Various techniques are described to create the primary stoma during laryngectomy to avoid stenosis later (straight transection of trachea, ,, bevelling the trachea, ,,, plastic or flap construction technique). ,,, No clear-cut evidence is available in the literature to indicate which method is superior. Site of stoma (either in main incision or lower down separately) does not contribute to stenosis either. Female sex, improper mucocutaneous approximation and infection or fistula at stomal site seem to be the main contributing factors in the development of stenosis. 
Stomal stenosis, once sets in, is a progressive disorder and leads to airway limitation and inability to use TEP. One simple method is to do repeated dilatations and stenting as described by Soo.  Practically, this does not solve any of the problems. The stoma continues to contract, secretions are not cleared properly, crusting occurs, that further complicates the problem the use of stent prevents TEP function. All our patients were initially using stents after repeated dilatations and were facing similar problems.
Various surgical techniques have been described to widen the stoma. The most simple technique is to excise the scar tissue all around and suture the refreshed edges together. The results of this technique are not good and TEP may get displaced. Other techniques include advancement flaps, V-Y flaps, Z plasty and interposition flaps. ,,,,, The results of various techniques are variable, but it seems that excision of majority of scar tissue is essential and breaking of circular scar with interposition flap gives better results.  CO 2 laser has been used to dilate the narrowed stoma. In few published series, authors have reported good results with excision of scar tissue using laser and leaving it to heal with secondary intention. ,
In the technique described, almost all the scar tissue is excised at the anterior two-thirds of stoma and a skin flap is interposed.  Lateral suturing of the tracheal flap to the clavicular head and division of the medial fibres of sterno-mastoid further assists lateral splaying of trachea and prevents re-stenosis. TEP site is left undisturbed.
Though the study had a small patient population with a relatively short duration of follow-up the results obtained are encouraging. Significant improvement in the postprocedure diameter of stoma could be achieved with this simple technique and it remained adequately large even after 1 year. Except for one patient, no patient needed further stenting or revision surgery. All patients could produce speech with a speech valve after stoma plasty.
Stoma stenosis still remains a frequent and troublesome complication in postlaryngectomy patients significantly compromising their quality of life. The results of various techniques described in the literature are variable with no technique shows a clear advantage over the other. Speech production after laryngectomy is an important quality of life parameter and very few studies have evaluated this after stoma revision surgery. This simple method of anterior advancement flap with lateral splaying of trachea for stoma plasty has shown good results in creating and maintaining adequate sized stoma without disturbing TEP site.
Anterior advancement flap with lateral splaying of trachea is a simple and effective procedure for treating stomal stenosis after laryngectomy. This provides adequately large stoma for the breathing and enables the use of TEP.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1], [Table - 2]