Mediastinal tracheostomy: techniques, outcomes and quality of life-a systematic review.

Background: Mediastinal tracheostomy (MT) is a rare, technically demanding salvage procedure in which the distal trachea is redirected into the upper mediastinum. It is indicated when extensive resection of the proximal trachea precludes conventional tracheal reconstruction or cervical tracheostomy. It is performed for a variety of underlying diseases. The aim of this systematic review was to summarize the available evidence on operative techniques, perioperative outcomes, disease-specific outcomes, and quality of life. Methods: A systematic review was conducted. PubMed was searched for case reports and case series. Data on surgical techniques, indications, perioperative outcomes, complications, and quality of life were descriptively analyzed. Results: Seventy publications reporting 437 mediastinal tracheostomies over 85 years were identified. Of these, 429 were permanent anterior mediastinal tracheostomies, the predominant type. Several techniques have evolved for this procedure over time. Extended manubrial resection was performed in most cases, whereas hemi-manubrial resection (2.8%) has gained popularity in recent years. Although a tracheal stump length of ≥5 cm is generally recommended, 12.6% of tracheostomies were created with a stump measuring 0-4 cm. Tracheal transposition was performed in 52.9% of cases to increase tracheal length and avoid contact with the brachiocephalic artery. Initially, direct collar skin (20.3%) or bipedicled upper thoracic skin flaps (13.8%) were used for reconstruction; more recently, the pectoralis major myocutaneous flap (32.9%) has become the predominant technique. Postoperative mortality was 7.0% and decreased over time. Major complications included great vessel rupture (6.8%), tracheal necrosis (8.4%), and tracheal stenosis (9.6%). Patients with a tracheal stump length of 0-3cm had a failure rate of 33.3%. Available data did not permit reliable conclusions on outcomes for specific malignancy types. Quality-of-life data were scarce, although individual reports described independent daily living and return to strenuous work for more than 10 years. Conclusions: Permanent anterior MT remains the standard form of MT and can provide acceptable outcomes when meticulous surgical technique is applied. Tracheal transposition and well-vascularized muscle flap reconstruction appear to reduce procedure-related complications, particularly in patients with short tracheal remnants. Prospective multicenter studies are needed to define optimal surgical strategies, long-term oncological outcomes, and patient-reported quality of life.