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CASE REPORT Closure of tracheoesophageal fistula with prefabricated deltopectoral flap Shigeyuki Murono*, Eriko Ishikawa, Yosuke Nakanishi, Kazuhira Endo, Satoru Kondo, Naohiro Wakisaka, Tomokazu Yoshizaki Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan Received 29 December 2012; received in revised form 24 December 2013; accepted 14 January 2014 Available online 25 March 2014 KEYWORDS deltopectoral flap; prefabricated; skin graft; total thyroidectomy; tracheoesophageal fistula Summary Tracheoesophageal fistula (TEF) is a serious complication associated with impaired quality of life. However, a successful TEF closure is difficult owing to the high incidence of recur- rence. We utilized a prefabricated deltopectoral (DP) flap for closure of a TEF that occurred after an extended total thyroidectomy. Prefabrication of the inner soft tissue lining the DP flap with a split skin graft was performed prior to surgical closure of a TEF. Esophageal and tracheal mucosa were sutured to the split thickness side and full thickness side of the prefabricated DP flap, respectively. A successful closure of the fistula was achieved with this procedure. Prefabricated DP flap is a useful procedure for the surgical treatment of TEF. Copyright ª 2014, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved. 1. Introduction Tracheoesophageal fistula (TEF) is a rare but life- threatening condition that promotes chronic aspiration, pneumonia, and tracheal stenosis. 1 Causes of acquired TEF include ventilatory cuff injury, local infection, caustic or foreign body ingestion, penetrating or nonpenetrating trauma, tracheal or esophageal malignancy, and iatrogenic surgical injury. Although various surgical approaches have been described, a successful TEF closure remains difficult owing to the high incidence of recurrence. 2 We utilized a prefabricated deltopectoral (DP) flap for closure of a TEF that occurred after an extended total thyroidectomy. 2. Case report A 65-year-old female patient was diagnosed with thyroid papillary carcinoma T4aN0M1 invading the trachea. A total Conflicts of interest: The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials discussed in the manuscript. * Corresponding author. Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Kanazawa University, Kanazawa, Ishikawa 920-8640, Japan. E-mail address: [email protected] (S. Murono). http://dx.doi.org/10.1016/j.asjsur.2014.01.003 1015-9584/Copyright ª 2014, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved. Available online at www.sciencedirect.com ScienceDirect journal homepage: www.e-asianjournalsurgery.com Asian Journal of Surgery (2016) 39, 243e246

Closure of tracheoesophageal fistula with prefabricated ... · with prefabricated deltopectoral flap Shigeyuki Murono*, Eriko Ishikawa, Yosuke Nakanishi, Kazuhira Endo, Satoru Kondo,

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Asian Journal of Surgery (2016) 39, 243e246

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.e-asianjournalsurgery.com

CASE REPORT

Closure of tracheoesophageal fistulawith prefabricated deltopectoral flap

Shigeyuki Murono*, Eriko Ishikawa, Yosuke Nakanishi,Kazuhira Endo, Satoru Kondo, Naohiro Wakisaka,Tomokazu Yoshizaki

Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Kanazawa University,Kanazawa, Ishikawa, Japan

Received 29 December 2012; received in revised form 24 December 2013; accepted 14 January 2014Available online 25 March 2014

KEYWORDSdeltopectoral flap;prefabricated;skin graft;total thyroidectomy;tracheoesophagealfistula

Conflicts of interest: The authorsfinancial or non-financial conflicts of inmatter or materials discussed in the m* Corresponding author. Department

Neck Surgery, School of Medicine, KanIshikawa 920-8640, Japan.

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.asjsur.201015-9584/Copyright ª 2014, Asian Su

Summary Tracheoesophageal fistula (TEF) is a serious complication associated with impairedquality of life. However, a successful TEF closure is difficult owing to the high incidence of recur-rence.Weutilized a prefabricated deltopectoral (DP) flap for closure of a TEF that occurred afteran extended total thyroidectomy. Prefabrication of the inner soft tissue lining the DP flap with asplit skin graft was performed prior to surgical closure of a TEF. Esophageal and tracheal mucosawere sutured to the split thickness side and full thickness side of the prefabricated DP flap,respectively. A successful closure of the fistula was achieved with this procedure. PrefabricatedDP flap is a useful procedure for the surgical treatment of TEF.Copyright ª 2014, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

1. Introduction

Tracheoesophageal fistula (TEF) is a rare but life-threatening condition that promotes chronic aspiration,pneumonia, and tracheal stenosis.1 Causes of acquired TEF

declare that they have noterest related to the subjectanuscript.of Otolaryngology, Head andazawa University, Kanazawa,

zawa-u.ac.jp (S. Murono).

14.01.003rgical Association. Published by E

include ventilatory cuff injury, local infection, caustic orforeign body ingestion, penetrating or nonpenetratingtrauma, tracheal or esophageal malignancy, and iatrogenicsurgical injury. Although various surgical approaches havebeen described, a successful TEF closure remains difficultowing to the high incidence of recurrence.2 We utilized aprefabricated deltopectoral (DP) flap for closure of a TEFthat occurred after an extended total thyroidectomy.

2. Case report

A 65-year-old female patient was diagnosed with thyroidpapillary carcinoma T4aN0M1 invading the trachea. A total

lsevier Taiwan LLC. All rights reserved.

Figure 2 Prefabricated skin graft was de-epithelialized for2.5 cm in diameter.

244 S. Murono et al.

thyroidectomy with partial tracheal resection followed bycreation of a tracheocutaneous fistula (TCF) was per-formed. However, leakage of saliva from the esophagus wasobserved after the surgery. Several procedures, including adirect closure and a pedicled myoperiosteal flap of thesternocleidomastoid muscle, were attempted to close thefistula. However, these procedures failed, resulting in a TEFmeasuring 1 cm in diameter at the left posterior wall of thetrachea while the TCF still existed (Fig. 1). A two-stageoperation was planned 92 days after the initial surgery.

The distal part of the DP flap was first elevated. At thesame time, a 5 � 4 cm split skin graft was taken from thepatient’s left upper leg. Then the split skin graft was su-tured to the inner soft tissue lining of the elevated DP flapusing dissolvable sutures. The second procedure to closethe TEF was performed 3e4 weeks later. First, an incisionwas made at the mucocutaneous junction along the uni-lateral edge of the TCF. The posterior wall of trachea wasundermined and separated from the esophagus. When asevere scar formation prevented the tracheal wall frombeing undermined and separated from the esophagus, acircumferential excision of esophageal mucosa around theTEF including the dense scar tissue was performed. Subse-quently, the prefabricated DP flap with well-healed skingraft was completely raised. The skin graft was de-epithelialized for a suitable size (Fig. 2). Esophageal mu-cosa was sutured around the split thickness side of the DPflap skin island to cover the esophageal defect (Fig. 3A).Tracheal mucosa was sutured to the full thickness side ofthe prefabricated DP flap to create a new TCF (Fig. 3B).

Videofluorography performed on the 36th day after thesurgery did not demonstrate either leakage from theesophagus or laryngeal penetration, restoring the pa-tient’s ability to ingest a normal oral diet. Furthermore,the suitable volume of the DP flap allowed the TCF tobecome slender like a slit, which allowed excellentand fluent speech to develop without covering the TCFwith her finger (Fig. 4). Moreover, the patient reportedthat there was no severe inconvenience during speechor food intake. Finally, closure of the TCF was thencompleted.

Figure 1 Tracheoesophageal fistula on the posterior wall ofthe trachea was observed through the tracheocutaneousfistula.

3. Discussion

The traditional surgical closure of a TEF includes fistulatract division and three-layer closure of the esophageal andtracheal linings with or without interposition of a pedicledregional skin or muscle flap.3 In this case, an alternative tothe traditional procedure was required because of a densescar formation around the TEF.

Although several free flaps including radial forearm flapand rectus abdominis flap and pedicled extracervical flapsincluding DP flap and pectoralis major myocutaneous flaphave been reported to be useful for reconstruction of thepharynx and esophagus,4e7 we chose a DP flap withmodification for closure of a relatively small TEF in thiscase. The removal of dense scarring around the TEFcaused a mucosal defect not only in the esophagus, butalso in the trachea. Therefore, a two-sided epithelialcoverage of the TEF was preferred to close the esophagealleak and to create a new TCF as well as to circumventpossible postoperative issues of re-epithelializationcompromise.

The procedure of grafting split-thickness skin onto thesoft tissue side to create a bilaminar cervical flap hasmainly been used for full-thickness cheek reconstructionincluding oral mucosa and facial skin.8 The only reportdescribing the closure of a TEF with skin-grafted bilaminarflap is a radial forearm free flap.9 The size of the TEF in thereport was relatively large, at 2 � 4 cm; therefore, using awide thin well-vascularized flap appeared to be optimal.The surgeons sutured the full thickness skin side of the flapto the esophageal mucosa, and the split thickness side tothe tracheal mucosa. In the present case, we utilized theDP flap as a skin-grafted bilaminar flap. We sutured the full

Figure 3 (A) Esophageal mucosa was sutured around the split thickness side of the deltopectoral flap skin island to cover theesophageal defect. (B) Tracheal mucosa was sutured to the full thickness side of the prefabricated deltopectoral flap to create anew TCF.

Prefabricated deltopectoral flap 245

thickness skin side of the flap to the tracheal mucosa, andsplit thickness side to the esophageal mucosa.

The present procedure has several advantages. First,twisting the DP flap upside-down to put the skin side intothe inner aspect of the esophagus is not required. There-fore, blood flow in the area is not affected by twisting.Second, a sufficient amount at the distal site of the DP flapis available not only to achieve closure of the esophagus,but also to create a new TCF. Thus, prefabrication of a DPflap using a split skin graft is a useful procedure for closureof TEFs. However, there exists an issue regarding cosmeticappearance when using this flap.

There is a report evaluating skin blood flow in the distalpart of the DP flap by the Xenon-133 clearance rate.10 Inthat report, five types of delayed procedures for DP flap

Figure 4 The suitable volume of the deltopectoral flapallowed the tracheocutaneous fistula to become slender andslit-like.

were analyzed. Group I was a “U-shaped, raised DP flap”,Group II was a “U-shaped, raised deltoid flap”, Group III wasa “DP flap lined with a split-skin graft”, Group IV was a“Tubed, raised DP flap”, and Group V was a “Bipedicled,raised DP flap”. Interestingly, the recovery of the periph-eral blood flow was fastest and greatest in Group III amongthose five groups. Group III was similar to the proceduresperformed in the present case. Therefore, the skin-graftedprefabrication of a DP flap also has the advantage offacilitating increased recovery of blood flow after theelevation of the flap.

In the present case, the prefabricated DP flap was auseful procedure for the surgical treatment of TEF. Two-sided eplithelialization has the advantage of allowing thesimultaneous closure of both the esophageal and trachealmucosa.

References

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