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Acquired post-traumatic tracheoesophageal fistula (TEF) is an uncommon entity requiring early diagnosis. Among the many strategies in surgical management, we report a case successfully treated with a single-stage tracheal resection and esophageal repair with platysma myocutaneous interposition flap.
A 24-year-old man had a motor vehicle accident with head injury and cerebral contusion who required mechanical ventilation support. Three weeks later, he developed hypersecretion, and recurrent episodes of aspiration pneumonia. The chest computed tomography, esophagogastroduodenoscopy, and bronchoscopy revealed a large TEF diameter of 3 cm at 4.5 cm from carina. Single-stage tracheal resection with primary end-to-end anastomosis and esophageal repair with platysma myocutaneous interposition flap was performed. A contrast esophagography was done on post-operative day 7 and revealed no leakage. He was discharged on post-operative day 10. Esophagogastroduodenoscopy at 1 month revealed patient esophageal lumen. At present he is doing well without any evidence of complications such as esophageal stricture or fistula.
There are many choices of myocutaneous muscle flaps in trachea and esophageal closure or reinforcement. The platysma myocutaneous flap interposition is simple with the advantage of reduced bulkiness. Concern on the vascular supply is that flap should be elevated with the deep adipofascial tissue under the platysma to ensure that the flap survival is not threatened.
The treatment of acquired TEF with platysma myocutaneous flap is an alternative procedure for a large uncomplicated TEF as it is effective, technically ease, minimal donor site defect and yields good surgical results.
Large acquired post-traumatic tracheoesophageal fistula (TEF) is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Post-traumatic TEF can be a sequelae from the blunt injury, prolonged endotracheal intubation, high-pressure cuff-induced tracheal necrosis, and prolonged retention of nasogastric tube.1,2 The surgical management of acquired post-traumatic TEF is controversial and challenged. The choice of surgery depends on the patient's status, size and location of the fistula, degree of contamination, and also the timing of surgery. The spectrum of surgical management ranged from direct closure of the fistula to resection with end-to-end anastomosis.3–5 The practice of pedicle flap interposition between the esophagus and trachea has been commonly performed for reinforcement of fistula closure. Sternohyoid and sternothyroid muscles were frequently used for pedicle interposition in the upper lesions in the thorax,6 while the pleura, intercostal muscle, pericardium, costal periosteum are commonly used in the lower thorax. Other flaps that were employed for TEF management were serratus anterior muscle, sternocleidomastoid muscle, latissimus dorsi, intercostals, pleural, pericardial fat, omohyoid muscle, pectoralis major muscle, sternohyoid muscle, and azygos vein flap.7–10
Platysma myocutaneous flap have been reported by Alvarez et al.11 for surgical closure of posterior pharyngeal wall tumor along with other reports of hypopharyngeal defect closure.12–15 However, no reports have been published on its application in acquired post-traumatic TEF setting. We report a case of a large acquired post-traumatic TEF treated with surgical resection and pedicle interposition using platysma flap.
A 24-year-old Thai male, victim of motor vehicle accident, suffered from cerebral contusion at right temporal lobe, contusion at right basal ganglia, subdural hematoma at left frontoparietal area and uncal convexity. He was admitted for 3 weeks and required mechanical ventilation support. Subsequently, he developed persistent coughing and frequent aspiration pneumonia. A chest computed tomography (CT) scan revealed a TEF at 4.5 cm above the carina, 2.7 cm in length, and 1.9 cm in width (Fig. 1). Percutaneous endoscopic gastrostomy (PEG) was performed for nutritional support and he was then referred to Siriraj hospital at 10 weeks post-accident. Esophagogastroduodenoscopy (EGD) examination revealed a large TEF located at upper part of esophagus 15 cm from incisor. Bronchoscopy confirmed the fistula at trachea 3 cm from vocal cord and 5 cm proximal to carina. He was scheduled for definite surgery (Fig. 2).
A multimodality approach surgical team was prepared with a cardiovascular and thoracic (CVT) surgeon, a plastic surgeon, and a gastrointestinal surgeon. After general anesthesia was applied, tracheal resection was performed via the median sternotomy incision. The TEF was identified and separated from the esophagus. Circumferential transection of the trachea was done approximately 6 cm above the carina and the spiral tube was advanced to ventilate the distal trachea. Direct closure of the esophageal defect with a two-layer technique was done.
The platysma myocutaneous flap was designed. An L-shaped incision was done on the left supraclavicular area with skin paddle 3 cm × 5 cm size. The dissection was continued down to the superficial cervical fascia. The width of the platysma muscle pedicle was 3 cm along its fiber. The dissection was carried on upwardly until 3 cm below the inferior border of the mandible. The flap was mobilized and interposed in to the space between the trachea and esophagus. Tracheal anastomosis was tested under the pressure of 40 mmHg and no leakage was present. Closure of the chest was performed with two drains placed in the pericardial space and right pleural space (Fig. 3).
He was extubated without any post-operative complications. A water-soluble esophagography revealed no leakage. On post-operative day 10, he was discharged and was able to take soft diet per oral. One month later, EGD showed patented esophageal lumen with no fistulous tract. Finally, the gastrostomy tube was removed (Fig. 4).
Acquired post-traumatic TEF is a rare condition suspected in patients with sudden increase in secretions from the respiratory tract, breathing problems, shortness of breath, chest pain, frequent coughing and aspirations, and Ono's sign (uncontrolled coughing after swallowing).16 The causes of acquired TEF are post-traumatic, malignancy, granulomatous infections, causatic agents, surgical complications, expandable stents, mechanical ventilation and endotracheal tube complications.2 The cause of fistula is most likely due to prolonged endotracheal cuff-related etiology. The location of the fistulous tract is frequently located at the posterior part of the trachea about 5 cm proximal to the carina.17–19 Once a TEF is suspected, further investigations20 with a chest film can demonstrate the sequelae of repeated aspirations, pneumonia and other complications. The definite diagnosis can be established by contrast esophagography, esophagoscopy, or bronchoscopy which can be useful in identifying the location and size of the fistula. Additional chest CT may be performed to identify fistula, the surrounding soft tissue, the lung parenchyma pathology, and mediastinal structures.
Acquired TEF normally requires surgery since they do not close spontaneously. The timing of the surgery depends on the patient's clinical status and associated injury. Higher incidence of TEF recurrence occurs in the patient with post-operative mechanical ventilation.21,22 If a tracheostomy is essential, the tube should be placed distally to the TEF.23 If persistent leakage from GI tract to trachea is persistent, esophageal diversion procedures may be required as a staged procedure.24 Elective surgery should be performed, once the patient has stabilized, good nutritional status, infection controlled, and weaned off mechanical ventilation. A single-stage attempt is preferred.25–27 Although there are numerous ways to repair, for this patient the fistula is quite large with a diameter of 3 cm located at mid-trachea portion and tracheal resection is obligatory. We decided to perform the anterior cervicomediastinal approach to aid in the adequate mobilization of the trachea, esophageal repair, and platysma myocutaneous interposition flap. Once the transection of the trachea was performed, adequate vascularization and healthy tissue of the proximal and distal margin of the trachea should be examined to ensure a satisfying anastomosis reducing the chances of anastomosis leakage and future stenosis.
The two-layer repair of suturing the first mucosa–submucosa layer followed by the muscular layer is preferred over the one-layer repair of the esophagus due to lower bursting wall tension in the latter.28,29 We performed a two-layer repair of the esophagus in this patient. Debate on interposition flaps depends on the fistula defect and surrounding soft tissue. Many surgeons prefer to place interposition flaps between the trachea and esophagus28,30,31 to prevent recurrence as some reports have doubts on the necessity of this additional procedure.32
There are many choices of myocutaneous muscle flaps in trachea and esophageal closure or reinforcement.6,7,9 For the majority of non-malignant upper tracheal lesions, anterior cervical approach with sternocleidomastoid, sternothyroid, and sternohyoid muscle flaps have been applied. For lesions in the lower trachea, intercostals muscle, pericardium, pleura and rib periosteum have been applied. A platysma myocutaneous flap has been reported in many operations reconstruction of the hypopharyngeal surgery and head and neck reconstruction.33–37 Alvarez et al.11 reported using the platysma flap in the repair of the posterior pharyngeal wall in tumor resection. The results are very satisfactory achieving laryngeal voice in 79% and it is oncologically safe with good comparable functional results. Another report by Dursun et al.14 using the platysma myofascial flap after vertical partial laryngectomy for laryngeal reconstruction have demonstrated its effectiveness and an alternative in laryngeal reconstruction. However, there has not been report on the usage of platysma myocutaneous interposition in acquired, non-malignant, post-traumatic TEF in literature. We decided to perform the platysma myocutaneous flap interposition between the suture lines. The flap is simple to construct and adequate vasculature with the advantage of less bulkiness than other myocutaneous flaps. However, concerns on the surgical technique38,39 in preserving the vascular supply from a report by Imanishi et al.40 suggests that the platysma flap should be considered a fasciocutaneous rather than myocutaneous flap. Therefore, the platysma flap should be elevated with the deep adipofascial tissue under the platysma to ensure flap survival is not threatened. Which is different with dissection of the usual myocutaneous flap being elevated without the adipofascial tissue under the muscle. We were aware of the vasculature and meticulously dissected the platysma muscle along with the fasciocutaneous tissues as mentioned above. The patient recovered without complications and is now doing well.
Acquired post-traumatic TEF is an uncommon but potential life-threatening situation requiring early diagnosis and optimizing the patient prior to surgical intervention. One-stage primary resection with anastomosis with interposition myocutaneous flaps has been commonly practiced as it had harbored safe and efficient results. The platysma myocutaneous flap is an effective alternative procedure for uncomplicated TEF repair as it is technically ease, minimal donor site defect and yields good surgical results.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Akaraviputh T, Nimmanwudipong T, Chinswangwatanakul V, Metasate A, Trakarnsanga A, Swangsri J, Taweerutchana V were the attending doctors for the patient, and involved in the editing of the study's concept and design. Akaraviputh T, Phanchaipetch T, Lohsiriwat V performed surgical operation. Angkurawaranon C involved in data collection, analysis, interpretation, and writing the paper. Akaraviputh T and Lohsiriwat V edited and revised the manuscript.
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