Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ThailandDivision of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University,angkok 10700, ThailandDivision of Head Neck and Breast Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
r t i c l e i n f o
rticle history:eceived 12 March 2014ccepted 17 March 2014vailable online 25 March 2014
INTRODUCTION: Acquired post-traumatic tracheoesophageal fistula (TEF) is an uncommon entity requir-ing early diagnosis. Among the many strategies in surgical management, we report a case successfullytreated with a single-stage tracheal resection and esophageal repair with platysma myocutaneous inter-position flap.PRESENTATION OF CASE: A 24-year-old man had a motor vehicle accident with head injury and cerebralcontusion who required mechanical ventilation support. Three weeks later, he developed hypersecretion,and recurrent episodes of aspiration pneumonia. The chest computed tomography, esophagogastroduo-denoscopy, and bronchoscopy revealed a large TEF diameter of 3 cm at 4.5 cm from carina. Single-stagetracheal resection with primary end-to-end anastomosis and esophageal repair with platysma myocu-taneous interposition flap was performed. A contrast esophagography was done on post-operative day7 and revealed no leakage. He was discharged on post-operative day 10. Esophagogastroduodenoscopyat 1 month revealed patient esophageal lumen. At present he is doing well without any evidence ofcomplications such as esophageal stricture or fistula.DISCUSSION: There are many choices of myocutaneous muscle flaps in trachea and esophageal closure orreinforcement. 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 tissueunder the platysma to ensure that the flap survival is not threatened.CONCLUSION: The treatment of acquired TEF with platysma myocutaneous flap is an alternative procedurefor a large uncomplicated TEF as it is effective, technically ease, minimal donor site defect and yields goodsurgical results.
Large acquired post-traumatic tracheoesophageal fistula (TEF)s an uncommon clinical entity that warrants surgical awarenessue to its life-threatening potential. Post-traumatic TEF can be a
equelae from the blunt injury, prolonged endotracheal intubation,igh-pressure cuff-induced tracheal necrosis, and prolonged reten-ion of nasogastric tube.1,2 The surgical management of acquired
∗ Corresponding author at: Med. Minimally Invasive Surgery Unit, Division of Gen-ral Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidolniversity, Bangkok 10700, Thailand. Tel.: +66 2419 8006; fax: +66 2412 1370.
lished by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
post-traumatic TEF is controversial and challenged. The choice ofsurgery depends on the patient’s status, size and location of the fis-tula, degree of contamination, and also the timing of surgery. Thespectrum of surgical management ranged from direct closure of thefistula to resection with end-to-end anastomosis.3–5 The practiceof pedicle flap interposition between the esophagus and tracheahas been commonly performed for reinforcement of fistula closure.Sternohyoid and sternothyroid muscles were frequently used forpedicle interposition in the upper lesions in the thorax,6 while thepleura, intercostal muscle, pericardium, costal periosteum are com-monly used in the lower thorax. Other flaps that were employed for
CASE REPORT – OPEN ACCESST. Akaraviputh et al. / International Journal of Surgery Case Reports 5 (2014) 282–286 283
. (A) L
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2
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cats
Fig. 1. Chest computed tomography demonstrates the large TEF
Platysma myocutaneous flap have been reported by Alvarezt al.11 for surgical closure of posterior pharyngeal wall tumorlong with other reports of hypopharyngeal defect closure.12–15
owever, no reports have been published on its application incquired post-traumatic TEF setting. We report a case of a largecquired post-traumatic TEF treated with surgical resection andedicle interposition using platysma flap.
. Presentation of case
A 24-year-old Thai male, victim of motor vehicle accident, suf-ered from cerebral contusion at right temporal lobe, contusiont right basal ganglia, subdural hematoma at left frontoparietalrea and uncal convexity. He was admitted for 3 weeks andequired mechanical ventilation support. Subsequently, he devel-ped persistent coughing and frequent aspiration pneumonia. Ahest computed tomography (CT) scan revealed a TEF at 4.5 cmbove the carina, 2.7 cm in length, and 1.9 cm in width (Fig. 1).ercutaneous endoscopic gastrostomy (PEG) was performed forutritional support and he was then referred to Siriraj hospital at 10eeks post-accident. Esophagogastroduodenoscopy (EGD) exami-ation revealed a large TEF located at upper part of esophagus 15 cm
rom incisor. Bronchoscopy confirmed the fistula at trachea 3 cmrom vocal cord and 5 cm proximal to carina. He was scheduled forefinite surgery (Fig. 2).
A multimodality approach surgical team was prepared with a
ardiovascular and thoracic (CVT) surgeon, a plastic surgeon, and
gastrointestinal surgeon. After general anesthesia was applied,racheal resection was performed via the median sternotomy inci-ion. The TEF was identified and separated from the esophagus.
Fig. 2. Endoscopic finding of the large tracheoesophageal fistula.
ateral view and (B) Coronal view with lung window resolution.
Circumferential transection of the trachea was done approximately6 cm above the carina and the spiral tube was advanced to venti-late the distal trachea. Direct closure of the esophageal defect witha two-layer technique was done.
The platysma myocutaneous flap was designed. An L-shapedincision was done on the left supraclavicular area with skin pad-dle 3 cm × 5 cm size. The dissection was continued down to thesuperficial cervical fascia. The width of the platysma muscle pedi-cle was 3 cm along its fiber. The dissection was carried on upwardlyuntil 3 cm below the inferior border of the mandible. The flap wasmobilized and interposed in to the space between the trachea andesophagus. Tracheal anastomosis was tested under the pressureof 40 mmHg and no leakage was present. Closure of the chest wasperformed with two drains placed in the pericardial space and rightpleural 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 dietper oral. One month later, EGD showed patented esophageal lumenwith no fistulous tract. Finally, the gastrostomy tube was removed(Fig. 4).
3. Discussion
Acquired post-traumatic TEF is a rare condition suspected inpatients with sudden increase in secretions from the respira-tory tract, breathing problems, shortness of breath, chest pain,frequent coughing and aspirations, and Ono’s sign (uncontrolledcoughing after swallowing).16 The causes of acquired TEF are post-traumatic, malignancy, granulomatous infections, causatic agents,surgical complications, expandable stents, mechanical ventilationand endotracheal tube complications.2 The cause of fistula is mostlikely due to prolonged endotracheal cuff-related etiology. Thelocation of the fistulous tract is frequently located at the posteriorpart of the trachea about 5 cm proximal to the carina.17–19 Oncea TEF is suspected, further investigations20 with a chest film candemonstrate the sequelae of repeated aspirations, pneumonia andother complications. The definite diagnosis can be established bycontrast esophagography, esophagoscopy, or bronchoscopy whichcan be useful in identifying the location and size of the fistula.Additional chest CT may be performed to identify fistula, thesurrounding soft tissue, the lung parenchyma pathology, and medi-astinal structures.
Acquired TEF normally requires surgery since they do notclose spontaneously. The timing of the surgery depends on thepatient’s clinical status and associated injury. Higher incidence of
TEF recurrence occurs in the patient with post-operative mechan-ical ventilation.21,22 If a tracheostomy is essential, the tube shouldbe placed distally to the TEF.23 If persistent leakage from GI tractto trachea is persistent, esophageal diversion procedures may
CASE REPORT – OPEN ACCESS284 T. Akaraviputh et al. / International Journal of Surgery Case Reports 5 (2014) 282–286
Fig. 3. Intraoperative findings and surgical procedures. (A) Tracheal resection and identify fistula tract. (B) Esophageal repair. (C) Incision of platysma myocutaneous flap.( ized. (
bptsoarvtpadia
lrltdipo
D) Harvest of platysma myocutaneous flap. (E) Platysma myocutaneous flap mobil
e required as a staged procedure.24 Elective surgery should beerformed, once the patient has stabilized, good nutritional sta-us, infection controlled, and weaned off mechanical ventilation. Aingle-stage attempt is preferred.25–27 Although there are numer-us ways to repair, for this patient the fistula is quite large with
diameter of 3 cm located at mid-trachea portion and trachealesection is obligatory. We decided to perform the anterior cer-icomediastinal approach to aid in the adequate mobilization ofhe trachea, esophageal repair, and platysma myocutaneous inter-osition flap. Once the transection of the trachea was performed,dequate vascularization and healthy tissue of the proximal andistal margin of the trachea should be examined to ensure a sat-
sfying anastomosis reducing the chances of anastomosis leakagend future stenosis.
The two-layer repair of suturing the first mucosa–submucosaayer followed by the muscular layer is preferred over the one-layerepair of the esophagus due to lower bursting wall tension in theatter.28,29 We performed a two-layer repair of the esophagus inhis patient. Debate on interposition flaps depends on the fistula
efect and surrounding soft tissue. Many surgeons prefer to place
nterposition flaps between the trachea and esophagus28,30,31 torevent recurrence as some reports have doubts on the necessityf this additional procedure.32
F) Complete repair of esophagus and trachea with platysma interposition.
There are many choices of myocutaneous muscle flaps in tra-chea and esophageal closure or reinforcement.6,7,9 For the majorityof non-malignant upper tracheal lesions, anterior cervical approachwith sternocleidomastoid, sternothyroid, and sternohyoid muscleflaps have been applied. For lesions in the lower trachea, inter-costals muscle, pericardium, pleura and rib periosteum have beenapplied. A platysma myocutaneous flap has been reported in manyoperations reconstruction of the hypopharyngeal surgery and headand neck reconstruction.33–37 Alvarez et al.11 reported using theplatysma flap in the repair of the posterior pharyngeal wall in tumorresection. The results are very satisfactory achieving laryngeal voicein 79% and it is oncologically safe with good comparable func-tional results. Another report by Dursun et al.14 using the platysmamyofascial flap after vertical partial laryngectomy for laryngealreconstruction have demonstrated its effectiveness and an alterna-tive in laryngeal reconstruction. However, there has not been reporton the usage of platysma myocutaneous interposition in acquired,non-malignant, post-traumatic TEF in literature. We decided to per-form the platysma myocutaneous flap interposition between the
suture lines. The flap is simple to construct and adequate vascula-ture with the advantage of less bulkiness than other myocutaneousflaps. However, concerns on the surgical technique38,39 in preser-ving the vascular supply from a report by Imanishi et al.40 suggests
trbtdtv
R
CASE REPORT – OPEN ACCESST. Akaraviputh et al. / International Journal of Surgery Case Reports 5 (2014) 282–286 285
Fig. 4. Patient at 1-month follow-up visit.
hat the platysma flap should be considered a fasciocutaneousather than myocutaneous flap. Therefore, the platysma flap shoulde elevated with the deep adipofascial tissue under the platysmao ensure flap survival is not threatened. Which is different withissection of the usual myocutaneous flap being elevated withouthe adipofascial tissue under the muscle. We were aware of theasculature and meticulously dissected the platysma muscle along
with the fasciocutaneous tissues as mentioned above. The patientrecovered without complications and is now doing well.
4. Conclusion
Acquired post-traumatic TEF is an uncommon but potential life-threatening situation requiring early diagnosis and optimizing thepatient prior to surgical intervention. One-stage primary resectionwith anastomosis with interposition myocutaneous flaps has beencommonly practiced as it had harbored safe and efficient results.The platysma myocutaneous flap is an effective alternative proce-dure for uncomplicated TEF repair as it is technically ease, minimaldonor site defect and yields good surgical results.
Conflict of interest statement
None.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient forpublication of this case report and accompanying images.
Author contributions
Akaraviputh T, Nimmanwudipong T, Chinswangwatanakul V,Metasate A, Trakarnsanga A, Swangsri J, Taweerutchana V werethe attending doctors for the patient, and involved in the editingof the study’s concept and design. Akaraviputh T, PhanchaipetchT, Lohsiriwat V performed surgical operation. Angkurawaranon Cinvolved in data collection, analysis, interpretation, and writingthe paper. Akaraviputh T and Lohsiriwat V edited and revised themanuscript.
Key learning points
• One-stage primary resection with anastomosis with interposition myocutaneous flaps is safe.• The platysma myocutaneous flap is effective alternative procedure for uncomplicated TEF repair.
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