Iliocostalis Muscle Rotational Flap: A Novel Flap for Esophagopleural Fistula Repair

Abstract

Intrathoracic fistulas present major challenges to reconstructive surgeons. Reconstruction with muscle flaps have been shown to improve patient outcomes; however, there are patients for whom one or more of the commonly used muscle flaps is not available for several reasons. We describe the use of an iliocostalis muscle rotational flap for the repair of a caudally located esophagopleural fistula in the setting of definitive chemoradiotherapy for treatment of nonsmall-cell lung cancer and reirradiation with photons for local recurrence 5 years later. Our repair remained intact through the nearly 12-month follow-up period during which the patient tolerated a regular diet. This report demonstrates that the iliocostalis lumborum muscle is a viable option for repair of intrathoracic fistulas that are located in the distal esophagus, even in the setting of previous thoracotomy and radiation, and should be part of the reconstructive surgeon's armamentarium in the management of intrathoracic fistulas.

Fig. 1.

A 2 × 3 cm hole in the esophagus seen through the Clagett window. The fistula is surrounded by dense fibrous tissue from radiation and serial VAC dressing changes.

Fig. 2.

Elevation of iliocostalis lumborum muscle flap based on T10 and T11 intercostal perforators. Ribs 9–11 are segmentally resected, and T10–11 intercostal vessels are divided laterally (*). Esophageal stent through the defect (arrow) is visible and numerous sutures are placed around the defect for parachuting the flap. The blue area (arrowhead) outlines the area that will seal the esophageal defect once rotated into intrathoracic space.

Fig. 3.

After the division of intercostal vessels (A), the mobilized iliocostalis muscle is rotated into intrathoracic space (B), then the caudal end of the flap is internally rotated (the pedicle as pivot point), (C) and advanced cephalad to cover the esophageal defect.

Fig. 4.

The iliocostalis muscle is the most lateral of the erector spinae muscles. Once can appreciate the proximity of the muscle to the esophagus. For illustration purposes, only one intercostal vessel and associated perforator to the muscle are shown. I, iliocostalis; L, longissimus; S, spinalis; E, esophagus; A, aorta.