Successful repair of acquired intrathoracic nonmalignant tracheoesophageal fistulas using thoracoacromial artery perforator flap through a midsternal incision approach: a report of three cases

Abstract

Background: Acquired intrathoracic nonmalignant tracheoesophageal fistulas (TEFs) are rare and challenging surgical problems. They can constitute a life-threatening condition due to severe pulmonary complications and poor nutrition. Surgical treatment is effective for most patients undergoing operative repair. However, in recent studies, the difficult-to-ignore early complications of surgical treatment can be as high as 62.5%. Among them, esophageal stricture occurring in 42-54% of patients, anastomosis leakage occurs at a rate of 22.7-26%, and the mortality rate can be as high as 29.4%. Here, we introduce our innovative experience repairing acquired TEFs with a thoracoacromial artery perforator flap, in which provides a clear surgical field of view, reliable reconstruction, and no serious complications during the perioperative period and no mortality or complications were observed within 180 days after the operation.

Case description: Surgical repair with a thoracoacromial artery perforator flap through a midsternal incision approach was performed in 3 patients. During the procedure, a midsternal incision was made. After the thymus and anterior mediastinal fat were resected, and the left innominate vein was transected, the trachea and esophagus were mobilized. The trachea was incised and pulled to the cranial and caudal sides. Then, the thoracoacromial artery perforator flap was harvested and transferred into the superior mediastinum for esophageal reconstruction. Subsequently, the trachea was anastomosed end to end after debridement, and the left innominate vein was either anastomosed or not. Two patients developed esophageal anastomotic leakage postoperatively and healed well after nonsurgical treatment. No mortality or other complications were observed at 180 days after the operation.

Conclusions: Repair of acquired TEFs using a thoracoacromial artery perforator flap through a midsternal incision approach is an effective, safe surgical treatment.

Keywords: Tracheoesophageal fistulas (TEFs); case report; thoracoacromial artery perforator flap (TAPF).

Figure 1

CT scan and tracheoscopy examination of all the patients. CT, computed tomography.

Figure 2

The esophagus was vertically incised beyond both ends of the stenosis and sutured to normal tissue after the trachea was incised and pulled toward the head and caudally, separately.

Figure 3

The incision along the body surface was used to reflect the thoracoacromial artery perforator (solid star: the midpoint of the manubrium sterni; hollow star: the midpoint of the clavicle; solid arrow: axillary artery and vein; hollow arrow: thoracoacromial artery perforator).

Figure 4

The TAPF flap was passed under the clavicular head of the pectoralis major and through a subcutaneous tunnel above the clavicle, and the sternocleidomastoid was passed into the superior mediastinum (arrows: pedicle of TAPF; stars: the pectoralis major). TAPF, thoracoacromial artery perforator flap.

Figure 5

A nasogastric tube (star mark) was inserted into the distal end of the esophageal defect. The flap was placed between the esophagus and trachea with the skin side toward the esophageal lumen. The flap was used to repair the front wall of the esophagus using interrupted 2-0 Ethibond sutures.

Figure 6

Tracheal anastomosis using continuous 3-0 Prolene sutures (arrow: pedicle of TAPF; star: TAPF). TAPF, thoracoacromial artery perforator flap.