Split Pectoralis Major Flap for Massive Tracheoesophageal Fistula

Abstract

Large tracheoesophageal fistulas (TEFs) occurring after a total laryngectomy are rare. Most often they are associated with the creation of a surgical speech fistula or puncture and the stomal recurrence of the malignant tumor. A large TEF is frequently complicated by significant nutritional problems and recurrent pulmonary infections; therefore it presents the surgeon a challenge for successful repair. Furthermore the effects of previous radiation therapy compound the problem by adversely affecting healing.We present two case reports of patients with large, delayed, nonmalignant TEFs after total laryngectomy. Neither case involved the creation of a speech fistula, and both patients underwent successful repair with a split myofascial pectoralis major flap. The surgical technique is described and pertinent literature reviewed. CASE REPORTSCase 1. Three years after undergoing a total laryngectomy for an advanced transglottic carcinoma (T4NOM0), a 63year-old man came to us with a report of progressive dysphagia for 5 months and coughing spells for 1 month. The patient noted frank coughing of food and weight loss of 100 pounds. After the laryngectomy he had received a postoperative radiation dose of 6300 cGy.On examination the patient was found to have a massive TEF that extended 5 cm below the stomal margin along the tracheoesophageal wall. The borders of the fistula were mature, and no associated tumors or mucosal lesions were seen. He had decreased breath sounds, and rhonchi were present at the right lower lobe on auscultation. A chest x-ray evaluation confirmed right lower lobe pneumonia. On his admission to the hospital the patient's oral feedings were stopped, and an enteral feeding tube and a cuffed tracheostomy tube were placed to stop aspiration. Aggressive respiratory therapy and intravenous antibiotics cleared the pneumonia. Enteral tube feedings improved the patient's nutritional status, his serum albumin levels increased from 2.7 to 3.2 gm/dl, and he gained 15 pounds. The patient underwent a metastatic workup that included CT of the chest and neck, a liver

Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature

“…10 The pedicled strap muscle flap is utilized most often, with the sternocleidomastoid a popular alternative. 4,8 The pectoralis major muscle flap is a reliable option for reconstruction throughout the head and neck [11][12][13] but its reported use is limited for COVID-19 patients and TEF.…”