CASE REPORT

Russell B. Smith, MD, Section Editor

STERNOHYOID MUSCLE FLAP INTERPOSITION IN THE

TREATMENT OF AN ACQUIRED TRACHEOESOPHAGEAL
FISTULA
Adolfo Pisanu, MD, Isabella Reccia, MD, Riccardo Nieddu, MD, Alessandro Uccheddu, MD

Department of Surgery, Clinica Chirurgica, University of Cagliari, Cagliari, Italy. E-mail: adolfo.pisanu@tin.it

Accepted 1 August 2008

Published online 3 March 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20985

Keywords: acquired tracheoesophageal fistula; cuffed

Abstract: Background. Tracheoesophageal fistula caused
tracheostomy; sternohyoid muscle flap; treatment
by prolonged intubation is a rare clinical entity. We report
the case of a patient successfully treated by interposition of a

Acquired tracheoesophageal fistula caused by

sternohyoid muscle flap.
Methods. Tracheoesophageal fistula secondary to pro-
longed ventilatory assistance developed in a 61-year-old prolonged intubation is a rare but serious
woman who had a septic shock related to fecal peritonitis. clinical occurrence. Early in 1969, Hedden et al
Fistula was located at the decubitus point of the cuffed tra- first reported 2 cases of tracheoesophageal fis-
cheostomy tube on the posterior tracheal wall. Esophageal
and tracheal defects were separately sutured and protected
tula caused by cuffed tracheal tube.1 Since 1971,
by interposition of a left inferiorly based sternohyoid muscle it appeared clear that cuffed tubes were the
flap. most frequent cause of acquired fistulas mainly
Results. There were neither local wound complications nor in patients who received positive pressure venti-
suture release and the procedure resulted in resolution of the lation for respiratory failure.2,3 Moreover, the
fistula allowing a full oral diet. Sixty days after the operation,
tracheal stoma was finally closed.
concomitant presence of a rigid nasogastric tube
Conclusion. The described approach has to be retained as is deemed to increase the risk of ischemia and
an alternative to other surgical methods such as tracheal necrosis of both tracheal and esophageal
resection and major flap mobilization. V C 2009 Wiley Periodi- walls.4–7
cals, Inc. Head Neck 31: 962–967, 2009 Nowadays, despite the extensive use of high-
volume low pressure cuffs has reduced the inci-
dence of tracheoesophageal fistulas, prolonged
intubation is still the most important cause
Correspondence to: A. Pisanu
of acquired fistulas.3,8–10 Because spontaneous
This report was presented at the 109th Congress of the Italian Society closure is rare and communication between
of Surgery, Verona, Italy, October 2007.
trachea and esophagus is a life-threatening con-
Contract grant sponsor: University of Cagliari (Italy). dition consequent to tracheo-bronchial contami-
V
C 2009 Wiley Periodicals, Inc. nation and aspiration pneumonia, surgical

962 Acquired Tracheoesophageal Fistula Treatment HEAD & NECK—DOI 10.1002/hed July 2009
closure of the fistula is mandatory.3,8 However,
the presence of tracheoesophageal fistula still
represents a complex treatment challenge.
There are several technical options useful to
repair the defect, ranging from direct closure to
tracheal resection and major muscle flap
mobilization.11
Herein we report the case of a patient who
underwent successfully surgical closure of an
acquired tracheoesophageal fistula by direct
suture and interposition of a sternohyoid muscle
flap between trachea and esophagus. We also
review the literature, highlighting a number of
diagnostic and technical aspects and strap mus-
cle flap interposition as a suitable treatment.

CASE REPORT
In October 2006, a 61-year-old white woman
was referred to our emergency department
because of a septic shock related to fecal perito-
nitis originating from a colonic perforation. She
underwent an emergency celiotomy and a colos-
tomy. Before the operation, the patient suffered
of chronic asthma and she received lifelong cor-
ticosteroid drugs. In the postoperative period,
she developed an adult respiratory distress syn-
drome that made ventilatory assistance manda-
tory via orotracheal cuffed tube. After the first
10 days of mechanical ventilation, prolonged
resuscitation required tracheostomy with cuffed
tube and nasogastric tube for suction and feed-
ing. Tracheostomy intubation lasted for 58 days.
On postoperative day 40, a tracheoesophageal
fistula secondary to prolonged ventilatory assis-
tance occurred.
This fistula was suspected as a result of air
FIGURE 1. CT scan demonstrating both tracheoesophageal
leak around the tube cuff and of suctioning of
fistula and cervico-mediastinal goiter on the left side.
gastric contents through the tracheostomy. Flex-
ible tracheobronchoscopy showed that fistula
had a length of 2.0 cm and a width of 1.0 cm.
The fistula was located correspondingly to the traindicated by the simultaneous presence of co-
decubitus point of the cuffed tracheal tube on lostomy and abdominal wound infection
the membranaceous pars of the trachea and its following fecal peritonitis. CT scan clearly con-
superior margin was detected at 2.0 cm below firmed the presence of the fistula and also
the tracheal stoma without laryngotracheal ste- showed a cervico-mediastinal goiter on the left
nosis. The nasogastric tube was seen in the side (see Figure 1).
esophagus through the defect. Esophagoscopy Because the patient was fed through gastros-
showed the fistula at 4.0 cm below the crico- tomy, conservative anti-gastric reflux measures
pharyngeal muscle. were absolutely needed together with the
First, the nasogastric tube was removed and administration of Omeprazole 40 mg daily. The
a percutaneous endoscopic feeding gastrostomy head of the bed was elevated on 20-cm blocks.
was performed. Feeding jejunostomy was con- Hypercaloric feeding formula and water were

Acquired Tracheoesophageal Fistula Treatment HEAD & NECK—DOI 10.1002/hed July 2009 963
FIGURE 2. (A–C) Left sternohyoid muscle flap interposition. 1, Trachea; 2, esophagus; 3, inferiorly based left sternohyoid muscle flap;
4, left recurrent laryngeal nerve; 5, superior parathyroid gland; 6, left sternothyroid m.; 7, left sternohyoid m. superior stump; 8 and 10,
left superior and inferior bellies omohyoid m.; 9, left sternocleidomastoid m. [Color figure can be viewed in the online issue, which is
available at www.interscience.wiley.com.]

administered from 4 to 5 times a day (no more of avoiding close contact of the suture lines and
250 mL per time) with a good positioning preventing recurrence, these sutures were pro-
(patient being sat on the bed) during and after tected by interposition of a strap muscle flap
feeding, avoiding administration at least 2 hours between trachea and esophagus. It was a left
before lying down and sleeping. inferiorly based sternohyoid muscle flap that
Afterward and when resuscitation was no was transposed and fixed together with the
longer needed, a surgical procedure for the clo- sutures as reinforcement (see Figure 2). Finally,
sure of the fistula was carried out. Initial venti- the wound was closed on a soft multiholed suc-
lation was obtained through the orifice of the tion drain. Tracheal stoma was left in site
tracheostomy with the endotracheal tube pass- because of the high risk of postoperative respi-
ing distal to the lesion. Through a cervicotomy ratory failure. There were neither local wound
along the anterior border of the left sternoclei- complications nor suture release.
domastoid muscle, the left thyroid lobe was Together with conservative anti-gastric re-
removed, preserving both left recurrent laryn- flux measures, a saliva ejector was also posi-
geal nerve and parathyroid glands. Then a tioned into the oral cavity to permanently divert
direct opening of the fistula was performed. salivary content by means of a dedicated aspira-
Esophageal wall and membranaceous pars of tor at a mean vacuum of 150 mm Hg (Alsa,
the trachea were separately sutured on the Vorteco AS100, Italy) until postoperative day 12,
healthy tissue by using absorbable 3-0 Vicryl when oral feeding with liquids was started.
(Ethicon). The membranaceous pars of the tra- The side effect of this procedure was the dehy-
chea was longitudinally closed while the esopha- dration of the oral mucosa that made local irri-
gus was transversally sutured in 2 separated gation necessary without swallowing water or
mucosal and muscular layers. With the purpose mouthwash.

964 Acquired Tracheoesophageal Fistula Treatment HEAD & NECK—DOI 10.1002/hed July 2009
 On postoperative day 25 the gastrostomy stinal goiter, thus allowing a more correct surgi-
was removed, and on postoperative day 30 the cal planning.
patient was discharged with an uncuffed trache- When performing a lateral cervical approach
ostomy tube in place, being able to maintain a on the left side, the exposure of the fistula may
full oral diet. Sixty days after the operation, the be improved by performing a thyroid lobectomy
tracheal stoma was finally closed. Six months and isthmusectomy, thus minimizing the poten-
after repair, the patient was asymptomatic. tial injury of the recurrent laryngeal nerve. On
Flexible tracheoscopy performed through the the other hand, some authors prefer ligating the
nose at 6 and 12 months from the operation middle thyroid vein and the inferior thyroid ar-
showed good functional results without tracheal tery, retracting the thyroid lobe without thyroid
stenosis or granulation. lobectomy, and exposing the recurrent laryngeal
nerve but not dissecting it in the tracheoesopha-
geal groove.7 In our case, the presence of a cer-
vico-mediastinal goiter on the left side made
thyroid lobectomy mandatory.
DISCUSSION The typical poor general status of patients
The extensive use of high-volume and highly with tracheoesophageal fistula must be taken
compliant cuffs has decreased the incidence of into account when planning a surgical recon-
tracheoesophageal fistulas to 0.5% of patients struction, because it may jeopardize the success
undergoing tracheostomy.4,8 Currently, long- of primary repair.5,11 Actually, in the recent lit-
term intubation may still produce necrosis at erature, there is agreement about the need to
the decubitus point of the cuffed tracheal tube fully stabilize the patient’s clinical condition
on the posterior wall of the trachea, but fistu- before surgery by providing nutritional support
las may also occur after no more than 7 days of and by scheduling the final repair of the fistula
tube use, and the erosion of the membrana- when the patient is weaned off the ventilator,
ceous pars of the trachea is increased as long being positive pressure responsible for anasto-
as the nasogastric tube is present in the esoph- motic dehiscence and early recurrence of the
agus.4,8,12,13 Moreover, risk factors associated fistula.3,5,8,9,11,14
with occurrence of an acquired tracheoesopha- To maximize both preoperative nutritional
geal fistula include immunocompromised sta- status and infectious control, a feeding jejunos-
tus, malnutrition, and diabetes,7 as well as tomy together with a draining gastrostomy
prolonged corticosteroid treatment8 as in our must be carried out.5,11 In our case, the nasogas-
case. tric tube was removed and a percutaneous endo-
In this article, we report the case of a patient scopic feeding gastrostomy was performed.
with tracheoesophageal fistula secondary to Unfortunately, feeding jejunostomy was contra-
prolonged ventilatory support via cuffed trach- indicated in a milieu of abdominal wound infec-
eostomy tube and nasogastric intubation, tion and concomitant colostomy following fecal
successfully treated by direct suture of both peritonitis. Indeed, when gastrostomy and jeju-
defects and interposition of a sternohyoid mus- nostomy are not feasible for technical reasons,
cle flap between trachea and esophagus. nutrition should be maintained through abso-
As in the majority of cases reported, diagno- lute endovenous infusion until the fistula will be
sis was suspected following air leak detection surgically corrected.3
around the tube cuff and suctioning of tracheal There are several surgical techniques of fis-
abnormal secretions and gastric contents tula repair ranging from direct closure of tra-
through the tracheostomy. Endoscopic evalua- cheal and esophageal defects with or without
tion was useful to detect the fistula and to clar- pedicled muscle flap interposition to segmental
ify the level of the pathologic communication tracheal resection and anastomosis with esopha-
influencing the choice of a cervical rather than a geal closure and/or diversion.8,14,15 Fistulas are
thoracic approach.6 preferably best treated with 1-stage surgical
Several authors pointed out the importance procedure consisting of tracheal resection, anas-
of CT scan to look at the state of lungs and tis- tomosis, and primary esophageal closure when
sues around the fistula.6,14 In our experience, the patient is stabilized and weaned off the ven-
CT scan clearly confirmed the presence of the tilatory support.3,11 Review of the literature
fistula and showed an associated cervico-media- shows new alternative approaches such as

Acquired Tracheoesophageal Fistula Treatment HEAD & NECK—DOI 10.1002/hed July 2009 965
endoscopic closure of the fistula with fibrin glue patient is able to maintain a full oral diet. More-
as a first-line attempt before surgical correction over, in patients with chronic respiratory insuffi-
and the use of a vascularized fascial free flap or ciency, careful attention must be given to the
a deepithelialized deltopectoral flap in the set- timing of tracheostomy removal.8 When the risk
ting where primary treatment has failed to of postoperative respiratory failure is retained
resolve the fistula.5,16–18 to be the highest as in our patient, tracheal
Among this range of solutions, we chose a stoma must be left in site rescheduling its
lateral cervical approach with the purpose of delayed closure.
isolating and closing both esophageal and tra- In our patient, flexible tracheoscopy showed
cheal defects and interposing a strap muscle good functional results without stenosis or gran-
flap as the simplest technique suitable for a ulation after 12 months from the operation.
patient in a very poor clinical condition and who However, the separation of the tracheal and
received lifelong corticosteroid drugs.19 In addi- esophageal lines can result in late tracheal ste-
tion, the lack of a stenotic tracheal segment and nosis at the level of the repair or the muscle
the greatest fistula diameter of 2.0 cm obviated flap interposition,7,8 occasionally requiring exci-
the need for tracheal resection. sion of the affected segment of trachea at a later
The interposition of an inferiorly based ster- stage.11,12
nohyoid muscle flap for laryngotracheal recon-
struction is a simple, quick, and safe procedure
with low donor-site morbidity, provided that flap REFERENCES
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