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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 32  |  Issue : 3  |  Page : 229-231

Recurrent tracheoesophageal puncture fistula closure using a previous flap as donor: a case report


Department of Plastic and Reconstructive Surgery, TATA Memorial Hospital, Parel, Mumbai, India

Date of Submission28-Jun-2015
Date of Acceptance11-Sep-2015
Date of Web Publication20-Jul-2016

Correspondence Address:
Rahul Dalal
Flat No. K-302, Queen's Tower, New D. P. Road, Aundh, Pune 411007, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1012-5574.186529

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  Abstract 

Tracheoesophageal puncture (TEP)-site fistula dysfunction is a serious complication of TEP prosthesis. We successfully addressed a recurrent TEP-site fistula dysfunction by utilizing the previously done deltopectoral flap. This avoided a fresh donor site. Utilization of sound plastic surgery principles helps in tackling these problems effectively.

Keywords: deltopectoral flap, neotracheostoma, random pattern flap, tracheoesophageal puncture fistula, tracheoesophageal puncture prosthesis


How to cite this article:
Jaiswal D, Yadav P, Shankhdhar V, Dalal R. Recurrent tracheoesophageal puncture fistula closure using a previous flap as donor: a case report. Egypt J Otolaryngol 2016;32:229-31

How to cite this URL:
Jaiswal D, Yadav P, Shankhdhar V, Dalal R. Recurrent tracheoesophageal puncture fistula closure using a previous flap as donor: a case report. Egypt J Otolaryngol [serial online] 2016 [cited 2019 Nov 16];32:229-31. Available from: http://www.ejo.eg.net/text.asp?2016/32/3/229/186529


  Introduction Top


Tracheoesophageal puncture (TEP) with prosthesis was described by Singer and Blom in 1980 [1]. In this procedure a one-way valve is placed between the tracheostoma and the neopharynx, which allows air to be shunted on demand through the neopharynx and produce speech similar to esophageal speech.

There are various complications related to this procedure − namely, leakage through and around the prosthesis, hemorrhage, infection, extrusion of prosthesis, etc.

In such cases the prosthesis needs removal and closure of the TEP fistula.

Case report

A 64-year-old male patient with carcinoma of the larynx underwent total laryngectomy with bilateral neck dissection with TEP and prosthesis placement, followed by adjuvant radiation therapy. Eight years later he developed enlargement and dysfunction at the TEP site. Prosthesis removal and fistula closure were carried out with a two-layered closure and reinforcement with a deltopectoral (DP) flap cover over the esophagus.

Postoperatively there was breakdown of the DP flap and the fistula reformed. The neck tissues and esophagus were extremely fibrotic. Four months later fistula closure was performed by utilizing the DP flap already present at the fistula site along with creation of a neotracheostoma.

Operative technique

Circumferential incision was made around the tracheostoma. Dissection from the normal cartilaginous trachea anterior and lateral to the fistula site was carried out with minimal excision of the esophageal wall. Excision of the fistula track was done. Securing of a single-layer horizontal esophageal closure using 4-0 PDS taking simple sutures with knots placed outside was carried out. End stoma was relocated at the inferior edge of the fistula site. Barrier vascularized tissue coverage of the raw area and esophagus was completed. For this a 6×2▒cm random pattern flap superiorly from the distal part of the previously operated DP flap was harvested.

The flap donor area was closed primarily. The standby back-up plan was pectoralis major muscle flap with skin graft if the random pattern flap did not bleed adequately [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1 Neotracheostoma formation and random pattern flap raising based superiorly on the previously operated deltopectoral flap.

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Figure 2 Flap in position.

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Figure 3 Flap final inset.

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Figure 4 Follow-up 8 weeks postoperatively.

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Figure 5 Radio-opaque dye study; no leak at the fistula site; follow-up 8 weeks postoperatively.

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  Discussion Top


In laryngectomized patients, tracheoesophageal speech is the endpoint for voice rehabilitation. There are various complications related to this procedure, such as prosthesis-related complications, which is seen in 77.3% of cases. Other common complications are leakage (82.5%), prosthesis displacement (41.2%), intractable aspiration (29.4%), and aspiration of the prosthesis (23.5%) [2]. In such cases the prosthesis needs to be removed and the TEP fistula needs to be closed.

Principles of fistula closure are complete excision of the fistula track, secure closure of the epithelial surfaces, and barrier vascularization between the two epithelial surfaces. The traditional surgical closure of a tracheoesophageal fistula includes fistula tract division and three-layer closure of the esophageal and tracheal linings with or without interposition of a pedicle regional skin or muscle flap [3].

Different methods of TEP fistula closure have been described in the literature: closure of the esophageal mucosa with inverted sutures and of the tracheal mucosa with everted sutures [4] and three-layered closure of a tracheoesophageal puncture site [5]; three-layer technique for closure by utilizing an interpositional dermal graft [6]; interposition of muscle between suture lines for leak-proof closure [7].Use of a pedicled DP flap on the basis of a single perforator for the closure of fistulae has been published with good success rate [8].

We have tried to close a recurrent fistula by utilizing the locally available flap part and thus sparing a new flap surgery. This works perfectly on basic plastic surgery reconstructive principles where nothing is discarded, and it can be used efficiently for neoreconstruction if the tissue is viable. We have used an old flap as a donor for harvesting a new flap. Thus, the patient benefitted and his recurrent fistula problem could be resolved effectively.


  Conclusion Top


Recurrent TEP fistula is a serious complication of TEP prosthesis, which needs prosthesis removal and fistula closure. Utilization of locally available flaps and sound plastic surgical principles help in tackling these problems effectively.


  Acknowledgements Top


Dr Dushyant Jaiswal, Dr Prabha Yadav, and Dr Vinay Shankhdhar contributed to study concept. Dr Rahul Dalal and Dr Dushyant Jaiswal contributed to drafting and manuscript revision.

conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;89:529–533.  Back to cited text no. 1
[PUBMED]    
2.
Dayangku Norsuhazenah PS, Baki MM, Mohamad Yunus MR, Sabir Husin Athar PP, Abdullah S. Complications following tracheoesophageal puncture: a tertiary hospital experience. Ann Acad Med Singapore 2010;39:565–4.  Back to cited text no. 2
    
3.
Annyas AA, Escajadillo JR. Closure of tracheoesophageal fistula after removal of the voice prosthesis. Laryngoscope 1984;94:1244–1245.  Back to cited text no. 3
[PUBMED]    
4.
Hosal SA, Myers EN. How I do it: closure of tracheoesophageal puncture site. Head Neck 2001;23:214–216.  Back to cited text no. 4
    
5.
Unal M. Three-layer closure of a tracheoesophageal puncture site :a technical note. Adv Ther 2006;23:733–738.  Back to cited text no. 5
    
6.
Rosen A, Scher N, Panje WR. Surgical closure of persisting failed tracheoesophageal voice fistula. Ann Otol Rhinol Laryngol 1997;106:775–778.  Back to cited text no. 6
    
7.
Judd O, Bridger M. Failed voice restoration: closure of the tracheo-oesophageal fistula. Clin Otolaryngol 2008;33:261–264.  Back to cited text no. 7
[PUBMED]    
8.
Balasubramanian D, Iyer S, Thankappan K, Irish J. Tracheoesophageal puncture site closure with single perforator-based deltopectoral flap. Head Neck 2013;35:E60–E63.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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