Progress of musculocutaneous flap repair in the surgical treatment for benign tracheoesophageal fistula_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZENG Ao , JIANG Gening ,  DAI Jie

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, P. R. China;

Corresponding?author：

DAI Jie, Email: daijie@#edu.cn

Keywords：

Tracheoesophageal fistula; musculocutaneous flap; sternocleidomastoid; repair; pectoralis major; latissimus dorsi; review

DOI：

10.7507/1007-4848.202412103

Video：

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Tracheoesophageal fistula (TEF) is a disease characterized by an abnormal connection between the trachea and esophagus. Benign TEF often results from tracheal intubation injury, typically presenting as coughing exacerbated by swallowing, and can be potentially life-threatening. However, no unified surgical standard currently exists for TEF. The choice of surgical method mainly depends on the location and size of the fistula, as well as the condition of the surrounding tracheal tissue. For small-to-moderate fistulas, tracheal segmental resection with reconstruction is a classic approach. For large, complex, and refractory TEFs, musculocutaneous flap repair is considered an ideal option. This article reviews the application of several common musculocutaneous flaps—including the sternocleidomastoid, pectoralis major, and latissimus dorsi—in the repair of benign TEFs, with the aim of providing a clinical reference.

Citation： ZENG Ao, JIANG Gening, DAI Jie. Progress of musculocutaneous flap repair in the surgical treatment for benign tracheoesophageal fistula. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(9): 1482-1486. doi: 10.7507/1007-4848.202412103 Copy

1.	Fu Y, Yang T, Liang P, et al. A case of asymptomatic tracheoesophageal fistula[J/OL]. Ear Nose Throat J, 2023, 102(9): 1455613231200810. DOI: 10.1177/01455613231200810.
2.	Kim HS, Khemasuwan D, Diaz-Mendoza J, et al. Management of tracheo-oesophageal fistula in adults[J/OL]. Eur Respir Rev, 2020, 29(158): 200094. DOI: 10.1183/16000617.0094-2020.
3.	Bibas BJ, Guerreiro Cardoso PF, Minamoto H, et al. Surgical management of benign acquired tracheoesophageal fistulas: a ten-year experience[J]. Ann Thorac Surg, 2016, 102(4): 1081-1087.
4.	Lagrotta G, Ayad M, Butt I, et al. Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: a case report[J]. World J Crit Care Med, 2022, 11(5): 335-341.
5.	Zeng A, Liu X, Shaik MS, et al. Surgical strategies for benign acquired tracheoesophageal fistula[J/OL]. Eur J Cardiothorac Surg, 2024, 65(2): ezae047. DOI: 10.1093/ejcts/ezae047.
6.	Bibas BJ, Cardoso PFG, Minamoto H, et al. Surgery for intrathoracic tracheoesophageal and bronchoesophageal fistula[J]. Ann Transl Med, 2018, 6(11): 210.
7.	Gurram RP, Gnanasekaran S, Kalayarasan R, et al. Stapled repair of benign acquired tracheoesophageal fistula: description of novel technique and assessment of outcomes[J/OL]. Cureus, 2020, 12(8): e9854. DOI: 10.7759/CUREUS.9854.
8.	Dai J, He W, Liu X, et al. Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis[J/OL]. Interdiscip Cardiovasc Thorac Surg, 2023, 37(2): ivad130. DOI: 10.1093/icvts/ivad130.
9.	Marulli G, Loizzi M, Cardillo G, et al. Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae[J]. Eur J Cardiothorac Surg, 2013, 43(6): e155-e161.
10.	Hasan L, Sharma B, Goldenberg SA. Acquired tracheoesophageal fistulas: a case report and review of diagnostic and management challenges[J/OL]. Cureus, 2022, 14(3): e23324. DOI: 10.7759/cureus.23324.
11.	Silon B, Siddiqui AA, Taylor LJ, et al. Endoscopic management of esophagorespiratory fistulas: a multicenter retrospective study of techniques and outcomes[J]. Dig Dis Sci, 2017, 62(2): 424-431.
12.	Ali O, Singh G, Kolachana S, et al. Successful closure of a tracheoesophageal fistula using an over-the-scope clip[J/OL]. Cureus, 2023, 15(4): e37577. DOI: 10.1016/j.gie.2023.04.156.
13.	Debourdeau A, Gonzalez JM, Dutau H, et al. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success[J]. Surg Endosc, 2019, 33(2): 549-556.
14.	Kim SP, Lee J, Lee SK, et al. Surgical treatment outcomes of acquired benign tracheoesophageal fistula: a literature review[J]. J Chest Surg, 2021, 54(3): 206-213.
15.	Amore D, Casazza D, Rispoli M, et al. Acquired benign tracheoesophageal fistula: an alternative tracheoplastic technique[J]. Ann Thorac Cardiovasc Surg, 2022, 28(6): 377-380.
16.	Yang G, Li WM, Zhao JB, et al. A novel surgical method for acquired non-malignant complicated tracheoesophageal and bronchial-gastric stump fistula: the "double patch" technique[J]. J Thorac Dis, 2016, 8(11): 3225-3231.
17.	Mammana M, Comacchio GM, Schiavon M, et al. Repair of adult benign tracheoesophageal fistulae with absorbable patches: single-center experience[J]. Ann Thorac Surg, 2020, 109(4): 1086-1094.
18.	Lane C, Wright M, Linton J, et al. Surgical closure of enlarged tracheoesophageal fistula after laryngectomy: a systematic review of techniques[J/OL]. Am J Otolaryngol, 2024, 45(1): 104023. DOI: 10.1016/j.amjoto.2023.104023.
19.	Bertheuil N, Duisit J, Isola N, et al. Perforator-based intercostal artery muscle flap: a novel approach for the treatment of tracheoesophageal or bronchoesophageal fistulas[J]. Plast Reconstr Surg, 2021, 147(5): 795e-800e.
20.	Hammoudeh ZS, Gursel E, Baciewicz FA Jr. Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas[J]. Heart Lung Circ, 2015, 24(6): e75-e78.
21.	Liu X, Li Q, Huang W, et al. Use of a pedicled sternocleidomastoid musculocutaneous flap in a large tracheoesophageal fistula[J]. Ann Thorac Surg, 2020, 110(3): e233-e236.
22.	Wreesmann VB, Smeele LE, Hilgers FJ, et al. Closure of tracheoesophageal fistula with prefabricated revascularized bilaminar radial forearm free flap[J]. Head Neck, 2009, 31(6): 838-842.
23.	Bertheuil N, Cusumano C, Meal C, et al. Skin perforator flap pedicled by intercostal muscle for repair of a tracheobronchoesophageal fistula[J]. Ann Thorac Surg, 2017, 103(6): e571-e573.
24.	Lyberis P, Nicosia S, Strignano P, et al. Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap[J]. Panminerva Med, 2023, 65(3): 400-403.
25.	Jaiswal D, Yadav P, Shankhdhar VK, et al. Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap[J]. Indian J Plast Surg, 2015, 48(3): 278-282.
26.	Rosskopfova P, Perentes JY, Schafer M, et al. Repair of challenging non-malignant tracheo- or broncho-oesophageal fistulas by extrathoracic muscle flaps[J]. Eur J Cardiothorac Surg, 2017, 51(5): 844-851.
27.	Dewey EH, Castro JR, Mojica J, et al. Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: report of 8 cases[J]. Head Neck, 2016, 38(Suppl 1): E172-E178.
28.	Mantovani S, Giovanniello D, Jaus MO. The sternocleidomastoid muscle reverse pad: a "safety net" in catastrophic tracheal surgery situation[J/OL]. Life (Basel), 2024, 14(11): 1423. DOI: 10.3390/life14111423.
29.	Chuang FC, Tung KY, Huang WC, et al. Using a sternocleidomastoid muscle flap to close an iatrogenic tracheoesophageal fistula in a patient with advanced laryngeal cancer: a case report and literature review[J]. Ann Plast Surg, 2019, 82(1S Suppl 1): S126-S129.
30.	Sakatoku Y, Fukaya M, Fujieda H, et al. Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer[J/OL]. Surg Case Rep, 2017, 3(1): 90. DOI: 10.1186/s40792-017-0371-6.
31.	Blatter J, Krueger T, Ris HB, et al. Complex tracheocarinal reconstructions using extrathoracic muscle flaps as airway substitutes[J]. Ann Thorac Surg, 2018, 105(5): 1492-1498.
32.	Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic airway defects using extrathoracic muscle flaps[J]. Ann Thorac Surg, 2004, 77(2): 397-405.
33.	Samarasam I, Chandran S, Shukla V, et al. A missing denture's misadventure[J]! Dis Esophagus, 2006, 19(1): 53-55.
34.	Siu KF, Wei WI, Lam KH, et al. Use of the pectoralis major muscle flap for repair of a tracheoesophageal fistula[J]. Am J Surg, 1985, 150(5): 617-619.
35.	Alemar GO, Anand VK. Split pectoralis major flap for massive tracheoesophageal fistula[J]. Otolaryngol Head Neck Surg, 1997, 117(6): S105-S108.
36.	Mayer HF, Palacios Huatuco RM, Pizarro Feijoo BA, et al. Silicone pectoral implant to solve aesthetic chest deformity after pectoralis flap harvesting for laryngotracheal reconstruction[J]. Aesthetic Plast Surg, 2024, 48(9): 1773-1777.
37.	Poissonnet V, Culie D, Rouanet C, et al. Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap[J]. Eur Ann Otorhinolaryngol Head Neck Dis, 2022, 139(5): 297-300.
38.	Saeedi A, Strum DP, Mir G, et al. Management of enlarging tracheoesophageal fistula with voice prosthesis in laryngectomized patients[J]. Laryngoscope, 2024, 134(1): 198-206.
39.	Machado RA, Moubayed SP, Urken ML. Repair of pharyngoesophageal stenosis and a tracheoesophageal fistula using a dual-paddled radial forearm free flap: flap design and surgical technique[J]. Laryngoscope, 2017, 127(9): 2081-2084.
40.	Sridhar S, Dhanda AK, Mohyuddin NG, et al. Closure of non-malignant acquired tracheoesophageal fistula with anterolateral thigh free flap: a case report[J/OL]. OTO Open, 2025, 9(1): e70088. DOI: 10.1002/oto2.70088.
41.	Murono S, Ishikawa E, Nakanishi Y, et al. Closure of tracheoesophageal fistula with prefabricated deltopectoral flap[J]. Asian J Surg, 2016, 39(4): 243-246.
42.	McMurtrie A, Georgeu GA, Kok K, et al. Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap[J]. J Laryngol Otol, 2005, 119(2): 129-131.
43.	Teixeira S, Costa J, Monteiro D, et al. Pharyngocutaneous and tracheoesophageal fistula closure using supraclavicular artery island flap[J]. Eur Arch Otorhinolaryngol, 2018, 275(7): 1921-1926.
44.	Giordano L, Di Santo D, Occhini A, et al. Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction[J]. Eur Arch Otorhinolaryngol, 2016, 273(12): 4403-4412.
45.	Park JS, Eom JS, Choi SH, et al. Use of a serratus anterior musculocutaneous flap for surgical obliteration of a bronchopleural fistula[J]. Interact Cardiovasc Thorac Surg, 2015, 20(5): 569-574.

1. Fu Y, Yang T, Liang P, et al. A case of asymptomatic tracheoesophageal fistula[J/OL]. Ear Nose Throat J, 2023, 102(9): 1455613231200810. DOI: 10.1177/01455613231200810.
2. Kim HS, Khemasuwan D, Diaz-Mendoza J, et al. Management of tracheo-oesophageal fistula in adults[J/OL]. Eur Respir Rev, 2020, 29(158): 200094. DOI: 10.1183/16000617.0094-2020.
3. Bibas BJ, Guerreiro Cardoso PF, Minamoto H, et al. Surgical management of benign acquired tracheoesophageal fistulas: a ten-year experience[J]. Ann Thorac Surg, 2016, 102(4): 1081-1087.
4. Lagrotta G, Ayad M, Butt I, et al. Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: a case report[J]. World J Crit Care Med, 2022, 11(5): 335-341.
5. Zeng A, Liu X, Shaik MS, et al. Surgical strategies for benign acquired tracheoesophageal fistula[J/OL]. Eur J Cardiothorac Surg, 2024, 65(2): ezae047. DOI: 10.1093/ejcts/ezae047.
6. Bibas BJ, Cardoso PFG, Minamoto H, et al. Surgery for intrathoracic tracheoesophageal and bronchoesophageal fistula[J]. Ann Transl Med, 2018, 6(11): 210.
7. Gurram RP, Gnanasekaran S, Kalayarasan R, et al. Stapled repair of benign acquired tracheoesophageal fistula: description of novel technique and assessment of outcomes[J/OL]. Cureus, 2020, 12(8): e9854. DOI: 10.7759/CUREUS.9854.
8. Dai J, He W, Liu X, et al. Use of an autologous dermal flap and rib cartilage graft in the repair of a large tracheoesophageal fistula with tracheal stenosis[J/OL]. Interdiscip Cardiovasc Thorac Surg, 2023, 37(2): ivad130. DOI: 10.1093/icvts/ivad130.
9. Marulli G, Loizzi M, Cardillo G, et al. Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae[J]. Eur J Cardiothorac Surg, 2013, 43(6): e155-e161.
10. Hasan L, Sharma B, Goldenberg SA. Acquired tracheoesophageal fistulas: a case report and review of diagnostic and management challenges[J/OL]. Cureus, 2022, 14(3): e23324. DOI: 10.7759/cureus.23324.
11. Silon B, Siddiqui AA, Taylor LJ, et al. Endoscopic management of esophagorespiratory fistulas: a multicenter retrospective study of techniques and outcomes[J]. Dig Dis Sci, 2017, 62(2): 424-431.
12. Ali O, Singh G, Kolachana S, et al. Successful closure of a tracheoesophageal fistula using an over-the-scope clip[J/OL]. Cureus, 2023, 15(4): e37577. DOI: 10.1016/j.gie.2023.04.156.
13. Debourdeau A, Gonzalez JM, Dutau H, et al. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success[J]. Surg Endosc, 2019, 33(2): 549-556.
14. Kim SP, Lee J, Lee SK, et al. Surgical treatment outcomes of acquired benign tracheoesophageal fistula: a literature review[J]. J Chest Surg, 2021, 54(3): 206-213.
15. Amore D, Casazza D, Rispoli M, et al. Acquired benign tracheoesophageal fistula: an alternative tracheoplastic technique[J]. Ann Thorac Cardiovasc Surg, 2022, 28(6): 377-380.
16. Yang G, Li WM, Zhao JB, et al. A novel surgical method for acquired non-malignant complicated tracheoesophageal and bronchial-gastric stump fistula: the "double patch" technique[J]. J Thorac Dis, 2016, 8(11): 3225-3231.
17. Mammana M, Comacchio GM, Schiavon M, et al. Repair of adult benign tracheoesophageal fistulae with absorbable patches: single-center experience[J]. Ann Thorac Surg, 2020, 109(4): 1086-1094.
18. Lane C, Wright M, Linton J, et al. Surgical closure of enlarged tracheoesophageal fistula after laryngectomy: a systematic review of techniques[J/OL]. Am J Otolaryngol, 2024, 45(1): 104023. DOI: 10.1016/j.amjoto.2023.104023.
19. Bertheuil N, Duisit J, Isola N, et al. Perforator-based intercostal artery muscle flap: a novel approach for the treatment of tracheoesophageal or bronchoesophageal fistulas[J]. Plast Reconstr Surg, 2021, 147(5): 795e-800e.
20. Hammoudeh ZS, Gursel E, Baciewicz FA Jr. Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas[J]. Heart Lung Circ, 2015, 24(6): e75-e78.
21. Liu X, Li Q, Huang W, et al. Use of a pedicled sternocleidomastoid musculocutaneous flap in a large tracheoesophageal fistula[J]. Ann Thorac Surg, 2020, 110(3): e233-e236.
22. Wreesmann VB, Smeele LE, Hilgers FJ, et al. Closure of tracheoesophageal fistula with prefabricated revascularized bilaminar radial forearm free flap[J]. Head Neck, 2009, 31(6): 838-842.
23. Bertheuil N, Cusumano C, Meal C, et al. Skin perforator flap pedicled by intercostal muscle for repair of a tracheobronchoesophageal fistula[J]. Ann Thorac Surg, 2017, 103(6): e571-e573.
24. Lyberis P, Nicosia S, Strignano P, et al. Tracheo-esophageal fistula repair in a positive COVID-19 patient: use of intercostal muscle flap[J]. Panminerva Med, 2023, 65(3): 400-403.
25. Jaiswal D, Yadav P, Shankhdhar VK, et al. Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap[J]. Indian J Plast Surg, 2015, 48(3): 278-282.
26. Rosskopfova P, Perentes JY, Schafer M, et al. Repair of challenging non-malignant tracheo- or broncho-oesophageal fistulas by extrathoracic muscle flaps[J]. Eur J Cardiothorac Surg, 2017, 51(5): 844-851.
27. Dewey EH, Castro JR, Mojica J, et al. Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: report of 8 cases[J]. Head Neck, 2016, 38(Suppl 1): E172-E178.
28. Mantovani S, Giovanniello D, Jaus MO. The sternocleidomastoid muscle reverse pad: a "safety net" in catastrophic tracheal surgery situation[J/OL]. Life (Basel), 2024, 14(11): 1423. DOI: 10.3390/life14111423.
29. Chuang FC, Tung KY, Huang WC, et al. Using a sternocleidomastoid muscle flap to close an iatrogenic tracheoesophageal fistula in a patient with advanced laryngeal cancer: a case report and literature review[J]. Ann Plast Surg, 2019, 82(1S Suppl 1): S126-S129.
30. Sakatoku Y, Fukaya M, Fujieda H, et al. Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer[J/OL]. Surg Case Rep, 2017, 3(1): 90. DOI: 10.1186/s40792-017-0371-6.
31. Blatter J, Krueger T, Ris HB, et al. Complex tracheocarinal reconstructions using extrathoracic muscle flaps as airway substitutes[J]. Ann Thorac Surg, 2018, 105(5): 1492-1498.
32. Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic airway defects using extrathoracic muscle flaps[J]. Ann Thorac Surg, 2004, 77(2): 397-405.
33. Samarasam I, Chandran S, Shukla V, et al. A missing denture's misadventure[J]! Dis Esophagus, 2006, 19(1): 53-55.
34. Siu KF, Wei WI, Lam KH, et al. Use of the pectoralis major muscle flap for repair of a tracheoesophageal fistula[J]. Am J Surg, 1985, 150(5): 617-619.
35. Alemar GO, Anand VK. Split pectoralis major flap for massive tracheoesophageal fistula[J]. Otolaryngol Head Neck Surg, 1997, 117(6): S105-S108.
36. Mayer HF, Palacios Huatuco RM, Pizarro Feijoo BA, et al. Silicone pectoral implant to solve aesthetic chest deformity after pectoralis flap harvesting for laryngotracheal reconstruction[J]. Aesthetic Plast Surg, 2024, 48(9): 1773-1777.
37. Poissonnet V, Culie D, Rouanet C, et al. Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap[J]. Eur Ann Otorhinolaryngol Head Neck Dis, 2022, 139(5): 297-300.
38. Saeedi A, Strum DP, Mir G, et al. Management of enlarging tracheoesophageal fistula with voice prosthesis in laryngectomized patients[J]. Laryngoscope, 2024, 134(1): 198-206.
39. Machado RA, Moubayed SP, Urken ML. Repair of pharyngoesophageal stenosis and a tracheoesophageal fistula using a dual-paddled radial forearm free flap: flap design and surgical technique[J]. Laryngoscope, 2017, 127(9): 2081-2084.
40. Sridhar S, Dhanda AK, Mohyuddin NG, et al. Closure of non-malignant acquired tracheoesophageal fistula with anterolateral thigh free flap: a case report[J/OL]. OTO Open, 2025, 9(1): e70088. DOI: 10.1002/oto2.70088.
41. Murono S, Ishikawa E, Nakanishi Y, et al. Closure of tracheoesophageal fistula with prefabricated deltopectoral flap[J]. Asian J Surg, 2016, 39(4): 243-246.
42. McMurtrie A, Georgeu GA, Kok K, et al. Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap[J]. J Laryngol Otol, 2005, 119(2): 129-131.
43. Teixeira S, Costa J, Monteiro D, et al. Pharyngocutaneous and tracheoesophageal fistula closure using supraclavicular artery island flap[J]. Eur Arch Otorhinolaryngol, 2018, 275(7): 1921-1926.
44. Giordano L, Di Santo D, Occhini A, et al. Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction[J]. Eur Arch Otorhinolaryngol, 2016, 273(12): 4403-4412.
45. Park JS, Eom JS, Choi SH, et al. Use of a serratus anterior musculocutaneous flap for surgical obliteration of a bronchopleural fistula[J]. Interact Cardiovasc Thorac Surg, 2015, 20(5): 569-574.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Progress of musculocutaneous flap repair in the surgical treatment for benign tracheoesophageal fistula

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