Persistent tracheocutaneous fistula closure by pectoralis major myocutaneous flap: surgical technique

Introduction

Persistent tracheocutaneous fistula (PTCF) is a recognized complication of prolonged tracheostomy cannulation, developing when squamous epithelium migrates into the tracheal lumen and forms a fully epithelialized stoma that fails to close spontaneously (1). Approximately 70% of adults with tracheostomies lasting longer than 16 weeks, and 13–43% of pediatric tracheostomy patients, may develop a PTCF (1).

In most cases, simple removal of the tracheostomy tube and occlusive dressing achieve spontaneous closure with satisfactory cosmetic and functional results. However, persistent fistulas may occur, particularly in patients with prior radiotherapy, advanced age, obesity, or multiple tracheostomies, leading to secretion retention, speech difficulties, recurrent airway infections, and aesthetic concerns (2).

A recent classification defines four types of tracheocutaneous fistulas based on diameter and healing potential: group A (<5 mm, self-healing), group B (<5 mm, non-healing), group C (5–10 mm), and group D (>10 mm) (1). While types B and C are usually amenable to direct closure, type D fistulas typically require flap-based reconstruction (3-5). We present this article in accordance with the SUPER reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-24-16/rc).

Preoperative preparation and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Before surgical intervention, it is essential to ensure that the patient’s upper airway can sustain adequate airflow once the tracheostomy is closed. Overnight oximetry testing after temporary stoma occlusion is strongly advised to detect any ongoing dependence on the tracheostomy for ventilation (6).

Furthermore, tracheal imaging or bronchoscopy should be performed to rule out significant tracheal stenosis or other obstructive lesions, particularly in patients with a history of prolonged or repeated intubations.

Standard preoperative evaluation should include a chest X-ray and optimization of any comorbid conditions.

Step-by-step description

This open surgical approach aims to achieve definitive closure of type D PTCF using a pectoralis major myocutaneous flap in a non-irradiated patient with a body mass index (BMI) of 22 kg/m² (Figure 1).

Figure 1 Anatomy of the pectoralis major myocutaneous flap. Schematic representation of the pectoralis major myocutaneous flap, illustrating its vascular anatomy and main landmarks. The flap is based on the thoracoacromial arterial trunk, which originates from the second segment of the axillary artery and divides into pectoral, clavicular, humeral, and acromial branches. The rich vascular network, including multiple perforators to the overlying skin, ensures excellent perfusion and makes this flap particularly suitable for reconstruction of cervical and upper thoracic defects. The orientation and potential arc of rotation over the clavicle are shown.

Under general anesthesia with single-lumen oro-tracheal intubation, the patient is placed in a supine position to provide complete access to the persistent tracheostomy site (Figure 2A). Care must be taken to avoid overinflation of the tracheal tube cuff, as excessive pressure may compromise the tracheal wall and contribute to fistula recurrence. Both arms are adducted, and the head is maintained in a neutral position. A full fistulectomy is performed to excise the epithelialized tract, separating the cutaneous planes from the anterolateral tracheal wall and exposing healthy tracheal margins. This step is paramount to prevent fistula recurrence. These are suspended with interrupted sutures for better visualization (Figure 2B).

Figure 2 Intraoperative steps of pectoralis major myocutaneous flap reconstruction for PTCF. (A) Preoperative aspect of the persistent tracheocutaneous fistula showing an epithelialized tract resistant to spontaneous closure. (B) Surgical exposure of the anterior tracheal wall after complete fistulectomy and dissection of surrounding scar tissue, allowing clear identification of healthy tracheal margins. (C) Elevation and tunneling of the pectoralis major myocutaneous flap above the clavicle to reach the tracheal defect in a tension-free fashion; intraoperative Doppler ultrasonography is used to verify adequate flap vascularization. (D) Intraoperative bronchoscopic view confirming the airtight closure of the anterior tracheal defect achieved by suturing the skin island of the flap to the tracheal wall, ensuring luminal patency and absence of intraluminal bulging. PTCF, persistent tracheocutaneous fistula.

A myocutaneous pectoralis major flap is then harvested based on the thoracoacromial arterial trunk, which arises from the axillary artery and provides excellent vascularization via multiple perforators. The flap is tunneled above the clavicle, ensuring a tension-free reach to the tracheal defect (Figure 2C). Intraoperative Doppler ultrasonography is useful for confirming adequate perfusion.

The flap’s cutaneous portion is sutured to the anterior tracheal wall with interrupted absorbable stitches, ensuring a watertight seal. The cutaneous surface of the flap is oriented toward the tracheal lumen to ensure optimal epithelial integration and airtight closure. Bronchoscopic inspection during surgery confirms airtight closure and the absence of intraluminal bulging (Figure 2D). The whole procedure lasted 114 minutes and no blood loss was reported.

Postoperative considerations and tasks

After surgery, bronchoscopy is repeated to verify tracheal lumen patency and secure the integrity of the repair (7). The patient should be observed for at least 24–48 hours with standard chest radiography to monitor for pneumothorax, pneumomediastinum, or subcutaneous emphysema.

Pain control, oxygen saturation monitoring, and airway surveillance are critical during early recovery. Any signs of respiratory distress should prompt immediate evaluation.

Tips and pearls

• Confirm airway independence before closure: perform overnight oximetry and temporary stomal occlusion to ensure the patient no longer relies on the tracheostomy for ventilation. Undiagnosed airway dependence is a major risk factor for postoperative respiratory distress and flap disruption.
• Exclude tracheal stenosis preoperatively: bronchoscopy or cross-sectional imaging should be performed in patients with a history of prolonged intubation to rule out high-grade stenosis that may complicate decannulation.
• Avoid overinflation of the endotracheal tube cuff: excessive cuff pressure may compromise the tracheal wall and predispose to recurrence; use minimal occlusive pressure during the entire procedure.
• Perform complete fistulectomy to healthy tracheal margins: full removal of the epithelialized tract is essential to prevent recurrence. Suspended traction sutures improve exposure and precision of closure.
• Harvest the pectoralis major flap on the thoracoacromial pedicle: the vascular anatomy is consistent and provides robust perfusion; intraoperative Doppler can be used to verify adequate blood supply.
• Create a tension-free flap tunnel: passing the flap above the clavicle avoids compression and ensures appropriate reach without distortion of the pedicle.
• Use intraoperative bronchoscopy to verify closure: endoscopic inspection confirms absence of air leakage and checks for luminal bulging that could compromise the airway.
• Postoperative airway monitoring is mandatory: observe the patient for 24–48 hours with chest imaging to detect pneumothorax, pneumomediastinum, or subcutaneous emphysema early.

Discussion

The pectoralis major myocutaneous flap offers several advantages for the closure of large or complex PTCFs. Its robust vascular supply, anatomical consistency, and ease of mobilization make it particularly effective in patients with irradiated, infected, or scarred cervical tissues. Because it lies outside the usual head and neck radiation fields, it provides healthy, well-vascularized tissue suitable for reconstruction.

Mobilization can be performed entirely in the supine position, simplifying the procedure and avoiding repositioning. The skin paddle provides a reliable, airtight closure when sutured to the trachea, though potential hair growth within the lumen may occasionally require laser treatment (8).

However, in cases of smaller defects, the flap may be unnecessarily bulky, and in female patients, it may lead to some degree of breast contour alteration. Despite these limitations, the technique remains a dependable single-stage solution for complex PTCFs, offering durable functional and aesthetic outcomes with minimal morbidity.

Conclusions

PTCFs can represent a challenging condition, particularly when the defect is large or associated with unfavorable local tissue characteristics. In such cases, simple closure techniques may be insufficient, and well-vascularized flap reconstruction becomes necessary. The pectoralis major myocutaneous flap provides a reliable option for definitive repair of type D PTCF, offering robust vascularity, consistent anatomical landmarks, and adequate tissue volume to achieve a tension-free and airtight closure. When combined with careful preoperative airway assessment and meticulous postoperative monitoring, this technique represents a safe, versatile, and effective strategy in the management of complex PTCFs.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-24-16/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-24-16/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-24-16/coif). F.P. serves as an unpaid editorial board member of Shanghai Chest from February 2025 to July 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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