Replacement of the complete posterior tracheal wall with autologous pericardium and latissimus dorsi flap after esophageal acid burn

Introduction: Reconstruction of large tracheal defects are complex, simply because there are no artificial materials for replacement and autologous tissues have distinctive limitations.

Case presentation: A 27 year old female patient was admitted after acid ingestion with severe acid burns of the mouth, pharynx and upper gastrointestinal tract. The patient developed progredient necrosis of the esophagus involving the tracheal posterior wall per continuitatem. After intubation and tracheotomy, endoscopic control documented an enormous esophagi-tracheal fistula: the entire tracheal posterior wall was destroyed and the completely necrotic esophagus was ruptured.

The reconstruction was carried out under support of veno-arterial extracorporeal membrane oxygenation (ECMO). Via a right thoracotomy the complete thoracic esophagus and the necrotic residual posterior wall of the trachea from the tracheostoma via the bifurcation into the left main bronchus were resected. The primary reconstruction of the posterior tracheal wall was made with an autologous pericardial patch. Subsequently the pediculed latissimus dorsi muscle was lifted, placed in the thoracic cavity through an incision in the 2nd intercostal space and fixated in the former esophageal bed to sustain and support the reconstruction of the tracheal wall. Postoperatively the extracorporeal lung assist was switched to veno-venous ECMO to assure a protective, low-pressure ventilation of the reconstructed upper airways. In a subsequent procedure, the cervical esophagus was drained out on the lateral neck. The stomach had to be resected due to necrosis with covered perforation. After prolonged weaning from mechanical ventilation the patient could be transferred to a rehabilitation clinic with a permanent tracheostomy because of persistent dysphagia. Further reconstructive procedures are planned.

Conclusions: Autologous pericardium in combination with muscle flap coverage allows for reconstruction of long tracheal defects. With this technique an instant airtight closure and an unproblematic healing of the pericardium without necrosis can be achieved.