{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T14:54:45Z","timestamp":1782312885513,"version":"3.54.5"},"reference-count":38,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2021,8,27]],"date-time":"2021-08-27T00:00:00Z","timestamp":1630022400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients. Patients and methods: 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh\/anteromedial thigh (ALT\/AMT, n = 1), jejunum (n = 3) or combined ALT\u2013jejunum flaps (n = 2). Results: Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF. Conclusion: TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT\/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.<\/jats:p>","DOI":"10.3390\/cancers13174329","type":"journal-article","created":{"date-parts":[[2021,8,27]],"date-time":"2021-08-27T09:53:23Z","timestamp":1630058003000},"page":"4329","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Intra- and Extrathoracic Malignant Tracheoesophageal Fistula\u2014A Differentiated Reconstructive Algorithm"],"prefix":"10.3390","volume":"13","author":[{"given":"Thomas","family":"Kremer","sequence":"first","affiliation":[{"name":"Burn Center, Department of Plastic and Hand Surgery, St. Georg Clinic, 04129 Leipzig, Germany"},{"name":"Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2826-2793","authenticated-orcid":false,"given":"Emre","family":"Gazyakan","sequence":"additional","affiliation":[{"name":"Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2308-7041","authenticated-orcid":false,"given":"Joachim T.","family":"Maurer","sequence":"additional","affiliation":[{"name":"Mannheim University Medical Center, Department of Ear, Nose and Throat Surgery, 68167 Mannheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katja","family":"Ott","sequence":"additional","affiliation":[{"name":"Department of General, Vascular and Thoracic Surgery, RoMed Klinikum, 83022 Rosenheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Gerken","sequence":"additional","affiliation":[{"name":"Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3947-8370","authenticated-orcid":false,"given":"Marc","family":"Schmittner","sequence":"additional","affiliation":[{"name":"Mannheim University Medical Center, Department of Anesthesia and Critical Care Medicine, 68167 Mannheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1107-813X","authenticated-orcid":false,"given":"Ulrich","family":"Ronellenfitsch","sequence":"additional","affiliation":[{"name":"Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany"},{"name":"Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle (Saale), 06120 Halle, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3402-2860","authenticated-orcid":false,"given":"Ulrich","family":"Kneser","sequence":"additional","affiliation":[{"name":"Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kai","family":"Nowak","sequence":"additional","affiliation":[{"name":"Department of General, Vascular and Thoracic Surgery, RoMed Klinikum, 83022 Rosenheim, Germany"},{"name":"Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,8,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1016\/j.ctrv.2017.07.003","article-title":"Treatment of late sequelae after radiotherapy for head and neck cancer","volume":"59","author":"Strojan","year":"2017","journal-title":"Cancer Treat. Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1007\/s00405-013-2608-8","article-title":"Radiotherapy for T1a glottic cancer: The influence of smoking cessation and fractionation schedule of radiotherapy","volume":"271","author":"Mehilal","year":"2014","journal-title":"Eur. Arch. Oto-Rhino-Laryngol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1159\/000342685","article-title":"Continuation of smoking after treatment of laryngeal cancer: An inde-pendent prognostic factor?","volume":"74","author":"Kikidis","year":"2012","journal-title":"ORL J. Otorhinolaryngol. Relat. Spec."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3368","DOI":"10.1158\/1055-9965.EPI-09-0944","article-title":"Alcohol and Tobacco Use Prediagnosis and Postdiagnosis, and Survival in a Cohort of Patients with Early Stage Cancers of the Oral Cavity, Pharynx, and Larynx","volume":"18","author":"Mayne","year":"2009","journal-title":"Cancer Epidemiol. Biomark. Prev."},{"key":"ref_5","first-page":"E2214","article-title":"Prognostic value of continued smoking on survival and recurrence rates in patients with head and neck cancer: A systematic review","volume":"38","author":"Kranenburg","year":"2016","journal-title":"Head Neck"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2074","DOI":"10.1056\/NEJMoa1112088","article-title":"Preoperative chemoradiotherapy for esophageal or junctional cancer","volume":"366","author":"Hulshof","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.radonc.2015.04.021","article-title":"The impact of cancer incidence and stage on optimal utilization of radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project","volume":"116","author":"Borras","year":"2015","journal-title":"Radiother. Oncol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1106","DOI":"10.1002\/lary.24372","article-title":"Pharyngotracheal fistula closure using the internal mammary artery perforator island flap","volume":"124","author":"Mirghani","year":"2013","journal-title":"Laryngoscope"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1016\/j.thorsurg.2018.04.007","article-title":"Management of Malignant Tracheoesophageal Fistula","volume":"28","author":"Shamji","year":"2018","journal-title":"Thorac. Surg. Clin."},{"key":"ref_10","first-page":"803","article-title":"Multicenter prospective crossover study on new prosthetic opportunities in post-laryngectomy voice rehabilitation","volume":"31","author":"Serra","year":"2017","journal-title":"J. Boil. Regul. Homeost. Agents"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1007\/s00104-010-1977-4","article-title":"Tracheoesophageal fistula","volume":"82","author":"Stamatis","year":"2011","journal-title":"Chirurg"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1016\/S0001-6519(06)78750-7","article-title":"El tubo de derivaci\u00f3n salival de montgomery: Una soluci\u00f3n sencilla para las f\u00edstulas faringocut\u00e1neas Montgomery salivary bypass tube: A simple solution for pharyngocutaneous fistulas","volume":"57","author":"Sevilla","year":"2006","journal-title":"Acta Otorrinolaringol. Esp."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1055\/s-0034-1395417","article-title":"Pectoralis Major Myocutaneous Flap versus Free Fasciocutaneous Flap for Reconstruction of Partial Hypopharyngeal Defects: What Should We Be Doing?","volume":"31","author":"Chao","year":"2014","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1055\/s-0034-1376887","article-title":"Pharyngoesophageal Reconstruction Outcomes Following 349 Cases","volume":"30","author":"Xue","year":"2014","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e75","DOI":"10.1016\/j.hlc.2014.12.166","article-title":"Split Latissimus Dorsi Muscle Flap Repair of Acquired, Nonmalignant, Intrathoracic Tracheoesophageal and Bronchoesophageal Fistulas","volume":"24","author":"Hammoudeh","year":"2015","journal-title":"Hear. Lung Circ."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1492","DOI":"10.1016\/j.athoracsur.2018.01.021","article-title":"Complex Tracheocarinal Recon-structions Using Extrathoracic Muscle Flaps as Airway Substitutes","volume":"105","author":"Blatter","year":"2018","journal-title":"Ann. Thorac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e571","DOI":"10.1016\/j.athoracsur.2016.12.054","article-title":"Skin Perforator Flap Pedicled by Intercostal Muscle for Repair of a Tracheobronchoesophageal Fistula","volume":"103","author":"Bertheuil","year":"2017","journal-title":"Ann. Thorac. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e155","DOI":"10.1093\/ejcts\/ezt069","article-title":"Early and late outcome after surgical treatment of acquired non-malignant tracheo-oesophageal fistulae","volume":"43","author":"Marulli","year":"2013","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e95","DOI":"10.1016\/j.jtcvs.2016.01.045","article-title":"Pedicled posterior pericardial repair of tracheoesophageal fistula after chemoradiotherapy for esophageal cancer","volume":"151","author":"Yasuda","year":"2016","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"E172","DOI":"10.1002\/hed.23966","article-title":"Reconstruction of expanding tra-cheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: Report of 8 cases","volume":"38","author":"Dewey","year":"2016","journal-title":"Head Neck"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1960","DOI":"10.1097\/PRS.0b013e3181f446a6","article-title":"Reconstruction of phar-yngolaryngectomy defects using the jejunal free flap: A 10-year experience from a single reconstructive center","volume":"126","author":"Moradi","year":"2010","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.bjps.2012.08.033","article-title":"Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 Consecutive cases","volume":"66","author":"Wagels","year":"2013","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1002\/hed.20971","article-title":"Closure of tracheoesophageal fistula with prefabricated revascularized bilaminar radial forearm free flap","volume":"31","author":"Wreesmann","year":"2009","journal-title":"Head Neck"},{"key":"ref_24","first-page":"353","article-title":"Reconstruction of Defects after Oncologic Resection and Radiation\u2014Indications for Microsurgical Reconstruction","volume":"47","author":"Kremer","year":"2015","journal-title":"Handchir. Mikrochir. Plast. Chir."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1093\/bja\/63.4.492","article-title":"ANAESTHETIC MANAGEMENT OF MALIGNANT TRACHEO\u2014OESOPHAGEAL FISTULA","volume":"63","author":"Grebenik","year":"1989","journal-title":"Br. J. Anaesth."},{"key":"ref_26","first-page":"819","article-title":"Management of acquired tracheoesophageal fistula","volume":"6","author":"Dartevelle","year":"1996","journal-title":"Chest Surg. Clin. N. Am."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1007\/s00540-008-0620-8","article-title":"Independent lung ventilation combined with HFOV for a patient suffering from tra-cheo-gastric roll fistula","volume":"22","author":"Ichinose","year":"2008","journal-title":"J. Anesth."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1016\/j.ijsu.2017.11.001","article-title":"Indocyanine green tissue angiography affects anastomotic leakage after esophagectomy. A retrospective, case-control study","volume":"48","author":"Karampinis","year":"2017","journal-title":"Int. J. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1159\/000506910","article-title":"Application of Fluorescent Dyes in Visceral Surgery: State of the Art and Future Per-spectives","volume":"36","author":"Nowak","year":"2020","journal-title":"Visc. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1055\/s-0040-1710552","article-title":"The Impact of Indocyanine-Green Fluorescence Angi-ography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery","volume":"36","author":"Bigdeli","year":"2020","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1017\/S0022215100122406","article-title":"Radiotherapy and complications of laryngectomy","volume":"107","author":"McCombe","year":"1993","journal-title":"J. Laryngol. Otol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1016\/j.athoracsur.2020.10.015","article-title":"Characteristics and Outcomes of Airway Involvement in Esophageal Cancer","volume":"112","author":"Goh","year":"2021","journal-title":"Ann. Thorac. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Geyer, M., Tan, N., Ismail-Koch, H., and Puxeddu, R. (2011). A simple closure technique for reversal of tracheoesophageal puncture. Am. J. Otolaryngol., 32.","DOI":"10.1016\/j.amjoto.2010.11.015"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1097\/00006534-197964050-00002","article-title":"Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers","volume":"64","author":"Ariyan","year":"1979","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1007\/s12663-019-01228-7","article-title":"PMMC Flap Revisited and its Clinical Outcome in 150 Patients","volume":"19","author":"Anehosur","year":"2020","journal-title":"J. Maxillofac. Oral Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"105e","DOI":"10.1097\/PRS.0000000000002915","article-title":"Optimizing Outcomes in Pharyn-goesophageal Reconstruction and Neck Resurfacing: 10-Year Experience of 294 Cases","volume":"139","author":"Sharaf","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1002\/micr.30259","article-title":"The radial forearm free flap as a \u201cvascular bridge\u201d for secondary microsurgical head and neck reconstruction in a vessel-depleted neck","volume":"38","author":"Ciudad","year":"2018","journal-title":"Microsurgery"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1002\/micr.30209","article-title":"Sequential chimeric medial femoral condyle and anterolateral thigh flow-through flaps for one-stage reconstructions of composite bone and soft tissue defects: Report of three cases","volume":"37","author":"Henn","year":"2017","journal-title":"Microsurgery"}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/13\/17\/4329\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:53:18Z","timestamp":1760165598000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/13\/17\/4329"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,8,27]]},"references-count":38,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2021,9]]}},"alternative-id":["cancers13174329"],"URL":"https:\/\/doi.org\/10.3390\/cancers13174329","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,8,27]]}}}