Recurrent, Nonmalignant Tracheoesophageal Fistulas and the Need for Surgical Improvisation Áron Altorjay, MD, PhD, Mihály Mucs, MD, Miklós Rüll, MD,

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Recurrent, Nonmalignant Tracheoesophageal Fistulas and the Need for Surgical Improvisation Áron Altorjay, MD, PhD, Mihály Mucs, MD, Miklós Rüll, MD, Zoltán Tihanyi, MD, Balázs Hamvas, MD, László Madácsy, MD, PhD, Balázs Paál, MD The Annals of Thoracic Surgery Volume 89, Issue 6, Pages 1789-1796 (June 2010) DOI: 10.1016/j.athoracsur.2010.02.017 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Four times recurring tracheoesophageal fistula extending to the cricoid cartilage (A), postoperative status (B), and position of sutures placed in the cricoid cartilage (C) (the red color indicates locations where suture placement should be avoided). The Annals of Thoracic Surgery 2010 89, 1789-1796DOI: (10.1016/j.athoracsur.2010.02.017) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Schematic diagram of esophagus exclusion in cases of long or multiple tracheal lesions involving the bifurcation (A) and (B), and a three-dimensional computed tomographic reconstruction of the postoperative status (C); the arrow indicates the fistula opening, which can be clearly seen even 3 years postoperatively. The Annals of Thoracic Surgery 2010 89, 1789-1796DOI: (10.1016/j.athoracsur.2010.02.017) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Schematic figure of the pedicled mediastinal pleura flap that can be pulled into the neck (A) and (B), and the intraoperative picture of the phases of its formation. In (C) the flap pedicled on the posterior paravertebral part of the chest dome is shown; (D) is the rolled flap on a plastic cylinder, and pulled out into the neck (E). The Annals of Thoracic Surgery 2010 89, 1789-1796DOI: (10.1016/j.athoracsur.2010.02.017) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 A long fistula destroying the thyroid cartilage with no subglottic mucosa (A), the attempt to pull in the Provox prosthesis under bronchoscopic assistance, the star indicating the Provox trocar (B) and (C), successful Dumon stent implantation after dilation (D), the individually fenestrated tracheostomy cannula (E), and the postoperative sagittal section, 1. inserted Dumon stent; 2. level of the vocal cords; 3. destructed residual part of cricoid cartilage; 4. scar mass obliterated subglottic part of the larynx; 5. level of the esophageal closure; 6. lumen of the esophagus; 7. individually fenestrated tracheostomy cannula (F). The Annals of Thoracic Surgery 2010 89, 1789-1796DOI: (10.1016/j.athoracsur.2010.02.017) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions