Volume 4 | March 2017
Image | Esophagus

Heterotrophic Ossification of Intercostal Muscle Flap Causing Refractory Esophageal Stricture

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Ali Alali, MBBCh, BAO, FRCPC, and Kevin Waschke, MD, CM, FRCPC, FASGE

Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada

ACG Case Rep J 2017;4:e50. http://dx.doi.org/10.14309/crj.2017.50. Published online: March 29, 2017.

Case Report

A 78-year-old man presented with a history of progressive solid food dysphagia for a few weeks. His history was notable for a recent diagnosis of gastroesophageal junction adenocarcinoma that was treated with Ivor-Lewis esophagectomy, with esophagogastric anastomosis and intercostal muscle flap (IMF) placement for leak and fistula management.

Upper endoscopy showed stenosis of the esophageogastric anastamosis precluding the passage of a diagnostic gastroscope. There was no evidence of tumor recurrence. Balloon dilation was performed using a through-the-scope dilating balloon. The patient underwent multiple dilatations over the next 2 months (every 2 weeks), up to a diameter of 16.5 mm. However, the patient’s symptoms recurred rapidly, with evidence of restenosis seen on endoscopy (Figure 1). Computed tomography (CT) showed extrinsic compression and narrowing of the esophageogastric anastomosis caused by heterotrophic ossification of the pedicled IMF (Figure 2). A fully covered esophageal stent was inserted to manage his refractory esophageal stricture. The stent was removed after 6 weeks, followed by rapid recurrence of his symptoms. The patient opted for nonoperative management with serial dilations.

Figure 1. Recurrence of the stricture with evidence of ulceration after dilation.

IMFs were initially described by Shenstone for the use in thoracic surgery in 1936.1 IMFs are used during bronchial or esophageal surgeries to reinforce the anastomosis.2 They have been used in cases of esophageal perforation related to benign or malignant etiologies.3 Heterotrophic ossification of IMF is a process of abnormal bony formation of these flaps. This entity has been reported as an incidental finding on imaging. However, bronchial obstruction with resultant pain and infection is well described.4 The characteristic radiological features seen on CT imaging include discontinuous linear calcification that appears either as a single stripe or two parallel stripes with an average thickness of 4 mm (range, 1–8 mm). The radiological changes can be seen as soon as 1 week postoperatively.5

Figure 2. Chest CT showing (A) heterotrophic ossification of the intercostal muscle flap with resultant esophageal luminal narrowing, and (B) heterotrophic ossification of the intercostal muscle flap.


Author contributions: A. Alali wrote the manuscript. K. Waschke edited the manuscript and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Correspondence: Kevin Waschke, Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Ave, Montreal, Quebec, Canada H3A 0G4 (kevin.waschke@mcgill.ca).

Received December 23, 2016; Accepted Feburary 17, 2017


  1. Shenstone NS. The use of intercostal muscle in the closure of bronchial fistulae. Ann Surgery. 1936;104(4):560–71. PubMed
  2. Rendina EA, Venuta F, De Giacomo T, Ricci C. Intercostal pedicle flap in tracheobronchial surgery. Ann Thorac Surg. 1996;62(2):630–1. PubMed
  3. Whyte RI, Iannettoni MD, Orringer MB. Intrathoracic esophageal perforation: The merit of primary repair. J Thorac Cardiovasc Surg. 1995;109(1):140–6. Article | PubMed
  4. Prommegger R, Salzer GM. Heterotopic ossification in pedicled intercostal muscle flaps causing clinical problems. J Thorac Cardiovasc Surg. 1998;115(2):466–7. Article | PubMed
  5. Kwek BH, Wain JC, Aquino SL. The radiologic appearance of intercostal muscle flap. Ann Thorac Surg. 2004;78(2):432–5. Article | PubMed

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© 2017 Alali et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.