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Journal Voice28/2/2012

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Case scenario

• )*+�,('-.�/����(� 6 �0

• Dx : bilat. TVCP � tracheostomy 1�2�%1�'�-

• 1�� �/�(34-� rima -� � off tracheostomy tube 5-+

• %1� � persistent tracheocutaneous fistula

Case scenario

Question

• What is the best surgical method to close tracheocutaneous fistula?

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Search Tracheocutaneous fistula (TCF)

• 70% of pt with tracheostomy > 16 wk : persistent fistula

Jacohs JR. Bipedicle delayed fiap closure of persistent radiated tracheocutaneous fistulas. J Surg Oncol 1995:59:196-8

Occurrence rate

• 3.3-50% (White KA, 1989; M. Mahadevan, 2007; Joseph H.T., 1991)

TCF and duration of canulation

• ↑ duration : ↑ epithelial tissue grow within

stoma and form epithelialized scar tissue &dense CNT � fistula

• Pt cannulated for >1 yr after tracheostomy : 50% persistent TCF (Eaton DA et al, 2003)

TCF and duration of canulation

• Early tracheostomy and prolonged time : ↑rate of fistula (P.J. Koltai, 1998)

• Duration of cannulation : ↑ risk TCF

(Ochi J.W.,1992; Wetmore RF,1982)

Complications from TCF

• Aspiration, pneumonia

• Skin irritation from secretion

• Voice problems

• Cosmetic defects

• Difficulty swimming &

bathing

• ↓ pulmonary function in pt

with underlying lung dz

Ref : Geyer M 2008; Priestley JD 2006

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Surgical methods

• Primary closure

• Bipedicle delayed flap closure

• Fistulectomy with primary closure in layers

• Fistulectomy with healing by secondary intention

• Z-plasty with rotation of 2 of 4 triangular skin flaps

• Elevation and rotation of epithelial lining of fistula inward as a marginally based flap

• Turnover hinge flap

• V–Y advancement flap

• Auricular cartilage transplanted to tracheal defect with DP flap

Primary repair

• Shorter recovery time

• Superior cosmesis result

• Disadvantage : subcutaneous

emphysema, pneumomediastinum,

pneumothorax �

respiratory distress

Healing by secondary intention

• Avoids subcutaneous air tracking provided the trachea heals before overlying skin

• Wound : time to heal

• Scar : may be cosmetically inferior

Complications of repair

• Surgical emphysema

• Emergency recannulation

• Wound infection

Local Repair of Persistent Tracheocutaneous Fistulas

Sobia F. Khaja, MD; Aaron M. Fletcher, MD; Henry T, Hoffman, MD Annals of

Otology. Rhinology & Laryngology !20(9):622-626.2011

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• Retrospective review of 13 pt with TCF

- Duration of cannulation : 6 - 658 days (average 186 days)

- Hx of multiple tracheostomies : 3/13 (23%)

• Time from decannulation to

correction of TCF : 7 day - 6 yr

(average 1 yr)

• LA and vertical elliptical incision

• Separate respiratory mucosa from skin,

with a small triangle of skin removed at inferior edge (sometimes superior edge)

• Undermine underlying peripheral tissue

• Hemostasis : bipolar cautery

• Two or three 4-0 nylon vertical mattress sutures passed deeply just short of entering the airway

• Sutures : loosely tied with air knots to allow air leakage

• D/C after procedure

• ATB : 1 wk

• F/U : 8 days to 5.3 yr (average 1 yr)

• Complication : 1 incomplete closure

Closure of tracheocutaneous fistula in children

Jamie D. Priestley *, Robert G. Berkowitz

Department of Otolaryngology, Royal Children’s Hospital, Vic., Australia

International Journal of Pediatric Otorhinolaryngology (2006) 70, 1357—1359

• Retrospective chart review

• 16 patients

• Mean age at decannulation : 54.2 mo

• Mean age at repair : 66.2 mo (21—187)

• Mean interval from decannulation to repair of : 12 mo (1—56)

• Mean age at tracheostomy : 8.2 mo(1-80)

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• Ellipse of skin : excised with fistulous tract

• Tract : peeled off trachea

• Defect in trachea : closed with interrupted 4/0 Vicryl

• Leak test

• Close overlying wound

• LA (bupivacaine with adrenaline) into wound

• No drain

• Non-occlusive dry dressing

• Observe for 48 hr

• Mean interval from decannulation to repair : 12 months (range 1-56)

• Mean post-op stay : 2.7 days

• 3 complications : UTI, URI

nocturnal desat � CPAP

• All patients : successful closure of their wound

• No complications assoc with tracheal air

leak & subcutaneous emphysema

Primary closure

• Shorter recovery period

• Good wound cosmesis

• Routine post-op stay

> 24 hr : unnecessary

Experiences of tracheocutaneous fistula closure in children:

how we do it

Geyer, M., Kubba, H. & Hartley, B.

Department of Paediatric Otolaryngology,

Great Ormond Street Hospital for Children, London, UK

• Clinical Otolaryngology 33, 359–369. 2008

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Surgical closure of TCF

• 100 children

• Tracheostomy : age 0–13 yr (median 5 mo)

• Sx repair TCF : age 21 mo - 18 yr (median 5

yr)

• Surgical repair : TCF> 6 months or earlier

(skin irritation from secretions or voice problems from air escape)

• Scar : excised by elliptical skin incision

• Tract dissected and divided flush with tracheal wall

• Trachea closed with absorbable sutures (except 2 cases)

• Strap muscles : sutured to cover tracheal closure in 57 cases (57%)

• Drain : 24-48 hr in 14 (14%)

• Perioperative ATB (co-amoxiclav

or erythromycin) : 14 (14%)

• Observe on ward : > 24 hr

Complications

• Some children : partly dependent on TCF

• Fistula closure � resp distress �emergency recannulation

• Preop overnight pulse oximetry sleep with

TCF occluded

� confirm adequate postop

upper airway

• Air leaking from trachea into subcu tissue

• Drain : cannot prevent

• Airtight seal at trachea : suture trachea and close strap muscles over & onto trachea

• Leak test : Saline irrigation of wound and simultaneous positive pressure ventilation

• Prevents secretions from trachea � wound infection

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Primary closure of persistent tracheocutaneous fistula in

pediatric patients

James W. Schroeder Jr et al.

Department of Surgery, Children's Memorial Hospital, Chicago, IL 60614-3394, USA

Journal of Pediatric Surgery (2008) 43, 1786–1790

• Retrospective study of 39 patients

• Mean age at tracheotomy : 1.2 yr

• Interval between tracheotomy and decannulation : 2.4 yr

• Decannulation to TCF closure : 1.2 yr

• TCF closure : age 4.8 yr

• Partial fistulectomy � 3-layered primary closure

• Decannulation to repair : > 3 months

• DL- rigid bronchoscopy at time of repair

• Horizontal, fusiform-shaped incision around fistula

• Subcutaneous scar tissue : dissected to

trachea after elevating superior and inferior subplatysmal flaps

• Dissection followed complete course of fistula into trachea

• Fistula was clamped and removed leaving a 4-mm cuff of fistula connected to trachea

• Cuff : closed horizontally with running, locking, absorbable suture

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• Horizontal closure prevents narrowing of tracheal lumen (first layer of closure)

• Leak test with NSS• Strap muscles : sutured over trachea with

interrupted absorbable suture

• Rubber band drain : placed

• Passive drain � remove day 1

• 23-hr postop observation

• IV antibiotics : before incision

• Oral ATB for 7 days

• F/U : 1 wk and

6 months

• No subcutaneous swelling or emphysema on postop day 1

• D/C after 23-hr observation

• Two major complications

1.subcu emphysema : postop day 7

2.wound dehiscence & infection : postop day

7

• Major complication rate : 5.3%

• Minor complications : 3 minor superficial wound infections (7.9%)

• 3-layered closure : ↓ complication

• Use of distal fistula tract as first horizontal

layer of closure � airtight seal of tracheal lumen without narrowing the lumen itself

• Safe and effective

Tracheocutaneous fistula

following paediatric tracheostomy—A 14-year

experience at Alder Hey Children’s Hospital

R.A. Tasca *, R.W. Clarke

Department of Otorhinolaryngology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

International Journal of Pediatric Otorhinolaryngology 74 (2010) 711–712

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• Retrospective review

• 193 children : 196 tracheostomies

• TCF : repaired following 6-12 months after decannulation

• 23 children (11.9%) : surgical closure of TCF

• Age at tracheostomy : < 1 yr

• Median age at

decannulation : 4 yr (2-9)

• Surgical repair : fistulectomy and 4 layer closure (tracheal wall edges, strap muscles, subcutaneous tissues and skin)

• Drain : some pt

• ICU 24 hr

• Complications :

2 haemorrhages

& 1 wound infection

• 4 minor complications : 1 wound infection, 2 haemorrhages and 1 early air leakage from the wound � no re-op

• No major complications

How to Do It

A Novel Technique for Closing

a Tracheocutaneous Fistula Using a Hinged Skin Flap

MITSUHIRO KAMIYOSHIHARA, et al.

Department of General Thoracic

Surgery, Maebashi Red Cross Hospital, Gunma, Japan

Surg Today (2011) 41:1166–1168

• Case report

• 73 yr man : persistent TCF from poor

wound healing after temporary

tracheostomy for drug-induced anaphylactic shock

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• 5.5-cm longitudinal spindle-shaped skin

incision around periostomal tissues with

oval skin pedicle from lower half of

tracheotomy site

• Lower half of skin around periostomal tissue : separated from underlying subcu tissues

• A hinged skin flap was made

• Retract pretracheal tissues, platysma, and sternohyoid & sternothyroid muscles

• Defect in ant tracheal wall : closed with hinged skin flap

• Suture flap to tracheal defect with 3-0absorbable monofilament and interrupted

• Soft tissue defect : covered by anterior cervical m

• No drain

• Prophylactic ATB 2days

• D/C : day 5

• no complications

• Advantage : ↓suturing � fewer problems with anastomotic insufficiency

• Epithelial layer of hinged flap will be replaced with mucosal layer

• Simple, reliable procedure, low donor-site morbidity

• Need longer F/U and additional cases

Management of Post-

Tracheotomy Scars and Persistent Tracheocutaneous

Fistulas With Dermal Interpositional Fat Graft

David C. Stanton, et al.

J Oral Maxillofac Surg

62:514-517, 2004

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• DL or rigid bronchoscopy

- Exclude supraglottic/subglottic granulation

- Assess size of tracheal defect

• C/I : inadequate pulmonary function

• Surgical correction

within 4-6 wk• Skin surrounding the TCF : widely excised

using horizontal elliptical excision

• Fistula tract : dissected down to anttracheal wall and divided

• Harvest abdominal dermal fat graft

• Infrahyoid strap muscles : mediallyelevated and closed over tracheal defect with 3-0 polyglactin suture (simple or vertical mattress)

• Place dermal fat graft over strap m and sewn to periphery of strap muscles (single

interrupted 4-0 resorbable chromic or polyglactin suture)

• Undermine wound margins

• Postop drain : ↓ emphysema or hematoma

• CXR : occult pneumothorax, pneumomediastinum, subcu emphysema

• Overnight airway observation

• D/C : postop day 1

• Adventage

- More natural appearance

- Prevents adhesion of overlying skin & subcu tissue to underlying m repair

• Disadvantage : abdominal donor site

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Summary

• Local primary closure

• Primary closure

• Primary closure + strap m

• Partial fistulectomy & 3-layered closure

• 4-layered closure

• Hinged skin flap

• Dermal fat graft