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17/10/55
1
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