Closure of Persistent Tracheocutaneous Fistulas in Pediatric Burn Patients*

Abstract

<jats:title>Abstract</jats:title> <jats:p>Tracheocutaneous fistula (TCF) is a common complication that occurs after decannulation of a long-term tracheostomy. Numerous studies have demonstrated the incidence of TCF formation to positively correlate with an increasing duration of cannulation, specifically in children. Treatment of a persistent TCF in a child has been well described in the literature, with good response to local measures such as curettage and silver nitrate. When this fails, fistulectomy followed by primary closure of the skin or secondary intention yields good results. However, there is a lack of knowledge on TCF formation in pediatric burn-injured patients, where a persistent TCF is a particularly challenging problem to correct given the paucity of supple tissue in the neck and potential for contractures after a large burn injury; effectively making the surgical repairs and management algorithms described in the available literature largely not applicable to this patient population. In this manuscript, we describe a series of pediatric burn patients with persistent TCF, successfully treated with a multilayered closure involving local tissue rearrangement in the form of medial mobilization of the strap muscles of the neck.</jats:p>

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction

“…20 In fact, studies of pediatric burn patients have suggested that poor wound healing and delayed re-epithelialization can increase the risk for persistent TCF after decannulation. 21 Tissue scarring above the stoma from open airway surgery dissection might limit contracture of the stoma site and explain the high rate of persistent TCF. Extending the inferior limit of soft tissue dissection to the undersurface of the tracheostomy stoma is routine.…”

Silver nitrate therapy for persistent tracheocutaneous fistula following prolonged tracheostomy and invasive ventilation: A case report

“…In some situations, reintubation, reinsertion of tracheostomy, or insertion of a tracheal stent has been utilised 6 . Cases of other conservative strategies aimed at obliterating the fistulous tract and promoting wound healing have been reported, including local curettage, electrocautery, or the use of silver nitrate 4 …”

“…We hypothesize that the positive pressure associated with these therapies contributed to splinting of the stomal tract and precluded the apposition required for wound healing. Persistent air leak from the TCF resulted in poor sleep quality and tolerability of NIPPV and is postulated to have resulted in decruitment of basal lung segments, creating an environment conducive to impaired sputum clearance and recurrent LRTI 1–4 …”

“…Persistent tracheocutaneous fistulas (TCF) after prolonged mechanical ventilation via tracheostomy are frequently described in paediatric populations but less commonly in adults 1–4 . Most published management strategies of TCF typically focus on surgical approaches 1,2,4 .…”

“…Persistent tracheocutaneous fistulas (TCF) after prolonged mechanical ventilation via tracheostomy are frequently described in paediatric populations but less commonly in adults. 1 , 2 , 3 , 4 Most published management strategies of TCF typically focus on surgical approaches. 1 , 2 , 4 However, in certain scenarios such as patients with respiratory insufficiency or chronic respiratory failure, surgical management poses an unacceptable perioperative risk.…”