Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases

Abstract

Summary Background A tracheocutaneous fistula is a known complication following tracheostomy decannulation. Although surgical techniques for its repair are well described, there is no consensus about perioperative management and this procedure may generate significant airway and respiratory complications intraoperatively, and in the early postoperative period. We aimed to describe variations in perioperative management in tracheocutaneous fistula closure, estimate the incidence of early airway and respiratory complications, and identify any predisposing factors. Methods The otorhinolaryngology surgical database identified 118 tracheocutaneous fistula closures from August 1994 to September 2015. Ninety‐seven case notes were located generating 96 procedures for retrospective review. The data collected included demographics, comorbidities, anesthetic, and surgical technique, and complications up to 24 hours postoperatively. Results The median age at surgery was 5 years 10 months (range 1 year 8 months to 19 years 6 months). Preoperatively, 72% of patients had a “mini” sleep study (where the tracheocutaneous fistula is covered and saturations measured overnight). Ninety percent had an inhalational induction and 96% a tracheal intubation. Intraoperatively, laryngospasm occurred in 2% and there was difficulty ventilating in another 2%. A “leak test” to check fistula repair airtightness was recorded in 35%. Postoperatively 24% had one or more episodes of oxygen desaturation. Major complications occurred in five patients (incidence 5%, 95% CI 0.8‐9.7); four patients had pneumothoraxes with two needing postoperative mechanical ventilation and one patient developed life‐threatening subcutaneous emphysema. Conclusion Perioperative care for children undergoing tracheocutaneous fistula closure was not standardized. Advocated tests such as preoperative “mini” sleep studies and “leak test” intraoperatively were not consistently performed. Intraoperative anesthetic complications were uncommon; however, major postoperative respiratory complications were 5%.

Pediatric tracheostomy decannulation: what's the evidence?

“…The primary postoperative concern is air escape causing subcutaneous emphysema, pneumothorax, and/or pneumomediastinum. Major airway/respiratory complications in the primary closure technique have recently been reported in a range from 3–7%, with overall complication rate between 20% and 24% [35 ▪ ,36–39]. Notably, severe respiratory complications are also reported in the secondary intention technique, though at a lower frequency of 2% [35 ▪ ].…”

Extensive Surgical Emphysema in a Child after Primary Closure of Tracheocutaneous Fistula

“…Surgical treatment of tracheocutaneous fistula (TCF) is the excision of fistula followed by either primary closure or secondary healing. e primary closure provides immediate resolution of the fistula but is associated with complications among which surgical emphysema with massive extension is rare [1], but it may lead to airway obstruction, which can be life-threatening.…”

The Predictors of Persistent Posttracheostomy Tracheocutaneous Fistula and Successful Surgical Closure

“…The surgeon needs to decide whether watchful waiting or surgical closure is the appropriate approach. Previous studies of PTCF usually compared different surgical procedures for fistula closure 3‐10 or focused on fistula formation and treatment in pediatric patients 11‐15 . A common strategy involved the introduction of a local flap to reduce the risk of closure failure, which may occur as a consequence of prolonged epithelialization of the fistula tract and peristomal soft tissue tension.…”

“…Previous studies of PTCF usually compared different surgical procedures for fistula closure [3][4][5][6][7][8][9][10] or focused on fistula formation and treatment in pediatric patients. [11][12][13][14][15] A common strategy involved the introduction of a local flap to reduce the risk of closure failure, which may occur as a consequence of prolonged epithelialization of the fistula tract and peristomal soft tissue tension. Only a few reports discussed the possible predictors of PTCF.…”