Surgical Management of Tracheocutaneous Fistula

Abstract

Tracheocutaneous fistula (TCF) is a complication of tracheotomy that adds a difficult and bothersome aspect to the patient's care and may exacerbate respiratory disease. Closure of the fistula is recommended, but complications associated with fistula closure include pneumothorax and respiratory compromise. Several surgical approaches have been advocated in the literature. We reviewed the operative techniques and outcomes of TCF closures performed at Cooper Hospital/University Medical Center between February 1990 and April 1995. Direct, or flap, closure of large tracheocutaneous fistulas was associated with significant complications and morbidity. Therefore, the closure technique was modified so that we now recommend, in patients with large tracheocutaneous fistulas (a defect of the anterior tracheal wall of ≥4 mm diameter), excision of the fistula, replacement of the tracheotomy tube and healing by second intention after a short recannulation period. No complications have occurred since this closure technique was adopted.

Closure of persistent tracheocutaneous fistula following “starplasty” tracheostomy in children

“…A variety of TCF closure techniques have been advocated and can be classified as primary closure in layers [13], primary closure with fistulectomy [2,7,14,16] and fistulectomy with closure by secondary intent [8,10,12,15]. Some authors argue that primary closure is associated with an unacceptable complication rate, opting instead for closure by secondary intention [3,8,10,12].…”

“…Some authors argue that primary closure is associated with an unacceptable complication rate, opting instead for closure by secondary intention [3,8,10,12]. Other authors cite low complication rates, improved cosmetic results and the ability to observe the patient in the hospital following immediate closure [2,7,13,14,16].…”

“…While there are several accepted techniques for TCF closure, there is nevertheless controversy about the safest method due to the low but well recognized incidence of associated morbidity from pneumothorax, pneumomediastinum, tracheal stenosis and infection [7][8][9][10][11][12]. Given the unique design of the ''starplasty'' procedure, closure of the resulting TCF requires a specific technique of closure.…”

Simple Technique for Tracheocutaneous Fistula Closure in the Pediatric Population

“…In addition, some authors have advocated a short recannulation period, which may have an unfavorable emotional impact on the family. 5,9,10 While cauterization with silver nitrate in the office setting is also a possibility, it does not allow bronchoscopic visualization of the airway. In addition, this technique is uncontrolled, in that it has the potential to cauterize healthy tracheal mucosa -something that our procedure under direct bronchoscopic visualization controls.…”

Defect classification and reconstruction algorithm for patients with tracheostomy using the tunneled supraclavicular artery island flap

“…As the term "tracheotomy" refers to the surgical procedure and tracheostomy describes the semi-permanent or permanent opening of the trachea, we will further refer to patients with tracheostomy only. For closure or, in patients with permanent tracheostomy, diameter reduction, simple procedures like local advancement flaps are inadequate because of the poor quality of the surrounding tissue and the multilayer structure of the defect [5]. In case of tracheal instability, the missing anterior wall of the trachea should be reconstructed with rigid tissue [2].…”