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Journal Voice
28/2/2012
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Case scenario
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Dx : bilat. TVCP tracheostomy ..a...a
..a!a rima a off tracheostomy tube a
a.. 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 -----s
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
VY 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
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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
Childrens Hospital, Vic., Australia
International Journal of Pediatric
Otorhinolaryngology (:aa-) :a, :-
Retrospective chart review
16 patients
Mean age at decannulation : 54.2 mo
Mean age at repair : 66.2 mo (21187)
Mean interval from decannulation to repair
of : 12 mo (156)
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 , ---. 2008
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Surgical closure of TCF
100 children
Tracheostomy : age 013 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 -a---, USA
Journal of Pediatric Surgery (:aas) , :s-:-a
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
tracheostomyA 14-year
experience at Alder Hey
Childrens Hospital
R.A. Tasca *, R.W. Clarke
Department of Otorhinolaryngology, Alder Hey
Childrens NHS Foundation Trust, Liverpool, UK
International Journal of Pediatric
Otorhinolaryngology : (:aa) :::
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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 (:a) :---s
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 3-0
absorbable 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
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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 ant
tracheal wall and divided
Harvest abdominal dermal fat graft
Infrahyoid strap muscles : medially
elevated 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