A Novel Approach to Tracheocutaneous Fistula Closure

Abstract

Objective: 1) Describe a novel, 3-stage approach to closure of a large tracheocutaneous fistula (TCF) and augmentation of an adjacent area of tracheal stenosis. 2) Present pre-, intra-, and postoperative photographs to illustrate surgical technique. 3) Discuss postoperative patient care considerations. 4) Review other techniques described for similar defects. Method: Case report of patient receiving treatment from May 2010 to present. The patient presented with a 1.4 by 1.6 cm TCF and adjacent tracheal stenosis. This was repaired in a 3-stage approach culminating in radial forearm free flap (RFFF) with banked conchal cartilage and buccal mucosal graft for tracheal closure. Results: This case resulted in successful closure of a 1.4 by 1.6 cm TCF in a previously radiated patient using a novel, 3-stage approach. The initial stage involved implanting a conchal cartilage graft in the left radial forearm. During the second stage a buccal mucosal graft was implanted to cover the conchal cartilage graft after removing the hair-baring skin. The third stage involved transfer of the RFFF with cartilage and mucosal graft for closure of the TCF, augmenting the support with an absorbable miniplate. The patient had no issues with breathing, speaking, or wound healing immediately or at four months postoperative. Conclusion: Large TCFs in irradiated patients present a unique surgical challenge. This case illustrates successful closure of an extensive TCF involving anterior trachea and partial bilateral sidewalls. The unique graft allowed for structural support with hairless mucosal lining on a fasciocutaneous flap.