Closure Of Tracheocutaneous Fistula Research Articles

Closing the Gap: Exploring the Role of Cap Grafts in Tracheocutaneous Fistula Closure

Closing the Gap: Exploring the Role of Cap Grafts in Tracheocutaneous Fistula Closure

103 Outcomes and Complications of Simple Layered Closure of Persistent Tracheocutaneous Fistula After Tracheostomy in Childhood

Abstract Aim Up to half of all children with a tracheostomy develop persistent trachea-cutaneous fistula (TCF) after decannulation. Surgical closure of it is technically easy but post-operative complications can be immediate and life-threatening. We reviewed our experience in TCF closures to identify potential risk factors for complications. Method Retrospective case records review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following the development of a persistent TCF after decannulation of a tracheostomy. Results 67 children were identified. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%): life-threatening air leak occurred in the immediate post-operative period in 2 children (3%) and respiratory distress in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. Conclusions Further analysis of the potential associations between patient factors, surgical factors, and complications is necessitated in guiding future practice.

FTP8.14 Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood

Abstract Up to half of all children with a tracheostomy develop persistent trachea-cutaneous fistula (TCF) after decannulation. Surgical closure of it is technically easy but post-operative complications can be immediate and life-threatening. We reviewed our experience in TCF closures to identify potential risk factors for complications. Methods Retrospective case records review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following the development of a persistent TCF after decannulation of a tracheostomy. Results 67 children were identified. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%): life-threatening air leak occurred in the immediate post-operative period in 2 children (3%) and respiratory distress in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. Conclusion Further analysis of the potential associations between patient factors, surgical factors, and complications is necessitated in guiding future practice.

Tracheocutaneous Fistula After Tracheostomy: Spotlight on a Closure Technique With a High Success Rate.

Tracheostomy is a commonly performed procedure in patients requiring prolonged mechanical ventilation. While it effectively provides a secure airway, tracheostomy can lead to complications, such as tracheal stenosis, tracheomalacia granulation tissue, pneumonia, aspiration tracheovascular fistula, tracheoesophageal fistula, and tracheocutaneous fistula. In this systematic review, we aim to identify the most suitable closure method and compare recurrence outcomes between methods for persistent tracheocutaneous fistula (TCF) in all age groups. We conducted a bibliographic search between January 1st, 2011 and March 10th, 2021 in the PubMed, B-on, Scopus, and Web of Science databases, and also performed a manual search to identify relevant articles. Our inclusion criteria were case series or comparative studies of surgery for persistent TCF and the success rate of TCF closure in patients both below and above 18 years of age. After applying the inclusion criteria to the research results, we included nine studies in our analysis. We found that closure by secondary intention is the most effective method for TCF closure, followed by primary and secondary intention combined. The success rate with most of the techniques was high, regardless of the size of the fistula or associated comorbidities, and its simplicity makes it an appealing treatment option in the care of patients with TCF. In conclusion, this systematic review highlights the importance of selecting an appropriate closure method for persistent TCF and provides valuable insights into the success rate of various techniques.

Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood.

Up to half of all children who have a tracheostomy will develop a persistent tracheo-cutaneous fistula (TCF) after decannulation. Surgical closure of the TCF is technically easy but post-operative complications can be immediate and life-threatening. These include air leak from the tracheal repair leading to massive surgical emphysema or pneumothorax. We reviewed our experience of TCF closure to try to identify potential risk factors for complications. Retrospective case record review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following development of a persistent TCF after decannulation of a tracheostomy. We identified 67 children. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%). Life-threatening air leak occurred in the immediate post-operative period in 2 children (3%). Respiratory distress occurred in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. Complications for TCF closure are unfortunately common and it is unclear from the available evidence how best to prevent them. Further research is required.

Closure of large tracheocutaneous fistula: how we did it

Closure of large tracheocutaneous fistula: how we did it

Primary versus secondary closure of tracheocutaneous fistula in pediatric patients

ObjectiveUp to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. MethodsPatients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. ResultsA total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. ConclusionClosure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.

Tracheostomy decannulation to noninvasive positive pressure ventilation in congenital central hypoventilation syndrome.

Noninvasive positive pressure ventilation (NPPV) may permit tracheostomy decannulation (TD) in patients with congenital central hypoventilation syndrome (CCHS) requiring nocturnal positive pressure ventilation via tracheostomy (PPV-T). There is limited evidence on optimal strategies for transitioning patients from PPV-T to NPPV. This study aimed to describe the clinical course and outcome of children with CCHS who underwent TD and transitioned from PPV-T to NPPV. Retrospective review was conducted on patients with CCHS using nocturnal PPV-T who underwent TD to NPPV. The results of clinical evaluations, airway endoscopy, polysomnography, and clinical course leading to TD were analyzed. We identified 3 patients with CCHS aged 8-17 years who required PPV-T only during sleep. Patients underwent systematic multidisciplinary evaluations with a pediatric psychologist, pulmonologist, sleep physician, and otolaryngologist utilizing a TD algorithm. These included evaluation in the sleep clinic, NPPV mask fitting and desensitization, endoscopic airway evaluation, daytime tracheostomy capping, acclimatization to low-pressure NPPV, polysomnography with capped tracheostomy and NPPV titration, and if successful, TD. All patients underwent successful TD following optimal titration of NPPV during polysomnography. The duration to TD from decision to pursue NPPV was between 2.4 and10.6 months, and the duration of hospitalization for TD was between 4 and 5 days. There were no NPPV-related complications; however, all patients required surgical closure of tracheocutaneous fistula. NPPV may be an effective and feasible option for patients with CCHS requiring PPV-T during sleep and permits TD. In patients with CCHS, a systematic multidisciplinary algorithm may optimize successful transition to NPPV and TD.

Analysis of complications and outcomes of tracheotomy with different etiology in children

Objective: To discuss the complications and postoperative outcomes of tracheotomy with different etiology in children. Methods: One hundred and eighty-six patients underwent tracheotomy were retrospectively analyzed from January 2016 to December 2018,including 117 males and 69 females. The children aged from 4 days to 14 years (median age 31.5months). One case was operated under local anesthesia in emergency room, 2 cases were operated under local anesthesia in pediatric intensive care unit, the rest 183 cases were operated under general anesthesia in operation room. The 186 children were divided into four groups according to their direct causes of tracheotomy. Group A(90 cases): Neuromuscular disease and severe infection,Group B(26 cases): Head and neck tumor,Group C(57 cases): Congenital malformation and upper airway obstruction,Group D(13 cases): Accidental injury. The basic information, surgical complications and postoperative outcomes were recorded and analyzed. All patients were followed up by clinic or by telephone. Spss 19.0 software was used for statistical analysis. Results: One hundred and eighty-six patients were followed up for one to four years. 33 children lost the follow-up and 46 died. Among the 186 patients, 23 cases had emergency tracheotomy (12.4%). The rate of emergency tracheotomy in group C(16 cases, 28.1%) was higher than that in the other three groups(χ2=28.08,P<0.05). The average age of patients and hospital stay in group C were significantly lower than those in the other three groups (F=33.76,P<0.05; F=14.95,P<0.05). Incision bleeding occurred in 11 cases, Subcutaneous emphysema occurred in 6 cases and accidental decannulation occurred in 10 cases (4 cases within 2 weeks and 6 after 2 weeks). Six patients underwent tracheocutaneous fistula closure operation after decannulation and the stoma healed spontaneously in other extubated children. Two patients underwent secondary tracheotomy due to accidental decannulation, and three patients underwent secondary tracheotomy for dyspnea after decannulation. In 107 cases of survival children, decannulation was successful in 65 patients and failed in 42 patients. The average duration of wearing tracheal tube was 8.8 months. The decannulation rates in the four groups were 55.6%, 45%, 69% and 77.8%, with no significant difference. Conclusions: The complications after tracheotomy in children are rare, and no severe complications occurred in long-term tracheotomy patients. The duration of wearing tracheal tube is related to the treatment of their primary disease.

Tracheocutaneous fistula closure by two hinged turnover flap and a fasciocutaneous pivot flap

Tracheocutaneous fistula is a known complication in patient who are tracheostomised for long duration. A 18-year-old girl presented in our department who was tracheostomised 2 years back, to secure airway, following a road traffic accident and tracheal injury. She underwent multiple surgeries to maintain upper airway, which were successful, but developed a tracheocutaneous fistula due to prolonged tracheostomy. Surgical closure of the fistula was done using a two hinged turnover flap and a fasciocutaneous pivot flap. The patient was discharged on 6 day of the surgery with no complication and no recurrence. Our technique explains one of the many procedures used to close a tracheocutaneous fistula, mentioned in literature. It is minimally invasive and is associated with minimal chance of tracheal stenosis and recurrence.

Closure of irradiated tracheocutaneous fistula with pectoralis major muscle flap and split skin graft

Tracheocutaneous fistula in an irradiated neck is often difficult to manage. Simple closure often leads to dehiscence and recurrence. We present a patient with supraglottic carcinoma, postradiotherapy, who presented with a persistent trachea-cutaneous fistula. We excised the fistula along with surrounding indurated tissue and covered the defect adequately with skin graft for tracheal lining and pectoralis muscle flap as a muscle cover. Fistula was closed and wound healed well. There was no recurrence of fistula as evidenced with indirect laryngoscopy. Pectoralis major flap is a well-vascularized flap that can be used to cover defects in anterior lower neck. Simple skin graft with a cover of muscle flap was enough to give adequate tracheal lining.

Diagnostic considerations prior to pediatric tracheocutaneous fistula closure

IntroductionAn airway assessment often occurs prior to tracheocutaneous fistula (TCF) closure in children. Bronchoscopy (MLB) with or without fistula-occluded polysomnography (PSG) helps determine candidacy and localize potential obstruction. To date, little has been published on MLB or PSG findings in children before surgically closing a TCF. MethodsA case series with chart review of children between 2017 and 2020 who underwent repair of a TCF after tracheostomy decannulation. ResultsThirty-six children were included for review. Mean age was 5.9 years (95% CI: 4.5–7.3), 58.3% were male, and 50% had chronic lung disease. Surgery occurred 13.3 months (95% CI: 11.9–14.8) after decannulation, with 80.6% by primary closure and 19.4% by secondary intention. There was one unsuccessful closure and two patients (5.6%) presented with a postoperative complication. An MLB was performed in 97.2% of children, where 22.9% identified supraglottic pathology, 11.4% had grade 2 subglottic stenosis, and 11.4% had difficult exposure of the larynx. Further, one child had a non-obstructing subglottic cyst, one had a supraglottoplasty for redundant arytenoid mucosa, and two children had suprastomal granulomas requiring removal. A PSG was obtained in 36.1%, with a mean Apnea-Hypopnea Index of 2.4 events/hour (95% CI: 0.9–3.9), nadir Oxygen saturation of 90.5% (95% CI: 87.9–93.0), and peak end-tidal CO2 of 46.1 mmHg (95% CI: 43.7–48.5). ConclusionThe selection of candidates for pediatric TCF closure requires careful evaluation of the airway. Surgeons should be familiar with the potential findings on MLB and PSG prior to closure.

Primary tracheocutaneous fistula closure with immediate transition to nocturnal noninvasive positive pressure ventilation in two children with Congenital Central Hypoventilation Syndrome

Transitioning children with Congenital Central Hypoventilation Syndrome (CCHS) from nocturnal invasive ventilation via tracheostomy to noninvasive positive pressure ventilation (NIPPV) is challenging due to the leak caused by the tracheocutaneous fistula (TCF), resulting in insufficient ventilation. Decannulation and primary closure of the TCF with immediate transition to nocturnal NIPPV was performed in two children with CCHS at a tertiary care children's hospital. Neither child developed significant adverse effects such as pneumomediastinum or pneumothorax. This technique is a novel approach that may improve decannulation outcomes and aid transition to NIPPV in this patient population.

Pediatric tracheocutaneous fistula closure following tracheostomy decannulation

ObjectiveTo determine the frequency and risk factors that lead to the development of persistent TCF (tracheocutaneous fistula) formation in children following tracheostomy decannulation at our institution. MethodsA retrospective chart review of all pediatric patients at Children's Hospital Colorado who underwent tracheostomy decannulation and were being followed between January 1, 2007 and December 31, 2013. TCF was defined as a persistent fistula six months following decannulation. We determined patient demographics, age at tracheotomy, primary indication for tracheotomy, tracheostomy-tube size, medical comorbidities, age at decannulation, date of TCF closure, and method of TCF closure. ResultsOne hundred twenty-nine patients ranging from 51 days to 19 years of age underwent tracheostomy decannulation. 63 (49%) patients underwent surgical closure of TCF. Compared to those with spontaneous closure by multivariable analysis, those with surgical closure were younger at tracheostomy placement (p = 0.0002), had a tracheostomy for a longer duration (p = 0.0025), and were diagnosed with tracheobronchomalacia (p = 0.0051). The likelihood of spontaneous closure decreased over time. Tracheostomy tube internal diameter correlated with age (R = 0.64, p < 0.0001). ConclusionsApproximately 50% of pediatric tracheostomy stoma sites will close spontaneously. Development of a persistent TCF was associated with younger age at placement, longer duration of tracheostomy, and the presence of tracheobronchomalacia. These observations may help clinicians anticipate outcomes following tracheostomy decannulation in children.

Pediatric tracheostomy first tube change: When is it safe?

ObjectivesThe first tracheostomy tube change is typically performed on days 5–7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3–5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective. MethodsWe carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula. Results93 patients were identified, of which 83 were included. The age range was 0–16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure. ConclusionsThis study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.

Suture-ligature technique for the closure of tracheocutaneous fistula in adults.

Suture-ligature technique for the closure of tracheocutaneous fistula in adults.

Superiorly-based turnover skin flap: Pediatric tracheocutaneous fistula closure

ObjectiveTo present a novel superiorly-based turnover skin flap for the primary repair of pediatric tracheocutaneous fistula closure, and to determine the efficacy and safety of this tracheocutaneous fistula turnover flap primary closure technique. Subject and methodsThis retrospective review analyzed one surgeon's (DJK) pediatric tracheostomy decannulation methods and results, specifically relating to the development of tracheocutaneous fistulas, over a fourteen-year period, from October 2002 through June 2016. The review furthermore examined a turnover flap technique for the primary closure of tracheocutaneous fistulas described herein. ResultsOver the period of study, 57 patients were decannulated, of whom 31 (54%) developed a tracheocutaneous fistula. Mean duration of tracheostomy in patients who developed a tracheocutaneous fistula following decannulation was forty-two months compared to thirteen months in patients who did not. Duration of decannulation was an independently significant variable (P < .001) in tracheocutaneous fistula development while gender, age at tracheostomy and age at decannulation were not (P > .05). Of the 31 patients who developed a tracheocutaneous fistula, 30 (97%) elected to pursue tracheocutaneous fistula closure using the turnover flap technique described in this study. Mean time from decannulation to tracheocutaneous fistula repair was 132 days. All tracheocutaneous fistulas were successfully closed. There were no perioperative or postoperative complications and no patient required subsequent hospitalization or surgical revision. ConclusionsThe turnover technique presented is simple, straightforward, reliable, safe, and effective with excellent cosmetic results.

Tracheocutaneous Fistula Closure with Turnover Flap and Polydioxanone Plate.

An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.

Stomal maturation does not increase the rate of tracheocutaneous fistulas.

To determine the rate of persistent tracheocutaneous fistula (TCF) in pediatric patients managed with stomal maturation at the time of the tracheostomy. Retrospective chart analysis of all cases of tracheostomy performed at a tertiary pediatric care center between 2001 and 2011. The use of stomal maturation, number of decannulations, number of persistent TCFs, timing of TCF repair, and the overall mortality were assessed. A total of 264 patients received tracheostomy between 2001 and 2011. Of the total, 173 (66%) underwent stomal maturation. Of those 173 patients, 89 patients (51% of maturation group) underwent planned decannulation. Forty seven (53%) of the 89 decannulated were found to have a persistent TCF in the stomal maturation group. These were diagnosed an average of 1.3 years (range, 4-43 months) after decannulation. Of the 91 patients (34% of the total) who did not undergo stomal maturation, 44 (48% of nonmaturation group) underwent planned decannulation. Twenty of the 44 patients decannulated (45%) were diagnosed with a residual TCF 8 to 28 months later. Both groups achieved similar rates of decannulation (51% maturation vs. 48% non-maturation [P = .80]) and TCF (27% maturation vs. 22% non-maturation [P = .44]). Overall, mortality rates were (32/173) 18% (matured) versus (26/91) 29% (nonmatured). No mortalities were tracheostomy related. The mean (standard deviation) time from operation to TCF closure among those with TCF was 4.0 (1.9) years. Comparable rates of persistent TCF with stomal maturation (27%) and without maturation (22%) were found in this single institution's 10-year experience. 4. Laryngoscope, 126:2395-2398, 2016.

Tracheocutaneous fistula closure in children

ObjectiveSystematic review of surgical techniques for tracheocutaneous fistula closure in children and successful closure or development of adverse events. Data sourcesPubMed, EMBASE, Web of Science, and Cochrane Library. Review methodsA medical librarian was utilized to perform a systematic review. ResultsFourteen studies were identified. Eight studies reported outcomes for primary closure alone; one discussed results for secondary closure alone; and five included a combination of children who underwent either primary and secondary closure alone. No difference between surgical techniques was identified for effectiveness of closure (RR = 1.03, 95% CI: 0.97 to 1.10) and major (RR = 1.68, 95% CI: 0.56 to 5.05) or minor complications (RR = 1.28, 95% CI: 0.50 to 3.27). No mortalities were identified. ConclusionsBoth primary and secondary closure techniques for persistent tracheocutaneous fistulas in children are effective and associated with acceptable rates of complications. Given the available evidence, neither approach appears to be superior. Considerations for decision making in surgical approach may include family and social considerations, facility resource utilization, and cost differential. Further investigation may be directed at improving patient selection.