Tracheocutaneous Fistula Research Articles

Incidence of complications of emergency tracheostomy in a rural medical college setting: a prospective study

<p><strong>Background: </strong>Tracheostomy done as an emergency procedure for the purpose of saving lives, is mostly associated with aerodigestive tract malignancies, though a few may be associated with foreign body aspiration. The incidences of complications intraoperatively as well as postoperatively are high in emergency tracheostomies. Few studies exist documenting the incidence of these complications .Thus this study was undertaken in a rural Medical College setting to find the incidence of complications associated with emergency tracheostomy.</p><p><strong>Methods: </strong>After Institutional ethical committee clearance, a prospective study was conducted over a period of 2 years which included 120 patients of all ages and both genders, who presented to the emergency room with stridor. All tracheostomies were performed, using standard techniques, in the emergency operation theatre under monitored anaesthesia care or general anaesthesia. Complications were noted during the procedure as well as in the postoperative period at regular intervals upto one year and were categorized as immediate, intermediate and late.</p><p><strong>Results: </strong>Though there was no case of mortality, the incidence of complications was 53.3%. The commonest immediate complication was haemorrhage (12.5%) followed by cardiopulmonary arrest (5%) and apnoea (3.3%). The commonest intermediate complications were infection (18.3%), crusting (12.5%), displacement of tube (8.3%) and bleeding (8.3%).Late complications noted were stomal stenosis (8.3%), keloid formation (5%) and tracheocutaneous fistula (3.3%).</p><p class="abstract"><strong>Conclusions: </strong>Some of these complications can be avoided by early intervention as a semi emergency procedure when you first think about it. This can avoid the hazzle of hurried tracheostomy in a struggling patient thus bringing down the incidence of complications.</p>

Primary reconstructive method for tracheal defect from invasion by differentiated thyroid carcinoma

Differentiated thyroid carcinoma is not highly malignant, and thus surgical resection is the most common treatment even if the carcinoma has invaded the trachea. Although some cases exist in which the carcinoma invades the trachea, using the tracheal window resection method allows complete resection of the carcinoma. Yet these patients must often control a large tracheocutaneous wound until reconstructive surgery is performed because such surgery occurs secondarily. Our hospital admitted three patients for which tracheally invasive, differentiated thyroid carcinoma was surgically resected. Tracheal defects of 1/2 to 2/3 of the tracheal circumference were reconstructed primarily using the free forearm flap and costal cartilage during carcinoma resection. Following surgery, only a small tracheocutaneous fistula remained open, which was closed at about three months post-operation. The reconstructed tracheal space and transferred costal cartilage thickness were monitored by CT scan imaging at about 12 months post-operation. Details of the reconstructive method and postoperative changes in the reconstructed trachea and thickness of the costal cartilage are described in this report.

Indications, risk of lower airway infection, and complications to pediatric tracheotomy: report from a tertiary referral center

Background: Although pediatric tracheotomy is potentially life-saving, the procedure is associated with high risk of complications, and indications have changed the last decade. We report indications, complications, and lower airway infections (LAIs) to pediatric tracheotomy performed at a tertiary referral center.Methods: We identified all children (<18 years) who underwent tracheotomy at our institution during 2008–2015. A review of hospital records was performed to extract data on indication of the procedure, complications, and information on pre- and postoperative LAI.Results: At a median age of 8 years (range: 4 months to 17 years), a total of 69 tracheotomies were performed. Neuromuscular disease (n = 21) was the most common cause for tracheotomy. The postoperative complication rate was 22%; early complications (<30 days) occurred in four patients, and nine patients encountered late complications such as wound granulation and tracheocutaneous fistula. Children without LAI prior to tracheotomy were at increased risk of LAI from the initial 30-days following surgery (OR: 2.91, 95% CI: 1.17–7.21; p = .02). Fifty-three percent (10/19) of all LAIs following tracheotomy were caused by Staphylococcus aureus (p < .01).Conclusions: Pediatric tracheotomy was associated with considerable rates of minor early and late complications and high risk of short-term LAI. The main cause leading to tracheotomy was neuromuscular disease.

Starplasty tracheostomy: case series and literature review.

The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Bedside open tracheostomy at intensive care unit-our experiences of 1000 cases at a tertiary care teaching hospital of eastern India

IntroductionTracheostomy is usually done on critically ill patients those requiring prolonged mechanical ventilation at the intensive care unit (ICU). Bedside tracheostomy is often helpful for avoiding transferring the unstable patients to operation theater and also minimizing the cost. AimAssessing the safety, cost and procedure time, complications of bedside open tracheostomy at intensive care unit considering comparison to open tracheostomy at operation theater and bedside percutaneous dilatational tracheostomy (PDT) with its complications, cost and its simplicity. Materials and methodsThis descriptive retrospective study was carried out at a tertiary care teaching hospital during December 2006 to January 2016. It included 1000 patients, undergone open bedside tracheostomy along with 152 undergone open tracheostomy at operating room(OR) and 112 bedside PDT. All these patients were undergone bedside tracheostomy, followed up for next 3months. Complications occurring during and after tracheostomy were documented. Results and discussionThis study group comprised patients with age group of 8years to 82years. The complications among open bed side tracheostomy within 30days were 10 minor bleeding, 1 major bleeding, 2 cardiac arrest, 1 pneumothorax, 6 stomal sepsis, 5 cervical emphysema. Late complications like 2 laryngotracheal stenosis (LTS) were seen where as other complication like tracheocutaneous fistula and tracheoinominate fistula were not observed. The complications rate is less in bedside open tracheostomy than open tracheostomy at OR and bedside PDT in our study. ConclusionBedside elective open tracheostomy is safe, effective, cost effective and allowing timely tracheostomy with low morbidity.

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.

Systematic review of surgery for persistent pediatric tracheocutaneous fistula.

To compare the treatment outcomes and adverse event rates for primary closure compared to simple excision with healing by secondary intention for persistent tracheocutaneous fistula (TCF) in children. Systematic review. Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. MEDLINE, Embase, Cochrane Library, and manual search were used to identify articles. Inclusion criteria were case series or comparative studies of surgery for persistent TCF in children under age 18 years. Exclusion criteria were age 18 years or older, duplicate patient series, case series with less than two patients, or case reports. Data were pooled using random effects meta-analysis to assess outcomes, adverse events, and comparative effectiveness. We identified 14 articles with 413 patients treated with excision with primary closure and 233 patients treated with excision with closure by secondary intention. Pooled success rates were 95.7% with primary closure (95% confidence interval [CI]: 93.1% to 97.4%) and 92.7% with secondary intention (95% CI: 88.4% to 95.4%). Subcutaneous emphysema or urgent airway problems were uncommon, occurring in 3.8% and 3.6% of patients, respectively. Five studies had data suitable for comparative meta-analysis, which showed no differences by closure technique for treatment success (P = .480), overall complications (P = .551), need for revision surgery (P = .624), or the incidence of subcutaneous emphysema or pneumothorax (P = .512), urgent airway problems (P = .126), wound infection (P = 1.00), or wound dehiscence or fistula (P = .818). There are no differences in the rates of success or complications with surgical closure of TCF in children, whether performed by primary closure or by secondary intention. Both techniques have high success rates with a low incidence of serious complications. Laryngoscope, 127:241-246, 2017.

Tracheostomy in childhood: review of the literature on complications and mortality over the last three decades

IntroductionTracheostomy is a procedure with unique characteristics when used on pediatric patients due to the greater technical difficulty and higher morbidity and mortality rates relative to the procedure in adults. In recent decades, there have been significant changes in the medical care available to children, particularly for those who need intensive care. Surgical conditions have also improved, and there has been an advent of new equipment and medications. These advances have brought changes to both tracheostomy indications and tracheostomy complications. ObjectiveTo perform a review of the articles published over the last three decades on the complications and mortality associated with tracheostomies in children. MethodsArticles were selected from the Cochrane, Latin American and Caribbean Health Sciences Literature, SciELO, National Library of Medicine (Medline Plus), and PubMed online databases. The articles selected had been published between January 1985 and December 2014, and the data was compared using the Chi-square test. ResultsA total of 3797 articles were chosen, 47 of which were used as the basis for this review. When the three decades were evaluated as a whole, an increase in tracheostomies in male children under one year of age was found. The most common complications during the period analyzed in descending order of frequency were granuloma, infection, and obstruction of the cannula, accidental decannulation, and post-decannulation tracheocutaneous fistula. In the second and third decades of the review, granulomas represented the most common complication; in the first decade of the review, pneumothoraces were the most common. Mortality associated with tracheostomy ranged from 0% to 5.9%, while overall mortality ranged from 2.2% to 59%. In addition, the review included four studies on premature and/or very underweight infants who had undergone tracheostomies; the studies reported evidence of higher mortality in this age group to be largely associated with underlying diseases. ConclusionImproved surgical techniques and intensive care, the creation of new medications, and vaccines have all redefined the main complications and the mortality rates of tracheostomy in children. It is a safe procedure that increases chances of survival in those who require the prolonged use of mechanical ventilation.

Trichloroacetic Acid Chemocauterization: A Simple Method to Close Small Tracheocutaneous Fistula.

To evaluate the effectiveness of chemocauterization using trichloroacetic acid with or without suturing for the small tracheocutaneous fistula closure The Seoul National University Hospital database was analyzed retrospectively for 55 patients with a small tracheocutaneous fistula measuring less than 5 × 5 mm(2). Of these, 39 patients were treated by chemocauterization only, and 16 patients were treated by chemocauterization with suturing. Demographic, perioperative data, and treatment outcomes were evaluated for all patients. The success rate of single trial was 56.4% (31/55), and the final success rate after repeated procedures if indicated was 80.0% (44/55). There were no statistically significant differences in age, sex, cannulation period, fistula size, presence or absence of maturation suture during tracheostomy, number of procedures, and success rates. Interval between decannulation and procedure was significantly different among 2 groups. Trichloroacetic acid chemocauterization could be a simple, noninvasive, and safe method to close small tracheocutaneous fistula.

The Global Tracheostomy Collaborative: one institution's experience with a new quality improvement initiative

ObjectiveGiven the low frequency of adverse events after tracheostomy, individual institutions struggle to collect outcome data to generate effective quality improvement protocols. The Global Tracheostomy Collaborative (GTC) is a multi-institutional, multi-disciplinary organization that utilizes a prospective database to collect data on patients undergoing tracheostomy. We describe our institution's preliminary experience with this collaborative. It was hypothesized that entry into the database would be non-burdensome and could be easily and accurately initiated by skilled specialists at the time of tracheostomy placement and completed at time of patient discharge. MethodsDemographic, diagnostic, and outcome data on children undergoing tracheostomy at our institution from January 2013 to June 2015 were entered into the GTC database, a database collected and managed by REDCap (Research Electronic Data Capture). All data entry was performed by pediatric otolaryngology fellows and all post-operative updates were completed by a skilled tracheostomy nurse. Tracked outcomes included accidental decannulation, failed decannulation, tracheostomy tube obstruction, bleeding/tracheoinnominate fistula, and tracheocutaneous fistula. ResultsData from 79 patients undergoing tracheostomy at our institution were recorded. Database entry was straightforward and entry of patient demographic information, medical comorbidities, surgical indications, and date of tracheostomy placement was completed in less than 5min per patient. The most common indication for surgery was facilitation of ventilation in 65 patients (82.3%). Average time from admission to tracheostomy was 62.6 days (range 0–246). Stomal breakdown was seen in 1 patient. A total of 72 patients were tracked to hospital discharge with 53 patients surviving (88.3%). No mortalities were tracheostomy-related. ConclusionThe Global Tracheostomy Collaborative is a multi-institutional, multi-disciplinary collaborative that collects data on patients undergoing tracheostomy. Our experience proves proof of concept of entering demographics and outcome data into the GTC database in a manner that was both accurate and not burdensome to those participating in data entry. In our tertiary care, pediatric academic medical center, tracheostomy continues to be a safe procedure with no major tracheostomy-related morbidities occurring in this patient population involvement with the GTC has shown opportunities for improvement in communication and coordination with other tracheostomy-related disciplines.

Tracheostomy Tube Placement: Early and Late Complications.

Tracheostomy tube placement is a therapeutic procedure that has gained increased favor over the past decade. Upper airway obstructions, failure to liberate from the ventilator, and debilitating neurological conditions are only a few indications for tracheostomy tube placement. Tracheostomy tubes can be placed either surgically or percutaneously. A percutaneous approach offers fewer surgical site infections and postsurgical bleeding than a surgical approach. A surgical placement posses a lower risk of injury to the posterior tracheal wall and spontaneous decannulation is less common. Late complications of both approaches include stenosis, malacia, along with tracheoesophageal, tracheoinnominate, and tracheocutaneous fistulas. This review describes the indications and methods of placement of tracheostomy tubes along with early and late complications that may occur following placement.

Tracheotomy in children: A series of 57 consecutive cases

ObjectivesWith medical improvements in pediatrics, the role of tracheotomy has evolved. The aim of this study was to specify the indications for and complications of tracheotomy performed on children in a teaching hospital containing a level-3 maternity department and pediatric intensive care unit. Material and methodsA retrospective study was conducted in pediatric tracheotomies performed from 2004 to 2014. Indications, early and late complications and the number and timing of decannulations were collated. ResultsFifty-seven patients were included. Tracheotomy was motivated by upper airway obstruction in 39 children (68%) (median age, 4.9months) or the need for prolonged ventilation in 18 children (32%) (median age, 6months). There were 4 early complications (7%) (2 decannulations, including 1 fatal; an obstructive plug, responsible for another death; and 1 pneumothorax during an EXIT procedure), and 15 secondary complications requiring further surgery (26%). Twenty-seven patients (47%) were decannulated, with a mean tracheotomy duration of 26months. In 9 cases (33% of decannulations), persistence of tracheocutaneous fistula required surgical repair. ConclusionTracheotomy for infection is almost a thing of the past; tracheotomy for airway obstruction is also likely to decrease, thanks to medical treatment (for hemangioma) and surgical techniques (for congenital stenosis). Tracheotomy for prolonged ventilation, on the other hand, remains. Complications of tracheotomy in children are rare but potentially serious, requiring care in a specialized center within a multidisciplinary team with defined care protocols.

Clinical outcomes of tracheoesophageal diversion and laryngotracheal separation for aspiration in patients with severe motor and intellectual disability

Conclusions: Tracheoesophageal diversion (TED) and laryngotracheal separation (LTS) can prevent aspiration pneumonia and improve the morbidity of patients with severe motor and intellectual disability (SMID). By improving hospitalization rates and care needs, the quality-of-life can be improved for the patients and their parents. Objectives: This study evaluated the clinical outcomes of TED and LTS in patients with intractable aspiration and SMID. Methods: This study retrospectively reviewed patients with SMID and intractable aspiration pneumonia who underwent TED or LTS at the institution between January 2008 and January 2015. It assessed the frequency of sputum suctioning, the number of pre-operative and post-operative hospitalizations, the operative time, and complications. Results: Forty patients were identified during the study period. After surgery, there were significant reductions in the frequency of secretion suctioning (from 165.0 times/day to 33.0 times/day) and the number of hospitalizations because of aspiration pneumonia (from 5.4 times/year to 0.2 times/year). A tracheocutaneous fistula occurred in one (2.5%) patient, and two (5.4%) patients developed tracheoinnominate artery fistulas. In the latter group, the innominate arteries were successfully ligated and endovascular embolization was performed.

Successful closure of a tracheocutaneous fistula after tracheostomy using two skin flaps: a case report.

A tracheocutaneous fistula may develop when a tracheostomy orifice epithelializes during a prolonged course of healing or undernutrition. Various techniques for closing such fistulae have been reported. However, a standard procedure has not yet been established. We, herein, present a case involving a 35-year-old woman who developed a tracheocutaneous fistula after tracheostomy. We closed the fistula using two skin flaps to cover the tracheal lumen and skin defect, respectively. The advantage of this technique is that it allows the tracheal lumen to be covered by inversed skin epithelium and ensures that the suture line of the skin does not match up with that of the subcutaneous tissue.

A persistent tracheocutaneous fistula closed with two hinged skin flaps and rib cartilage interpositional grafting

Persistent tracheal fistula after tracheostomy decannulation is a recognized sequel to long-term tracheostomy use, causing important morbidity including difficult to vocalization and control of air secretions, recurrent pulmonary infections, and cosmetic and social problems. Herein, we reported a new method for closure of persistent tracheocutaneous fistula with rib cartilages. Compared to other techniques previously reported, the variations of our strategy were the use of temporary metal-covered tracheal stent and the hinged turnover skin bi-flaps reinforced withrib cartilage grafts. Rib cartilages were useful in order to reconstruct the trachea and prevent stenosis. Since it become difficult to obtain the maintenance of the trachea stability until healing of suture was well established, a covered metallic stent was also inserted to avoid flap collapse. The stent was removed 3months later. Six months follow-up showed normal tracheal patency.

気管孔閉鎖術症例の検討

気管孔閉鎖術症例の検討

Tracheocutaneous Fistula Closure in Pediatric Tracheostomy Patients: A Systematic Review

Objectives: Compare success and complication rates of primary tracheocutaneous fistula closure compared with fistulectomy with secondary fistula healing. Methods: A systematic literature search was performed on PubMed. All prospective and retrospective studies of tracheocutaneous fistula (TCF) closure techniques in pediatric patients were included for initial analysis. The authors’ unpublished cohort of 13 fistulectomy patients was also included in the overall analysis. Primary outcomes were surgical success rate and major complication rate. Fisher exact test was used for statistical analysis. Results: Thirteen studies were identified for inclusion in the systematic review; 8 studies reported both success rates and complications. The total number of patients in all included studies was 259 (median, 19; range, 8-98). Techniques included fistulectomy with multilayer closure (197), primary closure alone (2), and fistulectomy alone with healing by secondary intention (60). Success rates were comparable between fistulectomy alone (95.0%) and primary closure techniques (97.5%) ( P = .275). There was a statistically significant increased rate of reported major complications among patients treated with primary closure techniques compared to fistulectomy (0.0% vs 8.5%, P = .038). Conclusions: While both primary closure techniques and secondary healing techniques for pediatric TCF closure have excellent success rates, fistulectomy with healing by secondary intent is associated with less reported major complications.

Tracheostomy

The most common indications for modern tracheostomy are prolonged ventilation for respiratory failure and airway protection following traumatic brain injury with neurologic dysfunction. For background purposes, history and facts related to early tracheostomy are provided. Thereafter, anatomy and physiology are discussed, as are other anatomical considerations, including the site of the procedures, anesthesia, and patient positioning. Counseling and informed consent are also discussed. The operative techniques are provided for emergent surgical airway (cricothyroidotomy and transtracheal needle ventilation and oxygenation) and open and percutaneous tracheostomy. Tracheostomy management is described. Complications are listed and described. Early complications include displacement, pneumomediastinum/pneumothorax, bleeding, infection, acute obstruction, and negative pressure pulmonary edema. Late complications include subglottic tracheal stenosis, tracheal granulation, vocal cord dysfunction, tracheoesophageal fistula, tracheoinnominate fistula, and tracheocutaneous fistula. This review contains 13 figures, 1 video, 2 tables, and 38 references.

Operation airway: the first sustainable, multidisciplinary, pediatric airway surgical mission.

This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country. This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care. Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/). We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.