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A Novel Approach to Tracheocutaneous Fistula Closure
INTRODUCTION RESULTS
CONCLUSIONS
DISCUSSION
REFERENCES
ABSTRACT
OBJECTIVES:
1) Describe a novel, three-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.
METHODS: 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 three-
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, three-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.
CONCLUSIONS: 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.
This case resulted in successful closure of a 1.4 by 1.6
cm TCF in a previously irradiated patient. 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 (Figure 2).
The conchal cartilage was de-epithelialized and the
tracheal defect was closed with interrupted and vertical
mattress 2-0 PDS sutures, followed by a layer of fibrin
glue. Support was augmented with an absorbable
miniplate. Additional RFFF tissue was positioned
between the tracheal closure and skin. Penrose and
Jackson-Pratt drains were placed in the neck (Figure 3).
The patient was extubated in the operating room
following reconstruction. Straining and speaking were
avoided in the immediate postoperative period.
Pulmonary expansion was discouraged. Drains were
removed individually when output became minimal. The
patient had no issues with breathing, speaking, or
wound healing immediately or at six months
postoperatively (Figure 4).
Large TCFs in previously 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. This surgical technique and postoperative management strategy can be considered in patients who present with similar TCFs.
1) C Jackson and WW Babcock. Plastic closure of tracheocutaneous fistula. Surg Clin
North Am 14 (1934), pp. 199–221.
2) JB Bishop, J Bostwick, and F Nahai. Persistent tracheostomy stoma. Am J Surg. 1980
Nov;140(5):709-10.
3) UJ Lee, EK Goh, SG Wang, and SM Hwang. Closure of large tracheocutaneous fistula
using turn-over hinge flap and V-Y advancement flap. J Laryngol Otol. 2002 Aug;
116(8):627-9.
4) F Riedel, UR Goessler, S Grupp, G Bran, K Hormann, and T Verse. Management of
radiation-induced tracheocutaneous tissue defects by transplantation of an ear cartilage
graft and deltopectoral flap. Auris Nasus Larynx. 2006 Mar; 33(1): 79-84.
Various methods have been described for closure of
large TCFs. As early as 1934, Jackson and
Babcock described using a lined bipedicle flap
reinforced with conchal cartilage for closure (1).
Several subsequent case reports and case series
have described various techniques involving
different types of flaps, sometimes combined with
cartilage use for structural support (2-4). All of
these techniques had small sample sizes with
variable follow-up. Whether the patient had been
previously irradiated was not always discussed. Our
technique represents a novel approach in a
previously radiated patient who had undergone
multiple neck surgeries prior to TCF closure. The
banked mucosa-lined cartilage served as a
framework for structural support of the trachea. The
RFFF provided a tissue barrier and additional
support between the tracheal closure and the skin.
In the initial postoperative period, stress on the
tracheal anastamosis was minimized by limiting
straining and speaking. Forceful coughing was
discouraged, and pulmonary expansion was
avoided. These restrictions helped promote wound
healing without fistula formation.
Allison K. Taraska, Mark C. Royer, Jonathan Y. Ting, Edward C. Weisberger, and Michael G. Moore
Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN
Tracheocutaneous fistula (TCF) typically forms as a
sequelae of tracheostomy tube placement. Squamous
epithelium migrates into the trachea creating an
epithelialized tract which fails to close following tube
removal. Factors such as treatment with radiation
therapy and prolonged tracheostomy tube placement
increase the likelihood of fistula formation. Problems
associated with TCFs include increased possibility of
respiratory tract infections, difficulty with phonation,
coughing, cosmetic problems, and limitations on
swimming and bathing, among others.
CASE REPORT
The patient is a sixty-six-year-old man who presented
with a history of thyroid lymphoma treated with
chemoradiation and total thyroidectomy. He required
emergent tracheostomy placement. He developed a
tracheoesophageal fistula (TEF) as well as a
tracheocutaneous fistula. The TEF was closed with a
sternocleidomastoid flap. The TCF was 1.4 x 1.6 cm in
size and had an adjacent section of tracheal stenosis
(Figure 1). Given his history of radiation and the size
and complexity of the TCF, the decision was made to
repair the defect in a three-stage approach culminating
in radial forearm free flap (RFFF) with banked conchal
cartilage and buccal mucosal graft for tracheal closure.
Figure 1. The TCF defect included the entire anterior
tracheal wall and a portion of the bilateral sidewalls (a). A
bronchoscopic view (b) shows the TCF with an
endotracheal tube passed through it. Proximal tracheal
stenosis is evident.
a. b.
Figure 4. The wound at six months
postoperative. The TCF is closed
completely and wound is well-healed.
Figure 3. The RFFF was anastamosed
to the right superior thyroid artery and
external jugular vein. The mucosa-lined
cartilage was positioned over the
tracheal defect and secured (a and b).
The subcutaneous tissue and skin of
the RFFF served as additional tissue
support in final wound closure. Drains
were placed in the neck (c).
Figure 2. The conchal cartilage covered with buccal
mucosa and implanted in the radial forearm shown prior to
the start of stage three (a). The RFFF with the mucosa-lined
cartilage graft and skin paddle following harvest during
stage three (b and c).
b.
c.
a.
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