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.