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

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

Exploring the Role of Cap Grafts in tracheocutaneous fistula Closure. A tracheocutaneous fistula (TCF) is an abnormal connection that forms between the trachea (windpipe) and the skin of the neck. If spontaneous closure does not occur, fibrosis of the surrounding tissue may result in a persistent TCF and in some cases, iatrogenic laryngotracheal stenosis at the level of tracheostoma, the so-called A-frame deformity. In all 5 patients, Conchal cartilage was harvested. The new de-epithelialized stoma is measured, and the previously harvested graft is cut to match the defect. Passing through the centre of the tracheal cartilage and into the centre of the auricular cartilage graft, 3-0 PDS, horizontal mattress sutures are placed sequentially around the periphery of the graft, stabilised with Right SCM flap and skin was closed in layers. In each of the five cases, we achieved a resounding success by skilfully closing the fistulas and meticulously restoring the structural integrity. Equally noteworthy, all patients expressed contentment with the cosmetic outcomes at both the donor site and the neck region, deeming it as an acceptable aesthetic result.

Tracheal reconstruction with pedicled tandem grafts engineered by a radial stretch bioreactor

The engineering of tracheal substitutes is pivotal in improving tracheal reconstruction. In this study, we aimed to investigate the effects of biomechanical stimulation on tissue engineering tracheal cartilage by mimicking the trachea motion through a novel radial stretching bioreactor, which enables to dynamically change the diameter of the hollow cylindrical implants. Applying our bioreactor, we demonstrated that chondrocytes seeded on the surface of Poly (ε-caprolactone) scaffold respond to mechanical stimulation by improvement of infiltration into implants and upregulation of cartilage-specific genes. Further, the mechanical stimulation enhanced the accumulation of cartilage neo-tissues and cartilage-specific extracellular macromolecules in the muscle flap-remodeled implants and reconstructed trachea. Nevertheless, the invasion of fibrous tissues in the reconstructed trachea was suppressed upon mechanical loading.

Tracheostomy healing time after decannulation

Background

Prolonged healing of tracheostomy after decannulation has a negative impact on respiration, hygiene, cosmetics, and social life. Even so, evidence-based observations of tracheostoma healing time are lacking. Therefore, the aim of this study was to determine tracheostomy wound healing time after decannulation.

Methods

In this prospective observational cohort study, we included 30 subjects undergoing decannulation following prolonged mechanical ventilation via tracheostomy. Our primary endpoint was tracheostomy healing time defined as time from decannulation to airtight healing. To identify any factors related to healing time, we included information about patient demographics, comorbidities, tracheostomy method, tube size, and intubation time. All subjects were observed daily until their tracheostomy wound had healed.

Results

The median tracheostomy healing time was 6.5 (1-22) days. The duration of tracheal cannulation was the only factor significantly correlated with prolonged healing (p=0.03). Four patients were subjected to recannulation shortly after decannulation due to hypercapnia, respiratory failure, secretion accumulation, or self-decannulation. All wounds achieved complete spontaneous airtight closure.

Conclusions

Duration of spontaneous tracheostomy closure after decannulation was 1-22 days, and closure time correlated with duration of cannulation.

Decision algorithm and surgical strategies for managing tracheocutaneous fistula

Background

Persistent tracheocutaneous fistula (TCF) is a complication of prolonged use of tracheostomy tube. Although many procedures exist to correct this issue, there is no consensus regarding its optimal management. We constructed a decision algorithm to determine appropriate surgical strategies for TCF repair.

Methods

Retrospectively reviewing our hospital’s records, we found fourteen consecutive patients who had received surgical repair of tracheocutaneous fistula (primary closure or advanced local flap) between February 2013 and December 2018 and collected data relevant to their cases.

Results

We identified 11 male and 3 female patients. Duration of tracheostomy dependence was 8.1±4.7 months, and timespan from decannulation to surgical closure 7.4±6.5 months. Seven patients received primary closures, six received hinged turnover flaps, and one received random and perforator flap reconstruction. There was no perioperative mortality or morbidity except for one patient requiring a repeat tracheostomy 11 months after TCF repair due to pneumonia and subsequent respiratory failure. We used our findings and those reported in the literature to construct a modified risk factor scoring system based on patient’s physical status, major comorbidities, perifistular soft tissue condition, and nutritional status and an algorithm for managing TCF based on the patients’ fistula size and modified risk factor scores.

Conclusions

In conclusion, we were able to review our cases and those of other studies to create a risk scoring system and a decision algorithm that we believe will help optimize patient-directed surgical management of TCF repair.

Reconstruction of tracheocutaneous fistula with a rhomboid flap

Various complications associated with tracheal stomas have been reported, including mechanical trauma to the peristomal skin, infection, folliculitis, granuloma, and fistula. Among them, a tracheocutaneous fistula generally requires surgical repair. A number of methods have been reported for reconstruction of fistulas using musculocutaneous flaps or free flaps. However, those surgical techniques are all designed for complete close of the tracheocutaneous fistula and stoma, while partial closure of the stoma around the indwelling tracheal tube is not well described in the literature. We report on the use of a rhomboid flap for partial closure of a tracheal stoma. The rhomboid flap is a local flap that is frequently used by plastic surgeons because of its broad applications and not being very invasive. This is a low invasive and simple technique for partial closure of an excessively enlarged stoma.

Delayed complication of tracheocutaneous fistula closure with severe compromising subcutaneous emphysema

We report a significant complication after tracheocutaneous fistula (TCF) excision with closure by secondary intention in a 4-year-old boy who had been tracheostomy dependent since infancy. He had a persistent 3 mm TCF one year after decannulation. On postoperative day 2 the patient developed profound subcutaneous emphysema and pneumomediastinum. He was extubated after 2 days and discharged from the hospital on postoperative day 7. At follow up he had complete resolution of subcutaneous emphysema and complete closure of the TCF. The main methods of TCF closure and management of subcutaneous emphysema are discussed along with the lessons learned from this case.

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.

Nonoperative Treatment of a Tracheocutaneous Fistula in a Burn Patient

Tracheocutaneous fistula (TCF) is a complication occurring after decannulation of a long-term tracheostomy and can lead to significant morbidity. We describe a case of a TCF in a burn patient treated without surgery. No previous cases have been described. A 65-year-old woman presented with symptomatic hypertrophic burn scar contractures of the anterior neck 6 months after undergoing excision and grafting of full-thickness burns to the neck and chest. She had a history of tracheostomy placement at the time of burn. Two months later, she was decannulated with no evidence of TCF. She subsequently underwent excision of hypertrophic burn scar contractures of the neck with placement of bilayer wound matrix followed by split-thickness skin grafting. Postoperatively she was noted to have a TCF with subgraft emphysema and difficulty in phonation and respiration. With local wound care, the TCF closed spontaneously and a new skin graft was placed uneventfully. At 18 months postoperatively, fistula closure was maintained with good functional and aesthetic outcome. Conservative management of an iatrogenic TCF in a burn patient may result in adequate soft-tissue coverage and allow for subsequent successful skin grafting. This method affords minimal morbidity to the patient and is a viable alternative to more elaborate flap reconstruction.

A new technique to repair huge tracheo-gastric fistula following esophagectomy

We reported the management of a life-threatening condition as a large tracheo-gastric fistula involved the carina, the left and the right bronchus that complicated Ivor Lewis esophagogastrectomy for esophageal cancer. An urgent right thoracotomy was performed and the tracheal defect was covered with a reversed pedicled pericardial patch reinforced with an intercostal muscle flap. Cervical esophagostomy and a feeding jejunostomy completed the operation. Five months later, the continuity of gastrointestinal tract was restored using a transverse colon.