Decision algorithm and surgical strategies for managing tracheocutaneous fistula

A Case of Refractory Tracheocutaneous Fistula Successfully Treated With the Combination of Auricular Cartilage Grafting and Sternocleidomastoid Muscle Flap

The tracheotomy site usually closes spontaneously after decannulation, but in rare cases, it develops into tracheocutaneous fistula. We experienced a case of tracheocutaneous fistula that was successfully treated with the combination of auricular cartilage grafting and sternocleidomastoid muscle flap. In this case, we performed the closure of tracheocutaneous fistula with a view to filling the tissue defect with soft tissue to prevent recurrence. The surgical procedure performed in this case was unique, which to our knowledge, has not been described previously. Herein, we report some findings obtained, together with a literature review. The patient was a 73-year-old male. Starting five months after tracheotomy, the closure of a tracheocutaneous fistula was attempted twice at an otolaryngology clinic, which resulted in recurrence. The patient visited our department with the desire to close the tracheocutaneous fistula. At the initial examination, we found a cutaneous fistula with a diameter of approximately 2 mm on the cranial side of the sternal notch and thinning of the surrounding tissue. Preoperative computed tomography (CT) showed a tracheal defect with a size of approximately 10 mm on the caudal side of the sternal notch. The surgery was performed under general anesthesia 10 months after tracheotomy. The platysma muscle was attached to elevate the skin flap, and the scarring at the cutaneous fistula opening was removed. The cartilage defect was 10×12 mm in size. A piece of cartilage was harvested from the posterior surface of the auricle (navicular fossa) and grafted to the tracheal opening. A part of the left sternocleidomastoid muscle body of the sternal head was dissected from the mandibular side using the sternal attachment site as a stalk and elevated. The muscle flap was rotated, with its tip folded back, doubled over, and fixed on top of the auricular cartilage graft. The platysma muscles were sutured together during which the skin flap suture line was shifted so that the suture line would not coincide with the tracheal fistula site. The course was favorable, with no recurrence for three years. In the closure of a tracheocutaneous fistula, two sides need to be considered: the trachea and the skin. The tracheal defect in the present case was larger than 10 mm in size and thus auricular cartilage grafting was performed. In addition, we filled the tissue defect with the soft tissue of a sternocleidomastoid muscle flap, which was a unique step. The combined use of auricular cartilage grafting and sternocleidomastoid muscle flap was effective for the closure of a refractory tracheocutaneous fistula.

Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap

Tracheocutaneous fistula and tracheostomy scar are complications associated with the prolonged use of tracheostomy tubes. They have functional and cosmetic problems owing to tracheal tugging during swallowing and easily visible scars. Although many procedures exist to correct this issue, there is no consensus on the optimal surgical technique. Therefore, an ideal surgical procedure was devised. The study was performed on 12 patients between September 2016 and May 2021. All patients had persistent tracheocutaneous fistulas or hypertrophic scars on the neck after tracheostomy. All procedures were performed using a hinged flap and two myocutaneous local flaps. All patients had no complications, and their aesthetics were excellent in postoperative photographs. The scar was better on the straight scar when the flap's skin is denuded than on the VY advancement flap. It should be noted, however, that this procedure can cause the flap to become congested in a short period after head and neck surgery. This procedure is safe, reliable and simple for surgical closure. This was found to produce excellent cosmetic results with no major complications.

Comparison Between Flap and Primary Closures of Persistent Tracheocutaneous Fistula: A Scoping Review

Objectives: To compare the susceptibility and complication rates between flap and primary closures for tracheocutaneous fistula (TCF). Methods: We searched 4 online databases (Web of Science, Cochrane Library, PubMed, and Scopus) for relevant articles published from study inception until August 2022. Studies including at least 5 adult or child patients with persistent TCFs who underwent closure surgery via primary or flap repair were included. All included studies reported outcomes of surgical repairs such as successful closure rates and complications. In addition, we performed single-arm meta-analyses for each surgical method using the Open Meta-Analyst software to calculate the pooled event rate with a 95% confidence interval (CI); compared the 2 surgical procedures using the Review Manager software using the risk ratio with 95% CI; and assessed study quality based on the National Heart, Lung, and Blood Institute criteria. Results: Overall, 27 studies with 997 patients were included. No significant difference was observed between the closure success and major complication rates of surgical methods. The primary and flap closures had overall success rates of 0.979 and 0.98, respectively. The overall major complication rates in primary and flap closures were 0.034 and 0.021, respectively; and that of minor were 0.045 and 0.04, respectively. In primary closure, a significant decrease in the success rate with increasing age at the time of decannulation was observed. In addition, the risk of major complications increased with increasing time from decannulation to closure. Conclusions: Both the primary and flap repairs of TCF are effective based on closure success and complication rates; therefore, they are both acceptable therapeutic alternatives, and flap repair can be considered when other techniques have failed. However, further prospective randomized studies comparing these 2 procedures are needed to support our results.

The Predictors of Persistent Posttracheostomy Tracheocutaneous Fistula and Successful Surgical Closure

OBJECTIVE

Persistent tracheocutaneous fistula is a well-described complication of prolonged tracheostomy, with a prevalence of about 70% when decannulation is performed after more than 16 weeks. Predictors of its occurrence and outcome of treatment in adults remain unclear. The aim of the study was to describe our experience with the treatment of persistent posttracheostomy tracheocutaneous fistula in adults and to investigate factors associated with its formation and with the success of surgical closure.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary medical center.

METHODS

Patients who underwent open-approach tracheostomy between 2000 and 2020 were identified by database review. Data on background, need for surgical closure, and the surgical outcome was collected from the medical files and analyzed statistically between groups.

RESULTS

Of 516 patients identified, 127 with sufficient long-term follow-up data were included in the study. Compared to patients whose fistula closed spontaneously (n = 85), patients who required surgical closure (n = 42) had significantly higher rates of smoking, laryngeal or thyroid malignancy, and airway obstruction as the indication for tracheostomy, on both univariate and multivariate analysis. In a comparison of patients with successful (n = 29) or failed (n = 11) surgical closure, factors significantly associated with failure were prior radiotherapy and lower preoperative albumin level, on univariate analysis.

CONCLUSION

Smoking, thyroid or laryngeal malignancy, and airway obstruction indication are risk factors for persistent posttracheostomy tracheocutaneous fistula. Patients should be closely followed after tracheostomy and referred for surgery if the fistula fails to close. Before surgery, careful evaluation of the patient's nutritional status and consideration of prior radiation treatment is mandatory.

Silver nitrate therapy for persistent tracheocutaneous fistula following prolonged tracheostomy and invasive ventilation: A case report

We report the case of a man with severe Guillain-Barré syndrome who developed a persistent tracheocutaneous fistula (TCF) following prolonged tracheostomy and mechanical ventilation. Following tracheostomy decannulation, the TCF had a deleterious effect on non-invasive positive pressure ventilation efficacy and ability to effectively clear airway secretions due to air leaking from the patent stoma. This case highlights a non-surgical approach to TCF management that is not well-described in the literature and presents an alternative management option for cohorts of patients in which the risk associated with surgical interventions may be undesirable.

Local skin flap procedure for repair of rectovaginal fistula: A case report

Introduction

Rectovaginal fistula (RVF) is an increasingly common rectal surgery complication. Although various RVF closure operations have been reported, no one approach is considered ideal. Consequently, some patients must undergo more complex and technically challenging surgical procedures. We describe the successful use of simple local skin flap plasty for RVF repair.

Presentation of case

A 74-year-old Japanese female developed RVF after robot-assisted laparoscopic proctectomy with intersphincteric resection, hand-sewn coloanal anastomosis, and a temporary ileostomy. Three months later, reconstructive surgery was performed using a local flap. The fistula was successfully closed and healed well without complications.

Discussion

A local flap consists of the skin and subcutaneous tissue harvested from a nearby site that maintains its intrinsic blood supply.

Conclusion

This novel approach to RVF repair appears simple, effective, and safe.

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A local flap consists of the skin and subcutaneous tissue harvested from a nearby site.

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A local flap is simple, less invasive, and considered early in the process.

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A local flap can be one of the RVF treatments.