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3.2: Closure of Pediatric Tracheocutaneous Fistula Surgical Technique

  • Page ID
    15441
  • OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

    CLOSURE OF PEDIATRIC TRACHEOCUTANEOUS FISTULA: SURGICAL TECHNIQUE

    Buhlebenkosi Hlomani, Shazia Peer


    A tracheocutaneous fistula (TCF) is an epithelial-lined communication between skin and trachea that persists after decannulation (removal) of a tracheostomy tube. TCF rates are higher in pediatric patients. It is a recognized complication of long-standing tracheostomies and has been linked to longer duration of tracheostomy dependence1.

    Complications associated with a persistent TCF include skin irritation; inadequate glottic closure causing a weak cough and airway compromise; poor phonation; poor cosmesis; increased risk of aspiration during swimming, bathing etc.2. Addressing a persistent TCF avoids delays with integration into society and mainstream schooling.

    TCF is due to squamous epithelialization of the tracheostomy lumen. Closure is achieved by excising the fistula followed either by primary closure or allowing for healing to occur by secondary intention. Although primary closure provides immediate resolution of the fistula and better cosmesis, it may be associated with life-threatening complications, regardless of the treatment center3. Allowing healing by secondary intention minimizes such potential complications. It may however be perceived as “inconvenient” for the patients.

    It is however the authors’ preference to allow healing by secondary intention, safety in the immediate postoperative period being the primary reason.

    Preoperative evaluation

    1. Patient selection is as important as timing of surgery: We employ the following eligibility criteria based on etiological and patient factors and use them as a guide for timing of surgery:

    • The original reason for the upper airway obstruction that necessitated the tracheostomy has resolved/been reversed
    • The child has been successfully decannulated for >1 year; this sees the child through 1 winter season
    • Typically, children are >4 years old, weigh >15 kg and have no central neurological deficits or cardiovascular compromise e.g. after cardiac surgery or pulmonary disease
    • If the surgery is done on a 2- 4-year-old child weighing >15 kg, it is advisable to insert a tracheostomy tube for the 1st 24 hours immediately postoperatively
    • Diagnostic assessment of the upper airways is routinely performed before any decision is taken about surgery. Anatomical and physiological factors are discussed later

    2. Flexible nasendoscopy: This is typically done in the clinic with the child awake. The nasopharynx, oropharyngeal inlet, base of tongue (BOT), supraglottis and vocal cord mobility are carefully assessed.

    3. Overnight sleep study / Overnight oximetry: This is useful to assess children with reported sleep disordered breathing. The TCF is covered while asleep to assess for proximal airway obstruction.

    4. Direct laryngoscopy, tracheoscopy and bronchoscopy

    • During induction of anesthesia, the patient must breathe spontaneously and cope well with bag mask ventilation. The TCF can be covered with a dressing 
    • Flexible bronchoscopy is then done through a laryngeal mask
      • Confirm cord mobility
      • Spray the larynx with topical lignocaine
      • Perform dynamic assessment of upper airways, especially in cases of tracheomalacia and bronchomalacia
      • When aspiration is a concern, a broncheoalveolar lavage (BAL) is also done
    • Perform rigid laryngoscopy +/- suspension
      • Assess all levels of the airway i.e. oropharynx, BOT, vallecula, epiglottis, supraglottis, false and true cords, subglottis, trachea (proximal to stoma), peristoma, distal trachea down to carina
      • If any pathology is identified, a staged approach with initial surgical correction required before the TCF can be addressed e.g. removing a suprastomal granuloma, addressing persistent subglottic stenosis etc o Record the size of the airway using appropriate-sized endotracheal tubes. A child of 4 years must admit at least a 4.5 ETT with a leak at 20 cm H2O. If older, use a size uncuffed ETT of (Age/4) + 4.

    If the child is considered eligible for closure of the TCF, then proceed to surgery

    Surgical procedure to close a TCF

    1a.png

    Figure 1a: Child placed supine with neck extended and north facing ETT

    1b.png

    Figure 1b: Patient with a prominent occiput positioned without a head ring

    • Administer a single dose of prophylactic antibiotics (Kefzol), and a single dose of intravenous steroids
    • Intubate the airway with an appropriate sized cuffed (0.5 size smaller to accommodate a cuff) north-facing endotracheal tube (Figures 1ab)
    • Position the child supine with a shoulder roll to extend the neck (Figures 1ab)
    • A head ring may be required to maintain the head in a neutral position

    2.png

    Figure 2: Infiltration with local anesthetic

    • Infiltrate the skin around the TCF with local anesthetic (Lignocaine with adrenaline). Do not exceed the maximum safe dose (Figure 2)

    3.png

    Figure 3: Occasionally, the TCF lies off the midline

    • After cleaning and draping, identify the midline structures as tracheostomy sites typically are in a paramedian position and the TCF may be further from the midline than expected (Figure 3)

    4.png

    Figure 4: Mark the skin around the TCF as an ellipse

    • Mark the skin around the stoma in an elliptical shape (Figure 4)
    • Incise the skin along the elliptical markings around the TCF

    5.png

    Figure 5: Skin incision, elevating the edges and grasping skin with tissue forceps

    • Elevate the two ends and grip them using a tissue forceps (Figure 5)
    • Dissect the soft tissue circumferentially around the stoma using cautery and blunt dissection

    6.png

    Figure 6: Excision of tract, down to trachea

    • Stay close to the TCF and expose a 10 mm margin of trachea (Figure 6)
    • Avoid dissecting into trachea (Figure 6)

    7.png

    Figure 7: Resected TCF

    8.png

    Figure 8: Defect following resection of TCF

    • Enter the trachea close to the TCF using an #11 blade, and circumferentially excise the TCF, removing as little tracheal tissue as possible (+/- 5 mm) (Figure 7)
    • Avoid a large defect by not excising too much of the anterior tracheal wall as it will take longer to close (Figures 7, 8)
    • Ensure that there is no remaining skin in the tract as this will prevent closure

    9.png

    Figure 9: Approximate wound edges with steristrips

    10.png

    Figure 10: Cover the defect with a pliable dressing

    • Oppose the skin with steristrips (Figure 9)
    • Cover the defect with a pliable dressing that allows for a reservoir of air with the child’s breathing (Figure 10)

    Postoperative care

    • The surgeon must accompany the child from the operating room to the recovery room with an unopened appropriately sized pediatric tracheostomy tube to be kept at the bedside
    • Once fully recovered, the child must be nursed in a high care ward
    • For the first 24 hours, continuous monitoring of oxygen saturation, respiratory rate and heart rate, and watching for signs of respiratory distress, is paramount
    • Sedation and good analgesia are recommended as crying and coughing increase the risk of surgical emphysema
    • Immediately remove the dressing if there is any breathing difficulty, and reinsert a tracheostomy tube
    • The child is transferred to a general pediatric ward for 24-48 hours
    • Give strict instructions to the caregiver to avoid water around the revised stoma
    • Change the dressing if it becomes soggy
    • If secretions are copious, it is preferable to keep the stoma uncovered
    • The child is reviewed at 1 week postoperatively

    11.png

    Figure 11: Stoma healed by secondary intention 1-week postoperatively

    • The stoma is typically healed by then (Figure 11)

    Complications

    Immediate / 1st 24 hours

    12.png

    Figure 12: Acute pneumothorax

    • Respiratory distress from
      • Pneumothorax (Figure 12)
      • Pneumomediastinum
    • Surgical emphysema
      • As a result of air escaping from the trachea into surrounding tissues
      • May be forced into the mediastinum causing a pneumomediastinum
      • Immediate management requires prompt reinsertion of the tracheostomy tube and oxygen supplementation

    Delayed

    • Failure of TCF to close
    • Peristomal granulation tissue 
    • Suprastomal (anterior) tracheal collapse
    • Tracheomalacia
    • Tracheal stenosis

    References

    1. Ha T, Goyal M, Ongkasuwan J. Duration of tracheostomy dependence and development of tracheocutaneous fistula in children. The Laryngoscope. 2017;127(12): 2709-12
    2. Wine T, Simons JP, Mehta DK. Comparison of 2 Techniques of Tracheocutaneous Fistula Closure Analysis of Outcomes and Health Care Use. JAMA Otolaryngol Head Neck Surg. 2014;140(3):237-42
    3. Osborn AJ, de Alarcón A, Hart CK, Cotton RT, Rutter MJ. Tracheocutaneous Fistula Closure in the Pediatric Population: Should Secondary Closure Be the Standard of Care? Otolaryngology–Head and Neck Surgery. 2013;149(5): 766–71

    Authors

    Buhlebenkosi Hlomani MBChB
    Otolaryngology resident
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    b_hlomani@yahoo.com

    Shazia Peer MBBCh, FCORL, MMed Head, Pediatric Otolaryngology
    Red Cross Children’s War Memorial Hospital
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    shazia.peer@uct.ac.za

    Editor

    Johan Fagan MBChB, FCS(ORL), MMed
    Professor and Chairman
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    johannes.fagan@uct.ac.za