Professional Documents
Culture Documents
Journal Tracheoutaneous Fustular
Journal Tracheoutaneous Fustular
Journal Tracheoutaneous Fustular
Journal Voice
28/2/2012
u. u.. a..
v.. ...a +. ..ur .
u-. u. a+.+a.
Case scenario
+v.a.a..a 6 v
Dx : bilat. TVCP tracheostomy ..a...a
..a!a rima a off tracheostomy tube a
a.. persistent tracheocutaneous fistula
Case scenario
Question
What is the best surgical method to close
tracheocutaneous fistula?
:a
:
Search Tracheocutaneous fistula TCF
70%of pt with tracheostomy > 16 wk :
persistent fistula
Jacohs JR. Bipedicle delayed fiap closure of persistent radiated
tracheocutaneous fistulas. J Surg Oncol -----s
Occurrence rate
3.3-50% (White KA, 1989; M. Mahadevan,
2007; Joseph H.T., 1991
TCF and duration of canulation
duration : epithelial tissue grow within
stoma and form epithelialized scar tissue &
dense CNT fistula
Pt cannulated for >1 yr after tracheostomy :
50% persistent TCF Eaton DA et al, 2003
TCF and duration of canulation
Early tracheostomy and prolonged time :
rate of fistula (P.J. Koltai, 1998
Duration of cannulation : risk TCF
(Ochi J.W.,1992; Wetmore RF,1982
Complications from TCF
Aspiration, pneumonia
Skin irritation from secretion
Voice problems
Cosmetic defects
Difficulty swimming &
bathing
pulmonary function in pt
with underlying lung dz
Ref : Geyer M 2008; Priestley JD 2006
:a
Surgical methods
Primary closure
Bipedicle delayed flap closure
Fistulectomy with primary closure in layers
Fistulectomy with healing by secondary
intention
Z-plasty with rotation of 2 of 4 triangular
skin flaps
Elevation and rotation of epithelial lining of
fistula inward as a marginally based flap
Turnover hinge flap
VY advancement flap
Auricular cartilage transplanted to tracheal
defect with DP flap
Primary repair
Shorter recovery time
Superior cosmesis result
Disadvantage : subcutaneous
emphysema, pneumomediastinum,
pneumothorax
respiratory distress
Healing by secondary intention
Avoids subcutaneous air tracking provided
the trachea heals before overlying skin
Wound : time to heal
Scar : may be cosmetically inferior
Complications of repair
Surgical emphysema
Emergency recannulation
Wound infection
Local Repair of Persistent
Tracheocutaneous Fistulas
Sobia F. Khaja, MD; Aaron M. Fletcher,
MD; Henry T, Hoffman, MD Annals of
Otology. Rhinology & Laryngology
:a--::-:-:a
:a
DL or rigid bronchoscopy
- Exclude supraglottic/subglottic granulation
- Assess size of tracheal defect
C/I : inadequate pulmonary function
Surgical correction
within 4-6 wk
Skin surrounding the TCF : widely excised
using horizontal elliptical excision
Fistula tract : dissected down to ant
tracheal wall and divided
Harvest abdominal dermal fat graft
Infrahyoid strap muscles : medially
elevated and closed over tracheal defect
with 3-0 polyglactin suture (simple or
vertical mattress)
Place dermal fat graft over strap m and
sewn to periphery of strap muscles (single
interrupted 4-0 resorbable chromic or
polyglactin suture)
Undermine wound margins
Postop drain : emphysema or hematoma
CXR : occult pneumothorax,
pneumomediastinum, subcu emphysema
Overnight airway observation
D/C : postop day 1
Adventage
- More natural appearance
- Prevents adhesion of overlying skin &
subcu tissue to underlying m repair
Disadvantage : abdominal donor site
:a
:
Summary
Local primary closure
Primary closure
Primary closure + strap m
Partial fistulectomy & 3-layered closure
4-layered closure
Hinged skin flap
Dermal fat graft