Tracheocutaneous fistula (TCF) repair is indicated in pediatric patients who have a persistent TCF 3 to 6 months following tracheostomy decannulation. The surgical repair can be primary, with a four-layer closure, including the tracheal wall, strap muscles, subcutaneous tissue, and skin, or it can be secondary, with excision of the TCF tract and delayed closure by secondary intention. The secondary type of repair is often advocated in an effort to decrease the risk of postoperative pneumothorax/pneumomediastinum, but no statistically significant difference is seen when primary repair and secondary repair are compared.
43 Tracheocutaneous Fistula Repair
TCF (▶ Fig. 43.1) is the result of a non-healing epithelized tracheostomy stoma after decannulation. In recent years the indications for tracheostomy have changed in the pediatric population. There has been a decrease in the rate of tracheostomy for infections, and an increase in tracheostomy for children with congenital anomalies. Currently, common reasons for placement of a tracheostomy in pediatric patients include upper airway obstruction related to craniofacial dysmorphism, vocal fold paralysis, neurologic impairment, and subglottic stenosis. Another sizable group of children require prolonged mechanical ventilation due to cardiac or pulmonary illnesses, and a tracheostomy is placed to assist with ventilation. The result is an increased number of younger children requiring tracheostomy for a longer period of time. 1 – 3 If pediatric patients meet criteria for decannulation, the rate of developing a TCF after tracheostomy removal is reported from 13.1 to 37.8%. 1 – 3 The rate of TCF increases if the tracheostomy is performed in children younger than 6 months of age or if the tracheostomy is in place for a longer duration of time. 1 – 4 Carron et al showed a 70% TCF rate in children that had a tracheostomy cannulation for greater than 2 years and 8.1% TCF rate if the tracheostomy was in place less than 2 years. 4
In addition to young age at tracheostomy creation and duration of cannulation, it is also thought that the type of tracheostomy procedure affects the incidence of TCF after decannulation. Procedures that are concerning for increased TCF are stoma maturation with sutures to the trachea, Bjork cartilage flap, and starplasty. Colmen et al found that stoma maturation did not have an impact on the incidence of TCF formation. 5 Conversely, Sautter et al reported 28 patients who underwent decannulation after starplasty tracheostomy with stoma maturation and 25/28 patients had a persistent TCF. 6 Clearly, there are differences in the reported outcomes after decannulation in the literature for patients who underwent stoma maturation. In patients with likely resolution of the underlying disease requiring tracheostomy, stoma maturation techniques including starplasty, should be used cautiously secondarily to the increased risk of TCF.
TCF should be repaired in pediatric patients with a non-healing fistula that is no longer needed. The persistent fistula has several potentially negative sequela including: (1) recurrent aspiration with subsequent respiratory infections, (2) skin irritation secondary to exposure to tracheal mucus, (3) ineffective cough, (4) difficulty in phonation, (5) inability to be submerged in water, and (6) cosmetic and social acceptance concerns. Repair generally should not be performed prior to 3 to 6 months after decannulation because many TCFs will heal spontaneously during this time period.
43.2 Preoperative Evaluation for TCF repair
After a period of several months following decannulation, and before surgical repair of the TCF, the patient should be evaluated for upper airway obstruction. Potential sources of upper airway obstruction include tonsil/adenoid hypertrophy, vocal fold paralysis, laryngomalacia, subglottic stenosis, subglottic cysts/hemangiomas, and suprastomal collapse of the trachea. Premature closure of a TCF that the patient is dependent on for ventilation could lead to acute airway obstruction and an urgent need for recannulation or endotracheal intubation. A diagnostic microdirect laryngoscopy with bronchoscopy should be performed prior to TCF repair. The endoscopic evaluation can be performed during the same procedure as the repair of the TCF to spare the patient a separate anesthesia. In addition, an overnight sleep apnea study or sleep endoscopy with occlusion of the fistula is indicated preoperatively if there are concerns on history for obstructive sleep apnea. Gallagher and Hartnick 7 recommend against closure in patients with persistent cough and patients with anatomic obstruction or severe trismus that would make reintubation difficult.