Abstract
Speech restoration after total laryngectomy has been revolutionized by the technique of tracheoesophageal puncture (TEP) and speech valve prosthesis placement. Unfortunately, complications may arise from this procedure, sometimes necessitating reversal and surgical closure of the TEP. We present a simple yet effective method of closing a TEP and review previously described techniques.
1
Introduction
Tracheoesophageal puncture (TEP) creation and speech valve prosthesis insertion are well-established techniques, enabling voice restoration in patients after total laryngectomy. The techniques were first described in the late 1970s by Singer and Blom , who developed the original speaking valve. The valve allows unidirectional passage of air from trachea to the neopharyngoesophagus, facilitating pharyngeal speech. The valve prevents aspiration by stopping the passage of ingested material from passing into the trachea when swallowing. Over the years, numerous refinements have been made; and the authors currently use the Provox II model (Provox II Valve; 8, 10, and 12.5 mm by ATOS Medical, Eastbourne, UK).
A TEP can be created either primarily at the time of primary surgery or as a delayed secondary procedure. However, immediate, delayed, and long-term complications may arise from iatrogenic puncture creation. A significant problem is gradual TEP widening and subsequent leakage of saliva and liquids around the valve into the trachea, resulting in recurrent aspiration and pneumonia. A problematic valve can be removed to allow the TEP to close spontaneously. Unfortunately, in some instances, a TEP may persist, requiring formal surgical closure. We present a surgical technique for TEP closure that is simple, effective, and with potentially low morbidity rates.
1.1
Surgical technique
The procedure is performed under general anesthesia with the patient supine and the tracheostoma intubated with a 5.5-mm tracheal tube. A modified crescentic skin incision is made around the superior aspect of the tracheostoma from 10 o’clock to 2 o’clock, variably extended along the previous laryngectomy scar ( Fig. 1 ). This facilitates retraction of the skin edges and soft tissue dissection in a plane between the neopharyngoesophagus and pars membranacea of the trachea down to the level of the TEP ( Figs. 2 and 3 ). The fistulous tract is identified as a cord-like band running anteroposteriorly between the pars membranacea of the trachea and the esophagus. Three hundred sixty–degree exposure of the fistula is achieved by freeing the puncture circumferentially from the surrounding tissue by careful blunt dissection. Visualization of the lower aspect of the tract can also be enhanced with the aid of a 45° rigid Hopkins rod telescope connected to a videoendoscopic system.
When the tract has been completely freed, suture ligation of the fistula with 2/0 nonabsorbable suture is performed at 2 points ( Figs. 4 and 5 ). In our patients, we used 2/0 Prolene (Ethicon Inc, Gargrave, UK). Because the tract is not divided, there is no need to place an interposition graft or a flap, as is the case in conventional 3-layer closure. A 10F active drain is sited and kept in place for 24 hours. The skin wound is closed with 3/0 Prolene. The total length of the procedure is usually not more than 90 minutes. Antibiotic cover with co-amoxiclav, 1.2 g TDS intravenously for the first 24 hours, is followed by 625 mg TDS per os for 4 days. A water-soluble (eg, Gastrografin) contrast swallow is performed 24 hours postoperatively ( Fig. 6 ). If no leak is confirmed, then oral feeding can be commenced, initially by liquid and soft diet and progressing to a normal diet at home over the following days. Skin sutures are removed 7 days postoperatively in the community.
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