How to close a tracheocutaneous fistula (trachea cutaneous fistula)?

From the Guidelines

Surgical closure of a tracheocutaneous fistula is the recommended approach, as it provides a definitive solution to the problem and improves the patient's quality of life by eliminating the risk of recurrent infections, difficulty with speech, and social embarrassment. When considering closure of a tracheocutaneous fistula, it is essential to prioritize the patient's airway patency and overall health status. According to the American Thoracic Society statement 1, the decision to close a tracheocutaneous fistula should be based on the patient's ability to maintain a safe and adequate airway independent of the tracheostomy tube.

The procedure for closing a tracheocutaneous fistula typically involves:

• Preoperative assessment, including bronchoscopy to confirm upper airway patency
• An elliptical incision around the fistula, followed by careful dissection of the tract down to the trachea
• Closure of the tracheal defect using absorbable sutures, such as 4-0 Vicryl, in a layered fashion
• Mobilization and closure of the surrounding soft tissues, with the strap muscles being approximated over the tracheal repair to provide additional support
• Skin closure with subcuticular sutures or skin staples

Postoperative care is crucial to prevent complications, and may include:

• Close monitoring for subcutaneous emphysema, pneumothorax, or respiratory distress
• Perioperative antibiotics, such as a first-generation cephalosporin like cefazolin 1-2g IV
• Voice rest for 24-48 hours and avoidance of coughing or straining to prevent disruption of the repair

It is essential to note that the success rate for primary closure of a tracheocutaneous fistula is generally high, but complex or recurrent fistulas may require more advanced techniques, such as muscle flap interposition. The decision to proceed with surgical closure should be made on a case-by-case basis, taking into account the patient's individual needs and health status, as highlighted in the American Thoracic Society statement 1.

From the Research

Methods of Tracheocutaneous Fistula Closure

There are several methods of tracheocutaneous fistula closure, including:

• Fistulectomy with primary closure in layers, which provides a good cosmetic result without the need for significant postoperative wound care 2
• Direct or flap closure of large tracheocutaneous fistulas, although this method has been associated with significant complications and morbidity 3
• Excision of the fistula, replacement of the tracheotomy tube, and healing by second intention after a short recannulation period, which has been recommended for patients with large tracheocutaneous fistulas 3
• Closure by secondary intention, which has been found to be the most effective method for TCF closure, followed by primary and secondary intention combined 4

Surgical Techniques

Various surgical techniques have been used to close tracheocutaneous fistulas, including:

• The use of temporary metal-covered tracheal stent and hinged turnover skin bi-flaps reinforced with rib cartilage grafts 5
• The use of rib cartilages to reconstruct the trachea and prevent stenosis 5
• The insertion of a covered metallic stent to avoid flap collapse, which can be removed after a few months 5

Considerations for Closure

When considering closure of a tracheocutaneous fistula, several factors should be taken into account, including:

• The size of the fistula, with larger fistulas potentially requiring more complex closure techniques 3, 5
• The presence of comorbidities, which can affect the outcome of closure 6, 4
• The need for a multidisciplinary approach and proper patient counseling 6