What are the preoperative, intraoperative, and postoperative considerations for a patient undergoing tracheoesophageal puncture?

Tracheoesophageal Puncture: Perioperative Considerations

Tracheoesophageal puncture for voice restoration after total laryngectomy requires meticulous attention to patient selection, procedural technique, and vigilant postoperative monitoring, as both minor and major life-threatening complications can occur, particularly in the early postoperative period.

Preoperative Considerations

Patient Assessment and Selection

• Obtain written informed consent after providing detailed information about the procedure, including perforation risk and potential need for endoscopic or operative intervention 1
• Screen for risk factors that may increase complication rates, particularly esophageal or hypopharyngeal stricture, which is associated with higher postsurgical complications 2
• Evaluate history of radiation therapy, as irradiated patients can still achieve successful TEP outcomes (97% continued use) with acceptable complication rates (10%) 3
• Assess for comorbidities including diabetes, chronic obstructive pulmonary disease, and alcoholism, though these have not been definitively linked to increased TEP complications 2

Timing and Technique Selection

• Secondary TEP (performed after laryngectomy healing) is the standard approach and can be safely performed in the office setting with local anesthesia, avoiding general anesthesia risks and reducing costs 4, 5
• Ensure patients fast for at least 6 hours before the procedure to ensure gastric emptying 1
• For office-based procedures, proper patient selection and regular speech-language pathologist follow-up are critical 4

Contraindications

• Do not perform TEP in patients with active or incompletely healed esophageal perforation, as this may extend the defect and promote mediastinal soiling 1
• Exercise caution in patients requiring stricture dilation, as this is associated with increased immediate complications, likely related to the esophagoscopy or dilation itself 2

Intraoperative Considerations

Personnel and Equipment

• Procedures should be performed only by experienced operators who maintain sufficient procedural volume, supported by at least two assistants (one must be a trained nurse) 1
• Ensure the procedure room has access to X-ray screening and surgical support, or perform in a similarly equipped radiological suite 1
• Have a clear protocol for managing perforations, with identified qualified surgeon availability (on or off site) 1

Procedural Technique

• Use wire-guided or endoscopically controlled techniques to enhance safety 1
• Consider fluoroscopic guidance for high-risk cases, though simple procedures can be performed safely without fluoroscopy 1
• For office-based secondary TEP, utilize a standardized kit-based approach with endoscopic snare available if difficulty passing the guidewire occurs 5
• Immediate voicing is achievable in most cases (12 of 14 patients in one series) 4

Anesthesia Approach

• For office-based procedures, local anesthesia without sedation is well-tolerated and eliminates general anesthesia risks 4, 5
• For operating room procedures, offer intravenous sedation with benzodiazepine and opioid analgesic as minimum, with propofol sedation or general anesthesia as alternatives based on complexity and patient preference 1

Postoperative Considerations

Immediate Post-Procedure Care (Days 0-4)

• Monitor for hemorrhagic signs every 3 hours postoperatively, checking both at the stoma site and during tracheal suction 1
• Verify prosthesis position and function immediately, ensuring easy tracheal suction and absence of subcutaneous emphysema in cervical or thoracic regions 1
• Check hemodynamic stability and absence of heart rhythm disorders 1
• Examine the stoma for signs of local infection 1
• Change dressing with physiological saline 3 times per 24 hours to prevent secretion accumulation and moisture at the stoma 1
• Position patient with head elevated 30 degrees in median position, preserving head-trunk axis during mobilization 1

Early Complication Recognition (First Month Critical)

• Life-threatening complications including mediastinitis and paraesophageal abscess can occur in the first postoperative month and require immediate recognition 6
• Monitor for persistent chest pain, fever, breathlessness, or tachycardia, which should prompt CT scan with oral contrast to evaluate for perforation 1
• If perforation is suspected, perform repeat endoscopy or contrast injection to consider immediate treatment with fully covered self-expanding metal stent 1
• In patients with tracheoesophageal fistula and respiratory compromise, double stenting of esophagus and airway or esophageal stenting is recommended with self-expanding metallic stents, though airway compromise must be assessed before esophageal stenting 1

Common Minor Complications

• TEP enlargement/leakage around prosthesis is the most common complication (19.1%) and the most frequent cause of complete TEP closure 6
• Granulation tissue formation occurs in approximately 4% of cases 6
• Prosthesis deglutition occurs in 12.7% of cases 6
• Overall complication rate during mean 15-month follow-up is approximately 42.6%, higher than previously suspected 6, 2

Ongoing Management

• Provide patients with written contact information for the on-call team for chest pain, breathlessness, or feeling unwell 1
• Ensure regular follow-up with speech-language pathologist for prosthesis management and voice optimization 4
• Monitor patients for at least 2 hours in recovery with clear written instructions on fluids, diet, and medications 1
• Ensure patients tolerate water before hospital discharge 1

Prosthesis Care

• Change tracheostomy tube (if present) based on clinical considerations, particularly for suspected local infection, bleeding, or to facilitate speech 1
• Perform tracheal suction according to usual practice, measuring maximum depth to carina plus one centimeter 1
• Provide airway humidification with heated humidifier as needed 1

Critical Pitfalls to Avoid

• Never ignore persistent postoperative pain, fever, or respiratory symptoms, as these may indicate life-threatening mediastinitis or abscess formation requiring urgent intervention 6
• Do not perform routine imaging after uncomplicated procedures, but maintain low threshold for CT imaging if symptoms develop 1
• Avoid performing TEP in patients with unhealed perforations or active esophageal pathology 1
• Do not underestimate complication rates—they are higher than historically reported and require vigilant monitoring throughout the early and late postoperative periods 6, 2