Perioperative management of tracheocutaneous fistula closure: a narrative review

Introduction

A tracheocutaneous fistula (TCF) is a common complication of tracheostomy decannulation and leads to a range of clinical challenges requiring a thorough understanding of perioperative management strategies. TCF is a pathological communication between the trachea and the skin that may persist after the tracheostomy tube removal. Most tracheal stomas heal by secondary intention after decannulation. However, a TCF occurs when squamous epithelialization and mucocutaneous overgrowth of the tracheal stoma tract prevents natural closure (1). TCF formation results in significant issues for patients due to skin irritation from secretions, a weak cough, decreased airway protection from loss of subglottic pressure, and the psychosocial impact of having a fistula on the neck (2).

Historically, development of a TCF was a rare complication, with rates ranging from less than 1% to just over 3% from studies in the 1960s and 1970s (3,4). However, more recent literature suggests a higher incidence, with rates ranging from 30% to 65% (5-9). This increase can be attributed to a shift in tracheostomy indication; with a focus on chronic disease such as prolonged respiratory failure and congenital malformation (10,11). In the past, tracheostomy insertion was primarily performed for acute infection of the upper respiratory tract. This change in indication has led to a longer duration of tracheostomy, which in turn, is independently associated with higher rates of persistent TCF (9,12,13).

In this review, we comprehensively overview perioperative management strategies for TCF closure, including risk factor identification, preoperative diagnostic testing, surgical and anaesthetic techniques, and potential postoperative complications. By reviewing the latest available evidence, the review will support the best care for patients with a TCF and serve as a valuable reference for managing TCF closure. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-23-40/rc).

Methods

A systematic literature search was conducted in November 2023, using the following databases and sources: PubMed, Medline, SciELO, LILACS, and Cochrane databases. The search employed the MeSH term and free text search term of “tracheocutaneous fistula” to capture articles related to the perioperative management of tracheocutaneous fistula closure.

No timeframe constraints were applied to the searches, ensuring a comprehensive inclusion of relevant articles. Inclusion criteria consisted of review articles, editorials, correspondence or trials related to TCFs. Evidence was excluded if not related directly to TCF closure.

The selection process was independently conducted by the first author (J.S.). Titles and abstracts were reviewed, and articles deemed clinically relevant to the perioperative management of TCF were included. References included in these articles were also reviewed and again those deemed relevant by title and abstract selected (Table 1).

Risk factors of TCF development

Multiple risk factors have been identified that significantly increase the likelihood of developing TCF in both paediatric and adult populations. These risk factors range from the patient’s age at the time of tracheostomy placement, duration of tracheostomy dependence, to underlying conditions and lifestyle choices.

Data from both Teplitzky et al. (9) and Ha et al. (13) indicate that paediatric patients have a high risk of developing TCF after tracheostomy decannulation. Children who had tracheostomies placed at a younger age (under 12 months of age) and those who were tracheostomy-dependent for a longer duration (over 24 months) had a greater risk of developing a TCF (9,12,13). Additional risks associated with the development of TCF in paediatric patients are, short gestation periods, congenital malformations, newborn complications, maternal complications, and chronic respiratory failure (9). Despite concerns of stomal maturation sutures, often used in paediatric patients, increasing the risk of TCF development recent studies have not found a significant association (14,15).

Although more common in paediatric patients, TCF also occurs in adult patients (16). Smoking, thyroid or laryngeal malignancy, and airway obstruction as an indication for tracheostomy are risk factors for persistent TCF after decannulation in adult patients (16). Patients with these risk factors should be closely followed after tracheostomy insertion and considered for surgical closure if fistula closure fails. In adult patients undergoing supracricoid partial laryngectomies, chronic aspiration and associated cough were found to play a significant role in the development of TCF (7).

Preoperative diagnostic testing

Preoperative diagnostic testing plays a crucial role in the perioperative management of TCF closure. In order to ensure successful closure of the fistula and minimise complications, it is essential to thoroughly assess the patient’s airway and identify any potential abnormalities or pathologies that may affect surgical outcome. Various diagnostic tests are employed to evaluate airway anatomy, function, and potential respiratory complications.

Direct laryngoscopy and bronchoscopy

Direct laryngoscopy and bronchoscopy are commonly performed procedures in the preoperative evaluation of TCF closure (12,17-20). This can be performed as a separate procedure prior to the TCF closure or in the same operation. The purpose of this diagnostic test is to directly visualise and assess the airway structures, particularly focusing on the region in and around the fistula site. This procedure allows for a thorough examination of the airway, enabling the identification of potential abnormalities that may impact the surgical approach and outcome.

During direct laryngoscopy and bronchoscopy, the aim is to identify specific findings that may influence the management of TCF closure. These findings can include:

• Size of internal stoma: direct closure of a large tracheal defect could result in an ‘A-frame’ deformity at the tracheostomy site, which may result in respiratory compromise;
• Tracheal granuloma: granuloma formation is a common complication following tracheostomy insertion (21,22), which must be identified and may necessitate removal before TCF closure (17,23-26);
• Vocal cord immobility: this can cause respiratory compromise and may require additional intervention during TCF closure (17,20);
• Suprastomal collapse: suprastomal collapse refers to the collapse of the tracheal wall above the stoma, which may require additional surgical procedures to correct (23,27);
• Acquired airway stenosis: airway stenosis is a potential complication of tracheostomy (22), and its presence must be assessed to guide the surgical approach or the requirement for additional surgical intervention (20,24,28).

Sleep studies

Recognising the dependency on a patent TCF for respiration is critical in the preoperative evaluation of TCF closure. Some patients rely on a patent TCF for adequate respiration and closing the fistula without adequate assessment and planning could lead to significant respiratory complications (29).

Preoperative overnight pulse oximetry monitoring, also known as a “mini sleep study”, is a noninvasive test that provides valuable information on the patient’s oxygen saturation and respiratory function during sleep. This test involves placing a pulse oximeter on the patient’s finger or earlobe to continuously monitor oxygen saturation levels throughout the night. The tracheostomy stoma must be occluded to provide accurate results. In a cases series by Ferns et al. (12), if the patient’s oxygen saturation remained above 92% with no respiratory distress, then closure proceeded. One patient in their cohort was cancelled due to overnight oxygen desaturation. In the literature, the prevalence of preoperative use of mini sleep studies varies, with reported rates ranging from 43% to 72% (12,30).

Polysomnography (PSG) is a comprehensive sleep study that serves as the gold standard for assessing respiratory function before tracheostomy decannulation (31). It provides a more complete assessment of upper airway obstruction compared to pulse oximetry, which only measures oxygen saturation levels. In a study by Chorney et al. (17), 36% of children undergoing TCF closure were referred for preoperative PSG. Most of these children had a normal PSG or mild obstructive sleep apnoea (OSA), with the highest apnoea-hypopnea index (AHI) identified being 7.6 events per hour. The results of the PSG led to two patients undergoing adenotonsillectomy in preparation for TCF closure.

Other diagnostic imaging techniques

Computed tomography (CT) and magnetic resonance imaging (MRI) can offer detailed anatomical information about the presence and positioning of a TCF in relation to surrounding structures (32). However, it is not standard practice to use these imaging modalities.

Virtual bronchoscopy is a noninvasive imaging technique that allows for a detailed intraluminal airway assessment (33). Virtual bronchoscopy can aid in imaging stenotic areas that may be difficult to navigate with a fibreoptic bronchoscope.

Surgical techniques for TCF closure

The surgical techniques for TCF closure have evolved over the years, with various methods being utilised to achieve optimal outcomes. The choice of technique often varies based upon surgeon preference and patient-specific factors such as fistula size or patient comorbidity. The most commonly performed methods are primary closure and secondary closure.

Primary closure involves direct suture closure of the fistula. This method generally consists of fistulectomy, where the entire tract of the TCF is excised followed by layered closure of the resultant defect (29). This approach ensures complete removal of the epithelialized fistula tract and proposed quicker healing with potentially better cosmetic results (26,34-36).

Alternatively, secondary closure, which involves healing by secondary intention, allows the tract to heal naturally over a period of time following fistulectomy, and has been proven to be successful in closing TCFs (34,37). In theory, leaving the tract open can allow for air to release whilst the excised area heals via physiologic contraction reducing the risk of complications relating to air leak (37). Despite this, current systematic reviews show no decreased risk of air leak and related complications when secondary closure is utilised (34,37). There is also a reported reduction in operative time, intensive care stay and hospital length of stay with secondary closure (2,38).

While primary and secondary closure of TCFs remain the common choices, surgeons are also exploring the benefits of using local flap techniques. Local flap techniques, using adjacent skin flaps and named muscle flaps, provide an alternative to primary or secondary closure (39-42). These methods use adjacent tissue to close the TCF, minimizing tension on the closure site, which may lead to improved healing times and cosmetic outcomes. They are especially useful in cases where primary or secondary closure is not feasible, such as when dealing with larger TCFs (43).

Our institution’s preference for the management of large TCFs, especially with patients on non-invasive ventilation, is to use a costal cartilage autograft. It is harvested and shaped into a shield graft and has the structural integrity to maintain a patent lumen on inspiration and expiration. This prevents the complication of ‘A-frame’ deformity, which may occur with direct closure of a larger TCF (44,45).

In certain scenarios, nonoperative techniques have been promoted. Cauterization with agents like silver nitrate and coblation are simple noninvasive alternatives to surgery, especially for closure of smaller fistulae (46-49).

The success rate for TCF closure using various techniques is generally high, with most studies reporting closure rates above 90% (34,36,37). Complications across different methods do not appear to differ significantly, with both primary closure and secondary intention presenting acceptable risks (34,37).

There is a difference of opinion amongst surgeons regarding the use of postoperative drains. While some advocate for their routine use (12,50), others only use drains in select cases (19,30). The reported purpose of using a drain is to allow the release of air and reduce the risk of subcutaneous emphysema or pneumothorax. However, studies have not shown a consistent decrease in risk (19,30,36), suggesting that the decision to use drains depends on the surgeon’s preference and the patient’s specific needs.

Anaesthetic techniques in TCF closure

While there is extensive literature on surgical techniques for TCF closure, there is relatively less information available on the anaesthetic management of these procedures. However, the existing literature does outline some key themes and techniques related to anaesthetic approaches for TCF closure.

Ferns et al. (12) provided details on the perioperative anaesthetic management of TCF closure in 96 children; 90% of cases utilised inhalational induction with 96% undergoing tracheal intubation. Neuromuscular blockade was administered in around 50% of cases and intraoperative systemic steroids in 60%. While induction and maintenance of anaesthesia were generally uneventful, their research highlighted complications such as laryngospasm and difficulty in ventilating in 2% of cases.

In contrast to traditional approaches involving intubation, Ji et al. (18) proposed the use of SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) during paediatric airway surgeries. This technique offers benefits such as maintaining spontaneous respiration, unobstructed surgical access, and applicability across various procedures. The use of STRIVE Hi in this study demonstrated feasibility in airway cases including TCF closure.

During surgery, a “leak test” was documented in approximately 35% of the cases reviewed by Ferns et al. (12) and 40% of cases by Wong et al. (30). This test involves irrigating the surgical wound with saline solution and simultaneously applying positive pressure ventilation in a “Valsalva” type manoeuvre. The purpose of this test is to assess the patency of the airway and the effectiveness of the fistula repair in preventing air leakage (29).

Prophylactic antibiotics are not consistently given to all patients, with usage rates ranging from 14% to 100%. This wide variation suggests that institutions have different approaches and there is a lack of clear evidence to guide their use. Nevertheless, they may be used in specific cases depending on the patient’s risk factors (24,29,30,50).

In challenging airway scenarios, Sawardekar et al. and Przybylo et al. highlighted a retrograde fibreoptic technique as an alternative method for securing the airway in patients with a difficult airway and a TCF (51,52). In these two cases a fibreoptic bronchoscope was passed through the TCF in a cephalad direction passing through the larynx and nasopharynx. An endotracheal tube was then advanced over the fibreoptic bronchoscope.

Postoperative complications after TCF closure

While TCF repair is generally safe and effective, like any surgical procedure, it is not without its risks. Complication rates in the literature range from approximately 5% to 20%, depending on whether one considers all complications or specifically major complications (12,19,25,29,30,53). Minor complications include issues like wound infection, dehiscence, and TCF recurrence, while major complications include subcutaneous emphysema, pneumomediastinum, and pneumothorax.

Respiratory complications

Respiratory distress, air leaks, pneumonia, and subcutaneous emphysema are significant concerns during TCF closure (12,30). Air leaks occur in up to 5% of cases and may result in subcutaneous emphysema, pneumomediastinum and/or pneumothorax, particularly in patients with prior respiratory distress, postoperative coughing and larger fistula size (12,24,30,54,55). Postoperative positive pressure ventilation is an independent risk factor for air leak, increasing the risk from 4% to 33% (25).

The management of air leak after TCF closure will depend on the degree of respiratory distress. The first step is to remove any surgical stitches to reopen the TCF tract. This reduces the air leak into the subcutaneous tissue, mediastinum or pleural space (20,54). If the leak is severe, resulting in airway and breathing compromise, oral endotracheal intubation or reinsertion of a tracheostomy may be indicated (20,54). Supplementation of oxygen should be provided to ensure adequate oxygenation and alleviate hypoxemia caused by the sequelae of the air leak. Close monitoring of the patient is essential to assess respiratory status and detect any deterioration; which may require admission to the intensive care unit (12).

Respiratory distress seen after TCF closure postoperatively is multifaceted. Approximately 24% in one study encountered desaturation episodes within the initial 24 hours (12). Supplemental oxygen use postoperatively ranges from 8–16% (12,25,53). Postoperative stridor requiring treatment with nebulized epinephrine, nebulized steroids or intravenous steroids has been shown to occur in approximately 10% of TCF closures (25). Rarely would the respiratory distress require the patient to be reintubated or recannulated (26).

Development of pneumonia during the perioperative period is uncommon with a reported incidence of up to 4% (30).

Wound complications

Wound related complications can pose notable challenges in TCF closure (30,56). Wound infection, with an incidence of up to 12% (24,30,50), occurs around the closure site, leading to inflammation and potential wound breakdown. TCF repairs may be at increased risk of infection due to small leaks in the internal suture line allowing saliva into the wound (50).

Wound dehiscence, a variable complication influenced by factors such as infection, nutritional status, and co-morbidity such as diabetes mellitus, is rarely seen (24). Tracheocutaneous sinus formation is an extremely rare complication that occurs following a wound dehiscence, resulting in a persistent open tract. This can potentially lead to recurring infection (56).

TCF closure, especially by secondary intention, can lead to poor aesthetic scar results due to atrophy and adhesion of the subcutaneous tissue to the tracheal wall (57). A reported benefit of local flap techniques of TCF closure is to improve the cosmetic result (57,58), although there is insufficient evidence to confirm this (37).

Airway complications

Tracheal stenosis and granulation necessitate careful consideration due to their significant long-term consequences (53). Tracheal stenosis, characterised by the narrowing of the trachea, is a theoretical postoperative complication that appears to be exceedingly rare (19). Tracheal granulation, characterised by excess tissue growth at the intratracheal stoma site, is another variable complication seen at a higher incidence when repair is completed with secondary intention (26,53).

Conclusions

The perioperative management of TCF involves a balance of preoperative assessment, surgical expertise, and perioperative management. This literature review revealed that the incidence of persistent TCF appears to be on the rise due to longer tracheostomy duration associated with an increase of tracheostomy use in chronic disease.

From a diagnostic perspective, the importance of thorough preoperative evaluation, including direct laryngoscopy, bronchoscopy, sleep study, and additional imaging, is important to optimise the success of the surgical approach and reduce postoperative complication. Techniques such as primary and secondary closure remain the mainstay approaches with high success rates and comparable complication profiles. Local flap techniques can be used in large and complex TCF and nonoperative techniques also stand as viable options for small TCFs.

Anaesthetic considerations are critical for ensuring safe and effective perioperative management, with an emphasis on tailoring the approach to individual patient needs. However, despite the advancements in management protocols and surgical techniques, complications remain an inherent risk. These range from minor wound infections to serious respiratory distress and require prompt recognition and management to avoid long-term sequelae.

Given the increasing incidence of persistent TCF, areas for future work and research in the management of TCF closure should focus on further identification and reduction of modifiable risk factors in TCF development. Other important unanswered questions are the use of antibiotics in reducing infection related complications and the utility of drain insertion to reduce air leak risk. Future research should also look to standardise preoperative diagnostic testing to ensure appropriate patient selection.

In conclusion, this literature review indicates that while TCF closure has become a routine and highly successful surgical procedure, attention to detail in the perioperative phase is essential for minimizing complication and optimizing patient outcome.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-23-40/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-23-40/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-23-40/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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