Successful Closure of a Tracheocutaneous Fistula After Prolonged Tracheostomy With Reverse Pectoral Muscle-Cutaneous Flap

Introduction

Tracheocutaneous fistula (TCF) is one of the most feared complications after prolonged tracheostomy. Problems related to the TCF include the increased possibility of respiratory infections, difficulty in phonation, ineffective coughing, skin irritation, cosmetic problems, limitations in swimming and bathing, and social problems. Its incidence ranges widely from 3.3% to 43%, and the persistence of TCF is related to the duration of cannulation, age at tracheostomy, and the technique employed. Direct closure of the fistula without a protection flap carries a high possibility of pneumothorax, pneumomediastinum, respiratory compromise, and wound breakdown.

Case Report

The authors report the case of a 65-year-old patient who had received a heart transplant for dilated cardiomyopathy and who needed a tracheostomy for mechanical invasive ventilation in the postoperative period. A spontaneous closure of the defect was expected after removal of the tracheal cannula but the fistula persisted, perhaps because the patient needed ventilation support with continuous positive airway pressure (CPAP) therapy. The preoperative computed tomography scan confirmed the fistula and fiber-optic bronchoscopy (FBS) showed a TCF without tracheal stenosis. Therefore, the authors decided to perform primary closure of the TCF using a pectoral muscle-cutaneous flap.

Surgical Procedure

Under general anesthesia, the patient was placed in the standard supine decubitus position. The authors performed a cervical transverse skin incision of about 4 cm. Subsequently, they performed a pectoral reverse muscle-cutaneous flap with supraclavicular tunneling. The tracheal defect was attached and covered with the flap, which was sutured to the tracheal wall with interrupted sutures. The operation took 100 minutes with insignificant blood loss. The intraoperative FBS showed a good tracheal lumen without stenosis and the patient was extubated immediately. The postoperative course was uneventful.
The FBS after one month showed that the TCF was completely repaired without recurrence or tracheal stenosis.

Suggested Reading

1. Tasca R, Clarke R. Tracheocutaneous fistula following paediatric tracheostomy—a 14-year experience at Alder Hey Children’s Hospital. Int J Pediatr Otorhinolaryngol. 2010;74(6):711-712.