Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction

Abstract

Objectives: Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction. Methods: A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019. Results: A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy ( P = .86), age at decannulation ( P = .97), duration of tracheostomy ( P = .43), or gestational age ( P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter ( P = .02) and stent size ( P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up. Conclusions: Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation

“…The observed rate of two‐thirds is consistent with recent series suggesting a frequency as high as 57% 4,9 . The only data suggesting a higher TCF rate was in a report of successfully decannulated children after laryngotracheal reconstruction where 85% developed a persistent TCF 16 . Recognizing the frequency of a persistent TCF guides management decisions after decannulation.…”

“…4,9 The only data suggesting a higher TCF rate was in a report of successfully decannulated children after laryngotracheal reconstruction where 85% developed a persistent TCF. 16 Recognizing the frequency of a persistent TCF guides management decisions after decannulation. Given the physiologic and cosmetic impact of a persistent communication between the trachea and the external environment, close monitoring to ensure closure after decannulation is necessary.…”

Pediatric tracheostomy decannulation: what's the evidence?

“…Recent reports suggest the rate of TCF following decannulation to be between 49% and 65% [31,32],33]. In patients decannulated following double-stage open airway reconstruction, the incidence has been found to be as high as 85% [34]. The most commonly identified risk factor related to TCF formation is duration of tracheostomy, with a cannulation period of over 24 months being most strongly correlated [31,32,33].…”

Moisture-Associated Skin Damage

“…29 In addition to these individuals requiring short-or long-term management with tracheostomy, as many as 70% of adults and children with a tracheostomy for more than 16 weeks will experience a persistent tracheocutaneous fistula that typically requires 1 or more surgical procedures to repair. [29][30][31] The pathophysiology of irritant contact dermatitis created when skin is exposed to respiratory secretions is not known. Research concerning the prevalence of peristomal irritant contact dermatitis is also sparse; a single report in Chinese indicated a 38.5% prevalence of respiratory secretion irritant contact dermatitis in persons with tracheostomies.…”

“…Similarly, Branco's group30 reviewed medical records of 5265 patient with cervical spinal cord injuries and reported that 20.6% required long-term tracheostomy for ventilatory support 29. In addition to these individuals requiring short- or long-term management with tracheostomy, as many as 70% of adults and children with a tracheostomy for more than 16 weeks will experience a persistent tracheocutaneous fistula that typically requires 1 or more surgical procedures to repair 29–31…”