A simple and effective method for closure of enlarged tracheoesophageal puncture in seven patients

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Revised: 15 April 2019

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Accepted: 29 April 2019

DOI: 10.1111/coa.13401

T E C H N I C A L N O T E

A simple and effective method for closure of enlarged

tracheoesophageal puncture in seven patients

Emine Deniz Gozen | Firat Tevetoglu | Caglar Eker | H. Murat Yener | Emin Karaman

Otorhinolaryngology Department, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey

Correspondence

Emine Deniz Gozen, Otorhinolaryngology Department, Istanbul University Cerrahpasa Medical Faculty, Fatih, Istanbul, Turkey. Email: nazas39@hotmail.com

1 | INTRODUCTION

Tracheoesophageal puncture (TEP) is one of the most preferred method for voice reconstruction following total laryngectomy. Persistent leakage around the voice prosthesis (VP) due to enlarged tracheoesophageal puncture is the most common complication.1_As

the risk of respiratory infections including aspiration pneumonia is high, effective treatment is crucial.2

Many conservative and surgical closure techniques have been described for the management of tracheoesophageal fistula (TEF). Conservative methods preserve voice by incomplete closure of the TEF by removing the voice prosthesis with placement of a nasogastric tube to prevent aspiration and waiting for spontaneous narrowing of the fistula. Insertion of a new prosthesis, replacement with silicone ring expanded prosthesis,3_{purse‐string suture}4_{or injection of differ‐}

ent materials like collagen or hyaluronic acid to decrease the diameter of the TEP can be used alone or in combination with other options.5,6

Total closure of the TEP is considered when conservative meth‐ ods fail. Among closure methods, septal button placement or suture ligation techniques are simple methods for especially smaller de‐ fects.7,8_{For large defects, pedicled or free flaps can be considered.}9,10

Due to the lack of studies which compare the treatment meth‐ ods, the most effective treatment is still not clear but in general, con‐ servative treatments have temporary effects and require repeated applications with recurrence rate being between 30% and 67%.1

We hereby present our technique for the closure of especially large TEF in total laryngectomy patients that the other techniques have failed to close.

2 | TECHNICAL NOTES

Patients (n = 7) applied to our clinic with large tracheoesophageal defect as a complication of TEP for voice rehabilitation following

total laryngectomy were treated with multilayer suturing technique. Under general anaesthesia and in supine head extended position, cervical collar incision is done at the level of tracheostomy which passes over the stoma in a circular manner and is extended later‐ ally (Figure 1A). Skin flaps are elevated both inferior and superior. Trachea and oesophagus are separated at the level of TEF site (Figure 1B). Trachea is dissected and freed from the surrounding tis‐ sues with blunt dissection (Figure 1C). The dissection is extended substernally to mobilise the trachea just as the preparation of the trachea in end‐to‐end anastomosis for subglottic stenosis. Mobilised trachea is transposed cranially (Figure 1D). The defect on the an‐ terior oesophageal wall is closed with multilayered primary suture (Figure 2A). The part of the trachea which is involved with the fistula tract is resected (Figure 2B). For tension‐free sutures, the head of the patient is flexed. Freed and cranially transposed trachea is su‐ tured to surrounding skin, and a new stoma is created which overlies the repaired oesophageal anterior wall. By this manner, the oesopha‐ gus is covered with intact and healthy tracheal posterior wall which is used as a vascularised local flap (Figure 2C, 2). This method was applied in seven patients, and in all of the cases, the fistula was suc‐ cessfully closed and oral food intake was achieved (Table 1).

3 | DISCUSSION

Voice rehabilitation following total laryngectomy can be achieved by oesophageal speech, electrolarynx and TEP with voice prosthesis placement. Although tracheoesophageal puncture has better voice results, surgical or postoperative complications can be devastat‐ ing. Most frequent and important complication of TEP is persistent leakage around VP due to enlarged TEP, with a rate of 1%‐29%.1

Considering that persistent leakage is a risk factor for aspiration pneumonia, management of this complication is important though challenging.

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Enlarged TEP can be managed conservatively or surgically. Temporary removal of the VP and waiting for spontaneous closure, while feeding the patient with a nasogastric tube, are usually the first choice for slightly enlarged TEP.1_{Prosthesis replacement with}

a different‐sized prosthesis can also be considered. Silicone ring enhancement is also reported to be successful in selected cases, especially in patients with previous radiotherapy as this technique has no effect on wound healing.3_{Submucosal purse‐string method,}

defined by Jacob,4_{aims to narrow the enlarged TEP. As a surgical}

method, having the advantage of preserving voice, it is not applica‐ ble to larger fistulas. Injection around enlarged TEP is another option to narrow the puncture but usually not available for larger defects.5,6

When conservative treatment methods fail or if the defect is large surgical closure should be considered. As patients usually have wound‐healing problems due to previous radiotherapy or previous treatment attempts the surgery is challenging. Mobashir8_defined

the suture ligation technique which consists of dissecting the tra‐ chea from oesophagus and identifying the fistula tract to ligate it from both ends with primary suture. Three‐layer repair techniques by placing a vascularised healthy tissue like pedicled flaps or free flaps between trachea and oesophagus have been successfully de‐ scribed for large defects.9,10_{However, these operations are more}

morbid and bulky muscular flaps would compromise the airway. We therefore present our technique, as a relatively simple method for closure of even large tracheoesophageal defects due to TEP failure, with lesser morbidity than microsurgical flap techniques

and with greater ability for closure as compared to primary suture and local flap methods. The method is adapted from the technique applied in end‐to‐end anastomosis for laryngotracheal stenosis. After separation of trachea and oesophagus, the fistula tract is resected, oesophageal defect is repaired by multilayer closure of mucosa and surrounding tissues, trachea is dissected substernally and mobilised cranially over the oesophagus. Our technique offers rapid repair of the fistula by creating a new tracheostoma which covers the repaired oesophagus. By this way healthy membranous tracheal wall is used as a vascularised flap to overlie the fistula site

Key points

• Management of tracheoesophageal fistula following voice prosthesis placement is challenging due to wound‐ healing problems and consists of many conservative and surgical techniques.

• Conservative techniques are less successful, have temporary effect and available for only small defects. Surgical treatment is considered for larger defects but is more morbid.

• In this report, a simple and rapid repair procedure adapted from end‐to‐end anastomosis for the treatment of large tracheoesophageal fistula.

F I G U R E 1 A, Incision. B, Fistula tract.

C, Separation of trachea and oesophagus. D, Mobilisation and cephalic repositioning of the trachea

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which decreases wound healing problems. This technique can also be combined with de‐epithelised local flaps that can be secured between the trachea and oesophagus to increase success espe‐ cially for larger defects.

CONFLIC T OF INTEREST

Authors of this manuscript have no conflicts of interest.

ORCID

Emine Deniz Gozen https://orcid.org/0000‐0002‐2586‐3721

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F I G U R E 2 A, Repair of the

oesophagus by multilayered closure. B, Resection of the tracheal fistula. C, Cephalic repositioning of the trachea to close the repaired oesophagus. D, New tracheostoma (A) (B) (C) (D) TA B L E 1 Patient information Age Date of laryngectomy Size of fistula (mm) Previous surgery Date of previous surgeries Date of fistula repair Follow‐up period (mo) 52 09/2014 1.3 – – 06/2017 17 64 01/2015 1.8 – – 10/2016 25 61 11/2013 2.2 Primary suture (multiple times) 02‐04/2016 06/2016 29 57 03/2016 2.9 Primary suture (multiple times) 03‐07/2017 10/2017 13

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How to cite this article: Gozen ED, Tevetoglu F, Eker C, Yener

HM, Karaman E. A simple and effective method for closure of enlarged tracheoesophageal puncture in seven patients. Clin

Otolaryngol. 2019;44:1224–1227. https ://doi.org/10.1111/ coa.13401