Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap.

Tracheocutaneous fistula and tracheostomy scar are complications associated with the prolonged use of tracheostomy tubes. They have functional and cosmetic problems owing to tracheal tugging during swallowing and easily visible scars. Although many procedures exist to correct this issue, there is no consensus on the optimal surgical technique. Therefore, an ideal surgical procedure was devised. The study was performed on 12 patients between September 2016 and May 2021. All patients had persistent tracheocutaneous fistulas or hypertrophic scars on the neck after tracheostomy. All procedures were performed using a hinged flap and two myocutaneous local flaps. All patients had no complications, and their aesthetics were excellent in postoperative photographs. The scar was better on the straight scar when the flap's skin is denuded than on the VY advancement flap. It should be noted, however, that this procedure can cause the flap to become congested in a short period after head and neck surgery. This procedure is safe, reliable and simple for surgical closure. This was found to produce excellent cosmetic results with no major complications.

Primary versus secondary closure of tracheocutaneous fistula in pediatric patients.

OBJECTIVE: Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS: Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS: A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION: Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.

An imaging study on tracheomalacia in infants with esophageal atresia: the degree of tracheal compression by the brachiocephalic artery is a good indicator for therapeutic intervention.

PURPOSE: Tracheomalacia (TM) is a frequent complication after esophageal atresia (EA) repair. This study aimed to review patients who underwent aortopexy for TM after EA repair and to compare their imaging features. METHODS: The patients who underwent thoracoscopic EA repair and contrast-enhanced computed tomography (CECT) at our hospital between 2013 and 2020 were retrospectively reviewed. The ratio of the lateral and anterior-posterior diameter of the trachea (LAR) where the brachiocephalic artery (BCA) crosses the trachea was defined. The LAR of the patients who underwent CECT for asymptomatic pulmonary disease was set as a normal reference. The Z-score of each LAR was calculated and compared between the patients that did or did not undergo aortopexy. RESULTS: A total of 51 patients represented the controls, 5 patients underwent aortopexy, and 12 patients were discharged without surgery. The mean LARs in the patients who underwent aortopexy, did not undergo aortopexy, and controls were 3.54, 1.54, and 1.15, respectively. The mean Z-score of the aortopexy group was 21.2. After successful aortopexy, each patient's LAR decreased to < 1.5. CONCLUSION: Aortopexy was preferred if the trachea was compressed by the BCA. The LAR is a useful indicator for predicting the therapeutic effect of aortopexy.

Cinematic rendering enhancements to virtual bronchoscopy: assessment of emergent tracheal pathology.

Utilizing complex lighting models, cinematic rendering is a novel technique for demonstrating computed tomography data with exquisite 3D anatomic detail. The tracheal lumen, tracheal wall, and adjacent soft tissue structures are represented with photorealistic detail exceeding that of conventional volume rendering or virtual bronchoscopy techniques. We applied cinematic rendering to a spectrum of emergent tracheal pathologies: traumatic tracheal tears, tracheoesophageal fistulas, tracheal foreign bodies, tracheal stenosis (intrinsic and extrinsic causes), tracheal neoplasms, and tracheomalacia. Cinematic rendering images enable visually accessible evaluation and comprehensive understanding of acute tracheal pathology, which is likely to be of value to both interventional pulmonologists and thoracic surgeons who are determining patient treatment plans.

Acute tracheal tear - A potential cause of spontaneous pneumomediastinum in patients with COVID-19.

Spontaneous pneumomediastinum following prolonged periods of severe coughing should raise the suspicion of tracheal rupture in COVID-19 patients.

Tracheal Injury during Endoscopic Transoral Vestibular Approach Thyroidectomy: A Case Report.

This report describes the intraoperative course of endoscopic thyroidectomy by oral vestibular approach in a female patient. This operation is new, and its perioperative management is not yet mature. In this case, the surgery resulted in trachea injury that could not be detected easily. As a result, the patient suddenly developed acute dyspnea and circulatory disorder. This procedure requires caution in surgical execution and anesthesia management.

Reducing Pediatric Tracheostomy Wound Complications: An Evidence-Based Literature Review.

OBJECTIVE: To discuss prevention strategies that can mitigate the frequency of tracheostomy-related wound complications. DATA SOURCES: A systematic literature review of PubMed between 2010 and 2019. STUDY SELECTION: Full-text articles written in English language and studying human participants younger than 18 years. DATA EXTRACTION: The primary outcome was the rate of tracheostomy-related skin complications after implementation of a given intervention. Secondary outcomes included rates of accidental decannulation or other complications. DATA SYNTHESIS: A total of 348 studies were identified and 6 met inclusion criteria. There were 1,607 children included with interventions designed to reduce peristomal and cervical wound complications in 1,174 (73.1%). Strategies considered safe and effective included protective skin barriers, reducing prolonged pressure, and early wound identification protocols. CONCLUSIONS: Wound complications after pediatric tracheostomy can be reduced using a multifaceted approach by providers committed to making skin care a priority.

Conservative management of trachea-to-innominate artery transfixion with a guidewire during percutaneous tracheostomy: a case report.

BACKGROUND: Tracheostomy is a standard procedure in critically ill patients requiring mechanical ventilation or airway protection for extended periods. The main cause of death is haemorrhage, most commonly owing to a trachea-to-innominate artery fistula, usually requiring surgical treatment. CASE PRESENTATION: Here we report the case of an 83-yr-old woman with a subarachnoid haemorrhage, who incurred a trachea-to-innominate artery transfixion following percutaneous tracheostomy, successfully and conservatively managed by interventional radiology. CONCLUSIONS: The use of peri-procedural ultrasound examination of the neck can reduce the risk of complications related to vessel anatomical variants. When the tracheostomy is complicated by bleeding, the procedure should be stopped in order to diagnose the vascular iatrogenic injury and to evaluate the best therapeutic approach by a multidisciplinary team.

Correlation of Symptoms with Bronchoscopic Findings in Children with a Prenatal Diagnosis of a Right Aortic Arch and Left Arterial Duct.

A right aortic arch (RAA) with a left arterial duct (LAD) together encircle the trachea and have the potential to cause tracheobronchial compression and published guidelines recommend bronchoscopy in symptomatic patients. The aim of the study was to describe the incidence of tracheal compression in a cohort of prenatally diagnosed RAA and LAD. Retrospective review of clinical course and imaging of prenatal cases of RAA and LAD assessed with flexible bronchoscopy over an 11-year period. 34 cases of prenatally diagnosed RAA with LAD underwent bronchoscopy at median age of 9 months (range 0.4-123) of whom 11 had respiratory symptoms and 23 were asymptomatic. In the neonatal period, three cases demonstrated respiratory symptoms. An aberrant left subclavian artery (ALSA) was identified in 29 cases. Pulsatile tracheal compression was identified in 32/34 (94%) cases and two cases showed normal tracheal appearances. Significant tracheal compression (> 70% occlusion) was present in 25/34 (74%) cases of which 16 were asymptomatic. Significant carinal compression (> 70% occlusion) was identified in 14/34 (42%) cases, an ALSA was observed in 13/14. Surgical relief of a vascular ring has been performed in 27 (79%) cases at a median age of 15 months (range 0.6-128 months). At surgery, a fibrous remnant of an atretic left aortic arch was identified in 11/27 (41%) cases. Significant tracheal compression may be present in infants even without symptoms. If early relief of airway compression is to be achieved to promote normal development of tracheal cartilage, early bronchoscopy should be considered.

Tracheal injury: late symptom after double-lumen tube intubation - A case report.

As a basic skill, endotracheal intubation, performed throughout the world by health care professionals is a relatively safe and effective maneuver. However, this technique is not risk free and could lead to many serious complications. We wanted to report that in a patient with double lumen tube intubation, airway trauma can cause late symptoms . We thought that such complications must be published to share experiences.

[Tracheal Injury Successfully Treated without Surgery;Report of a Case].

A 73-year-old man was injured after crashing his automobile into a concrete wall, and was admitted to our hospital with breathing difficulties. Chest computed tomography showed extensive mediastinal emphysema, right traumatic pneumothorax, and a suspected tracheal injury at the membranous region. Because of the associated tracheomalacia, the site of the tracheal injury was difficult to find by bronchoscopy. In addition, as the patient's respiratory condition was stable, surgical treatment was not chosen. Due to the continuous air leakage from the right lung, the patient underwent surgery after mediastinal and subcutaneous emphysema improved. The postoperative course was uneventful.

Comparison of Salvage Total Pharyngolaryngectomy and Cervical Esophagectomy Between Hypopharyngeal Cancer and Cervical Esophageal Cancer.

BACKGROUND: Total pharyngolaryngectomy and cervical esophagectomy (TPLCE) after chemoradiotherapy remains a challenge because of the high rate of complications and few available data on outcomes and safety. The purpose of this study was to evaluate the clinical significance of salvage TPLCE and to compare treatment outcomes between hypopharyngeal cancer and cervical esophageal cancer. METHODS: Data from 37 consecutive patients who were diagnosed with potentially resectable hypopharyngeal and cervical esophageal cancer after chemoradiotherapy were retrospectively analyzed. The survival and surgical outcomes were investigated between the hypopharyngeal cancer and cervical esophageal cancer groups. RESULTS: Twenty-six patients were included in hypopharyngeal cancer group and 11 patients were included in cervical esophageal cancer group. The baseline characteristics were balanced between the two groups. Compared to the hypopharyngeal cancer group, the cervical esophageal cancer group had significantly more frequent tracheal-related complications (p < 0.05) and stronger association of distal margin of the cervical esophagus and radiation field with tracheal ischemia after salvage surgery. CONCLUSIONS: Salvage TPLCE can offer the exclusive chance of prolonged survival. Association of tracheal ischemia with salvage TPLCE was seen more frequently for cervical esophageal cancer. Therefore, the indication for salvage TPLCE must be carefully considered to maintain the balance between curability and safety.

Individualized airway-covered stent implantation therapy for thoracogastric airway fistula after esophagectomy.

BACKGROUND: Thoracogastric airway fistula (TGAF) is a rare and dangerous complication of esophagectomy performed for esophageal and cardiac carcinomas. Herein, we aimed to explore the feasibility and efficacy of individualized airway stent implantation for the treatment of TGAF after esophagectomy. METHODS: Based on different TGAF types and relevant data on chest computed tomography, customized airway-covered stents were positioned so as to cover the entrance to the fistula by an interventional radiologist using fluoroscopic guidance. RESULTS: Of the 63 patients with TGAF, 12 had thoracogastric-tracheal fistulas, 14 had thoracogastric-carinal fistulas, 21 had thoracogastric-left main bronchial fistulas, 15 had thoracogastric-right main bronchial fistulas, and 1 had a thoracogastric-right intermediate bronchial fistula. The following different stent types were placed: 7 straight self-expandable covered metallic stents, 2 hinged self-expandable covered metallic stents, 41 Y-shaped self-expandable covered metallic stents, and 13 large Y and small Y paired self-expandable covered metallic stents. In all 59 cases (93.65 %), the implantation was successful at the first attempt, with the procedure times ranging from 5 to 10 min. Esophagograms with water-soluble iodinated contrast showed that the fistulae were completely covered with no contrast flowing into the airways and lungs, and with the stents fully expanded. We recorded four cases (6.35 %) of incomplete or recurrent fistula closure. CONCLUSION: Customized airway-covered stents may be an appropriate palliative therapy for patients with thoracogastric airway fistula who are unfit for surgery or have a high postoperative risk.

Obstructive Fibrinous Tracheal Pseudomembrane.

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a rare and potentially severe complication of endotracheal intubation characterized by a tubular pseudomembrane that obstructs the trachea and induces clinical symptoms of airway obstruction after extubation. In this report, we reviewed and summarized all published cases of OFTP (n = 58) between 1981 and 2015. Twenty-three of 52 patients were men, and the mean age was 36 ± 22 years. Intubation was emergent in 41 of 53 cases. OFTP was revealed by acute symptoms in 19 of 39 cases and led to acute respiratory failure in 13 of 39 cases. Symptoms occurred 3 ± 3 days after extubation. A tracheal obstruction ≥70% was observed in 14 of 18 cases. Bronchoscopic removal was performed in 49 of 58 cases with no recurrence. In conclusion, OFTP is characterized by a typical clinical and endoscopic presentation, with no recurrence after bronchoscopic removal. Early recognition and bronchoscopy are key elements for efficient diagnosis and treatment.

[Delayed Tracheal Perforation after Pulmonary Resection for Lung Cancer].

We have experienced a case of delayed tracheal perforation after pulmonary resection using soft coagulation system. A 58-year-old male underwent operation for primary lung cancer. A soft coagulation system was used for oozing near upper mediastinal lymph nodes. The patient was discharged on postoperative day 8 in a good condition, however sudden tracheal perforation and was occurred on postoperative day 30. An emergency operation revealed that improper use of the soft coagulation system might cause a necrosis of the bronchial wall. Although, a soft coagulation system is useful to control bleeding from small vessels such as bronchial arteries and lymph nodes, this system is different from conventional electrocautery and requires some attention when using.

Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience.

BACKGROUND AND OBJECTIVE: Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis. METHODS: We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance. RESULTS: Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities. CONCLUSION: Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.

Tracheoinnominate Fistula: Endovascular Treatment with a Stent Graft in a 4-Year-Old Child.

A 4-year-old boy presented with acute and profuse bleeding at the tracheostomy site. An emergency angiography was performed and identified a pseudoaneurysm at the innominate artery. A selective catheterization of the artery was executed and 2 Advanta V12 balloon-expandable covered stents were implanted in an overlapping manner to occlude the pseudoaneurysm. Final angiography demonstrated patency of the innominate artery and no signs of bleeding. The patient had no postoperative complications and no further bleeding during follow-up. A contrasted computed tomography scan was performed after 20 days and demonstrated no signs of pseudoaneurysm or bleeding. After 4 months, the patient was readmitted to tracheal dilatation and change of T-tube and died of respiratory complications.

Hyperelastic modeling of swelling in fibrous soft tissue with application to tracheal angioedema.

Angioedema, the rapid swelling of under-skin tissue, is typically triggered by complex biochemical processes that disrupt an original steady state filtration of liquid through the tissue. Swelling stabilizes once a new steady state is achieved in which the tissue has significantly increased liquid content. These processes are controlled by events at the molecular to the cellular length scale. For describing consequences at organ level length scales it is useful to invoke consolidated continuum mechanics treatments within a generalized hyperelastic framework. We describe the challenges associated with such modeling and demonstrate their use in the context of tracheal angioedema. The trachea is modeled as a two layered cylindrical tube. The inner layer and outer layer represent the soft mucosal tissue and the stiffer cartilaginous tissue respectively. Axially oriented fibers contribute anisotropy to the inner layer, and the swelling is largely confined to this layer. A boundary value problem is formulated; existence and uniqueness is verified. Numerical solutions track airway constriction as a function of mucosal swelling.