Decision algorithm and surgical strategies for managing tracheocutaneous fistula

Tracheostomies are frequently performed during the treatment of critically ill patients in intensive care (1). Decannulation methods vary depending on a patient’s ability to tolerate certain procedures and physician’s experience. In most cases, a simple removal of the tube and the application of occlusive dressings produce acceptable functional and aesthetic results (2). However, the procedure is performed with some risk of subsequent development of tracheocutaneous fistulas (TCF), which develop when the squamous epithelium migrates into the trachea creating an epithelialized tract that fails to close. Kulber et al. have reported that 70% of adult patients who have tracheostomies for more than 16 weeks end up with TCFs (3). It has also been reported that 13% to 43% of children with tracheostomies develop TCFs after decannulation (4). Prolonged cannulation can significantly increase the risk of persistent fistulas, which can then lead to difficulties in vocalization and secretion clearance, and recurrent respiratory infections as well as social and cosmetic problems (5). Thus, TCFs often require local wound care and plastic reconstruction