Keywords
punctures - prosthesis failure - tracheoesophageal fistula - wound closure techniques
- TEP closure - laryngectomy - meta-analysis
Introduction
Historically, voice rehabilitation after laryngectomy was focused on using esophageal
speech or electronic larynx, but since the introduction of the Blom-Singer Duckbill
prostheses (InHealth, Carpinteria, CA) a more intelligible and fluent speech has been
reported.[1]
[2] Nonetheless, progressive tracheoesophageal puncture (TEP) widening and leakage of
saliva and liquids around the valve into the trachea can result in persistent episodes
of aspiration and pneumonia.[1]
[2]
[3]
Placement of a nasogastric (NG) tube to prevent aspiration and removal of the valve
waiting for spontaneous narrowing of the fistula is usually the first technique attempted
in all such situations unless the fistula is of an atypical massive size. Other conservative
approaches such as replacement with silicone ring expanded prosthesis,[4] purse-string sutures,[5] hyperbaric oxygen therapy,[6] or injections of different substances such as autologous fat,[7] hyaluronic acid,[8] and granulocyte-macrophage colony-stimulating factor to reduce the diameter of the
tracheoesophageal fistula (TEF) have been reported.[4]
[5]
[9]
[10]
[11]
[12]
Unfortunately, TEPs may persist despite conservative management and formal surgical
closure may be indicated to avoid morbid consequences.[13] The purpose of this study was to systematically review the available evidence on
the surgical methods employed for TEP closure focusing on outcomes and reported complications.
Methods
Literature Search Strategy
This review was performed in accordance with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses protocol.[14]
[15] A comprehensive search was conducted across the medical indices PubMed MEDLINE,
Web of Science, SCOPUS, and Cochrane CENTRAL through October 2020. The search strategy
was designed by two authors (J.M.E. and S.M.). The terms ((“Punctures”[Mesh]) OR (“Prosthesis
Failure”[Mesh]) OR (“Prosthesis Implantation”[Mesh])) AND ((“Larynx, Artificial”[Mesh])
OR (“Larynx”[Mesh]) OR (“Laryngectomy”[Mesh]) OR (“Tracheoesophageal Fistula”[Mesh])
OR (“Trachea”[Mesh])) were used as keywords or Medical Subject Headings in several
combinations ([see Appendix, Supplementary Digital Content 1], which displays the search strategy across different databases).
Inclusion and Exclusion Criteria
Studies were included if they (1) described a surgical technique for TEP closure,
(2) were patient-based studies, (3) reported surgical outcomes and complications,
and (4) were written in English. Studies were excluded if they met one of the following
criteria: (1) review articles, (2) preclinical studies, (3) studies reporting patients
with congenital TEFs, and (4) articles presenting surgical methods for closure of
TEPs performed for indications other than puncture-based voice rehabilitation after
oncologic treatment. We excluded articles that included sporadic resolution of the
TEP site or in which conservative treatments for TEP enlargement or leakage were employed.
For quantitative analysis, studies with a sample size of 4 or more patients were included.
Selection of Articles and Data Extraction
After duplicated studies were eliminated, two authors (J.M.E. and V.P.B.) independently
screened the articles based on title and abstract. Then, full-text review of the remaining
theoretically relevant studies using the inclusion criteria was performed using Rayyan
QCRI (Rayyan Systems Inc., Cambridge, MA).[16] Data extraction was performed independently by two reviewers. The extracted data
included the reference, total number of patients, previous surgical history, history
of radiotherapy, type of TEP (primary, TEP performed at the time of reconstruction;
secondary, delayed TEP after reconstruction), indication for closure, surgical technique
for TEP closure, the presence or absence of complications, surgical outcomes following
TEP closure, and follow-up. A third author (O.J.M.) resolved any conflicts during
data extraction.
Outcomes
Successful TEP site closure was defined as the definitive occlusion of a previously
patent tract between the trachea and the esophagus requiring no further interventions.
The primary end-result was to assess the overall unsuccessful TEP closure rate following
surgical management. The secondary outcome was to evaluate the unsuccessful TEP resolution
rate using different surgical techniques (button insertion, dermal graft, forearm
free flap [FFF], ligation of the fistula tract, deltopectoral flap interposition,
sternocleidomastoid muscle [SCM] interposition, and primary closure).
Statistical Analysis
The pooled incidence of a failed TEP closure was calculated using meta-analysis with
Stata/IC 16.1 (StataCorp LLC, College Station, TX). Due to the heterogeneity in treatment
effects caused by differences in characteristics of patients, interventions reported,
follow-up period, and other factors, a logistic-normal-random-effect model was accomplished.[17] The effects size of study-specific incidence were exhibited by proportions 95% exact
confidence intervals (CIs) and the global pooled estimates with 95% binomial CI. A
Freeman–Tukey double arcsine transformation was performed.[18] The effect size and percentage of weight were displayed for every particular study.
Subgroup analysis of different surgical methods for TEP closure was performed.
Interstudy heterogeneity was evaluated using the Q statistic p-values and I
2 statistic.[19] Substantial heterogeneity was considered if I
2 was found to be 50 to 90%, and considerable heterogeneity when I
2 was found to be 75 to 100%.[20] Statistical significance was considered at p-value < 0.05.[20] Publication bias was assessed using a funnel plot graph and an Egger regression
test.[21] Calculations of an adjusted CI and an estimate of the number of missing studies
was accomplished by means of the trim-and-fill method.[22] Cumulative estimates of the patients' clinical and demographic characteristics were
calculated as a weighted mean ± standard deviation.
Quality Assessment
Reviewers independently evaluated the level of evidence and the quality of each publication
using the Oxford Centre for Evidence-Based Medicine: level of evidence (OCEBM).[23] Discrepancies between the reviewers were addressed by a third author.
Results
Literature Search and Quality Assessment
Overall, 1,602 publications were identified during the literature search. After removal
of duplicated references, 1,174 records were screened and 1,058 were excluded based
on review of title and abstract. Following full-text review, 33 articles met the inclusion
criteria and were selected for data extraction ([Fig. 1]).[9]
[10]
[11]
[13]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52] Using the OCEBM, 33 studies had a level of evidence of 4. No discrepancies during
quality assessment occurred.
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
Demographic and Clinical Characteristics
A total of 144 patients were identified, 62% were male (n = 90) and 8.9% (n = 12) were female. Biological sex was not reported in 42 patients. The mean age was
63.5 ± 7.91 years. Ninety-eight patients (68.5%) had previous history of radiotherapy.
Past medical history of radiotherapy was not reported nor specified in 28 patients
(19.4%). Primary or secondary TEP was reported in 66 patients, 92% (n = 61) received a primary TEP (voice prosthesis insertion during laryngectomy) and
7.5% (n = 5) received secondary TEP (insertion of voice prosthesis as a subsequent procedure
in a delayed fashion). The TEP age (time period from puncture to surgical closure)
was 23 ± 11.9 months. The average follow-up of all included patients was 19.7 ± 13.6
months. The demographic and clinical characteristics of included patients are summarized
in [Table 1].
Table 1
Overview of the clinical and demographic characteristics of included studies
|
Author/Year
|
Type of study
|
Patients
(n)
|
Age (y)
|
Oncologic surgical treatment
|
Type of puncture
|
TEP age(mo)
|
RT
|
Indications for closure
|
Fistula dimensions
|
|
Annyas and Escajadillo, 1984
|
Case series
|
6
|
N/R
|
N/R
|
N/R
|
N/R
|
N/R
|
N/R
|
N/R
|
|
Rosen et al, 1997
|
Case series
|
14
|
66.5 ± 11.9 (n = 14)
|
Total laryngectomy (n = 14)
|
N/R
|
14.5 ± 13.2 (n = 14)
|
Yes (n = 13) No (n = 1)
|
Aspiration pneumonia (n = 4)Persistent leakage (n = 8)Failed TE shunt phonation (n = 6)Emphysema (n = 1)Failure to tolerate (n = 3)
|
4.5 mm
|
|
Moerman et al, 2004
|
Case series
|
12
|
66.2 ± 7.5 (n = 12)
|
N/R
|
Primary (n = 11) Secondary (n = 1)
|
19.3 ± 9.82 (n = 11)
|
Yes (n = 10)
No (n = 2)
|
Failure to tolerate (n = 3) Enlargement of fistula (n = 5) Exophytic growth (n = 1)Failed TE shunt phonation (n = 1) Infection (n = 1)
|
N/R
|
|
Mirza et al, 2003
|
Case report
|
1
|
65
|
Total laryngectomy (n = 1)
|
Primary (n = 1)
|
N/R
|
N/R
|
Infection (n = 1)Enlargement of fistula (n = 1)
|
20 mm
|
|
Lee and Razi, 2004
|
Case report
|
1
|
64
|
Total laryngectomy + Partial pharyngectomy + Left radical neck dissection (n = 1)
|
Primary (n = 1)
|
6
|
Yes (n = 1)
|
Failure to tolerate (n = 1)
|
N/R
|
|
Cavalot et al, 2004
|
Case series
|
8
|
N/R
|
Total laryngectomy (n = 8)
|
N/R
|
N/R
|
Yes (n = 5)
No (n = 3)
|
Enlargement of fistula (n = 2) Prosthesis migration (n = 2) Failure to tolerate (n = 3) Granulation (n = 1)
|
N/R
|
|
Ünal, 2006
|
Case report
|
1
|
61
|
Total laryngectomy (n = 1)
|
N/R
|
24
|
N/R
|
Candida overgrowth (n = 1)
Persistent leakage (n = 1)
|
N/R
|
|
Gehrking et al, 2007
|
Case series
|
9
|
60.4 ± 11.5 (n = 9)
|
Laryngectomy (n = 9)
|
N/R
|
N/R
|
Yes (n = 9)
|
Persistent leakage (n = 9)
|
N/R
|
|
Baldwin and Liddington, 2008
|
Case series
|
4
|
59.3 ± 7.59 (n = 4)
|
Salvage laryngectomy (n = 1) Pharyngo-laryngo-esophagectomy + Free jejunal flap (n = 1)Tracheal resection -> Pharyngo-laryngo-esophagectomy + Free jejunal flap (n = 1)Total laryngectomy and B/L neck dissection (n = 1)
|
Secondary (n = 1)Primary (n = 3)
|
6.67 ± 5.03 (n = 3)
|
Yes (n = 4)
|
Failed TE shunt phonation (n = 1) Leakage (n = 1)Necrotic laryngeal cartilage (n = 1)
|
N/R
|
|
Wreesmann et al, 2009
|
Case report
|
1
|
52
|
Total laryngectomy + B/L modified radical neck dissection
|
Primary (n = 1)
|
5
|
Yes (n = 1)
|
Enlargement of fistula (n = 1)
|
40 mm
|
|
Judd and Bridger, 2008
|
Case series
|
5
|
N/R
|
Laryngectomy (not specified) (n = 5)
|
N/R
|
10.6 ± 8.08 (n = 5)
|
N/R
|
Persistent leakage (n = 5)Infection (n = 1)Failure to tolerate (n = 1)
|
N/R
|
|
Schmitz et al, 2009
|
Case report
|
1
|
70
|
Total laryngectomy (n = 1)
|
Primary (n = 1)
|
N/R
|
Yes (n = 1)
|
Dysphagia (n = 1)
|
N/R
|
|
Koch et al, 2010
|
Case series
|
5
|
N/R
|
Total laryngectomy (n = 5)
|
Primary (n = 5)
|
N/R
|
Yes (n = 5)
|
Enlargement of fistula (n = 5)
|
15 mm
|
|
Wong et al, 2011
|
Case report
|
1
|
62
|
Total laryngectomy (n = 1)
|
Secondary
|
N/R
|
Yes (n = 1)
|
Aspiration pneumonia (n = 1) Enlargement of fistula (n = 1)
|
N/R
|
|
Geyer et al, 2011
|
Case series
|
2
|
62.5 ± 9.19 (n = 2)
|
Total laryngectomy (n = 2)
|
Primary (n = 2)
|
46.5 ± 9.19 (n = 2)
|
Yes (n = 2)
|
Aspiration pneumonia (n = 1) Persistent leakage (n = 1)
|
N/R
|
|
Hu et al, 2011
|
Case series
|
6
|
86 (n = 1)
|
Total laryngectomy and partial esophagectomy (n = 1)
|
N/R
|
N/R
|
N/R
|
N/R
|
N/R
|
|
Balasubramanian et al, 2013
|
Case series
|
6
|
62.7 ± 10.8 (n = 6)
|
Total laryngectomy (n = 6)
|
N/R
|
N/R
|
Yes (n = 5) No (n = 1)
|
Persistent leakage (n = 6)
|
N/R
|
|
Mohan and Malata, 2014
|
Case report
|
1
|
60
|
Salvage total laryngectomy + Neck dissection (n = 1)
|
N/R
|
N/R
|
Yes (n = 1)
|
Persistent tracheoesophageal fistula (n = 1)
|
N/R
|
|
Mobashir et al, 2014
|
Case series
|
5
|
58 ± 2.75 (n = 5)
|
Total laryngectomy (n = 5)
|
Primary (n = 5)
|
N/R
|
Yes (n = 5)
|
Enlargement of fistula (n = 5)Persistent leakage (n = 5)
|
N/R
|
|
Unsal et al, 2015
|
Case series
|
4
|
63.5 ± 5.25 (n = 4)
|
Total laryngectomy + B/L neck dissection (n = 3)Total laryngectomy + Partial pharyngectomy + B/L neck dissection (n = 1)
|
Primary (n = 4)
|
64 ± 27.7 (n = 3)
|
Yes (n = 4)
|
Enlargement of fistula (n = 4)Persistent leakage (n = 1)
|
N/R
|
|
Jaiswal et al, 2015
|
Case series
|
9
|
52.3 ± 10.7 (n = 9)
|
Total laryngectomy (n = 9)
|
Primary (n = 9)
|
N/R
|
Yes (n = 7)No (n = 2)
|
N/R
|
N/R
|
|
Wasano et al, 2015
|
Case series
|
4
|
71.5 ± 6.76 (n = 4)
|
Total laryngectomy + U/L neck dissection (n = 1)Total laryngectomy + B/L neck dissection (n = 1)Pharyngo-laryngectomy + Free jejunal transfer + B/L neck dissection (n = 2)
|
Primary (n = 4)
|
34.4 ± 24.3 (n = 2)
|
Yes (n = 2)No (n = 2)
|
Patient request (n = 3)Aspiration pneumonia (n = 1)
|
N/R
|
|
Dewey et al, 2016
|
Case series
|
8
|
67 ± 3 (n = 8)
|
Total laryngectomy/laryngopharyngectomy (n = 8)
|
Primary (n = 7)Secondary (n = 1)
|
N/R
|
Yes (n = 7)
|
Enlargement of fistula (n = 8)Persistent leakage (n = 8)
|
32.5 ± 3.75 mm
|
|
Huang and Day, 2017
|
Case report
|
1
|
51
|
Total laryngectomy (n = 1)
|
Primary (n = 1)
|
24
|
Yes (n = 1)
|
Enlargement of fistula (n = 1)
|
N/R
|
|
Jaiswal et al, 2016
|
Case report
|
1
|
64
|
Total laryngectomy + B/L neck dissection (n = 1)
|
Primary (n = 1)
|
96
|
Yes (n = 1)
|
Enlargement of fistula (n = 1)
|
N/R
|
|
Mutlu et al, 2016
|
Case series
|
4
|
67.3 ± 8.14(n = 4)
|
Total laryngectomy (n = 2)
|
N/R
|
N/R
|
Yes (n = 3)
|
Enlargement of fistula (n = 4)Persistent leakage (n = 4)
|
17 ± 7.44 mm (n = 4)
|
|
Viñals Viñals et al, 2017
|
Case report
|
1
|
71
|
Total laryngectomy + B/L radical modified neck dissection (n = 1)
|
Primary (n = 1)
|
96
|
Yes (n = 1)
|
Aspiration pneumonia (n = 1)
|
50 mm
|
|
Daya and Pillay, 2018
|
Case series
|
3
|
N/R
|
Radical laryngectomy + B/L neck dissection (n = 2)
|
Primary (n = 1)
|
N/R
|
Yes (n = 3)
|
Enlargement of fistula (n = 3)
|
N/R
|
|
Yenigun et al, 2019
|
Case series
|
2
|
58 ± 2.83(n = 2)
|
Total laryngectomy (n = 2)
|
N/R
|
N/R
|
Yes (n = 2)
|
Persistent leakage (n = 2)
|
N/R
|
|
Riva et al, 2019
|
Case Series
|
5
|
63 ± 4(n = 5)
|
Total laryngectomy (n = 5)
|
N/R
|
N/R
|
Yes (n = 1)
|
Failed TE shunt phonation (n = 4)Enlargement of fistula (n = 1)
|
7 mm (n = 1)
|
|
Dwivedi et al, 2019
|
Case series
|
2
|
62.5 ± 27.6(n = 2)
|
Salvage total laryngectomy + B/L neck dissection (n = 1)Total laryngectomy + U/L neck dissection (n = 1)
|
Primary (n = 1)Secondary (n = 1)
|
5.5 ± 0.707(n = 2)
|
Yes (n = 1)
|
Enlargement of fistula (n = 2)
|
8.5 ± 4.95 mm (n = 2)
|
|
Gozen et al, 2019
|
Case series
|
7
|
66.28 ± 9.8(n = 7)
|
Total laryngectomy (n = 7)
|
N/R
|
N/R
|
N/R
|
Enlargement of fistula (n = 7)
|
2.61 ± 9.8 mm (n = 7)
|
|
Neves et al, 2020
|
Case series
|
4
|
85 (n = 1)
|
Total laryngectomy + B/L neck dissection (n = 4)
|
Primary (n = 1)
|
36 (n = 1)
|
Yes (n = 2)
|
Failed TE shunt phonation (n = 1)
|
N/R
|
Abbreviations: B/L, bilateral; N/R, not reported; RT, radiotherapy; TE, tracheoesophageal;
TEP, tracheoesophageal puncture; U/L, unilateral.
Previous surgical history was reported in 110 cases (76.3%). One hundred three patients
underwent total laryngectomy, two patients had total laryngectomy with partial pharyngectomy,
two patients had pharyngo-laryngo-esophagectomy, two had pharyngolaryngectomy, and
one a total laryngectomy with partial esophagectomy. Neck dissection was reported
in 15.72% (n = 22) of patients, 18 patients had bilateral neck dissection and 4 patients unilateral
neck dissection. However, the presence or absence of past surgical history of neck
dissection was not ubiquitously reported across included studies. Indications for
TEP closure were reported in 123 patients and were not mutually exclusive ([Table 2]).
Table 2
Indications for TEP reconstruction of 123 patients
|
Indication for reconstruction
|
No. of patients
|
Percentage
|
|
Patient request
|
51
|
34.93
|
|
Enlargement of fistula
|
51
|
34.93
|
|
Failed TE shunt phonation
|
13
|
8.90
|
|
Failure to tolerate
|
11
|
7.53
|
|
Aspiration pneumonia
|
8
|
5.47
|
|
Prosthesis migration
|
2
|
1.36
|
|
Infection
|
2
|
1.36
|
|
Persistent TEF
|
1
|
0.68
|
|
Necrotic laryngeal cartilage
|
1
|
0.68
|
|
granulation
|
1
|
0.68
|
|
Exophytic growth
|
1
|
0.68
|
|
Emphysema
|
1
|
0.68
|
|
Dysphagia
|
1
|
0.68
|
|
Candida overgrowth
|
1
|
0.68
|
Abbreviations: TE, tracheoesophageal; TEF, tracheoesophageal fistula; TEP, tracheoesophageal
puncture.
Surgical Procedures
One hundred forty-seven surgical procedures for TEP closure were reported, 130 were
successful ([Table 3]). Reported methods for TEP closure were as follows: primary closure of the fistula
(n = 48), two-point ligation of the fistula tract without transection (n = 8), placement of silicone septal button (n = 11), interposition of dermal grafts (n = 14), interposition of skin grafts (n = 6), interposition of other grafts (cartilage graft, n = 2; collagen graft, n = 1; fascia graft, n = 2), and interposition of SCM muscle or fascia flap (n = 24), deltopectoral pedicled flap (n = 9), pectoralis major flap (n = 4), FFF (n = 15), lateral arm free flap (n = 1), or gastro-omental flap (n = 1).
Table 3
Overview of the previous surgical history and reported outcomes of the included studies
|
Author, year
|
Patients
(n)
|
Previous nonsurgical/surgical closure treatment
|
TEP closure method
|
Surgical outcomes
|
Complications
|
Other outcomes
|
Follow-up(mo)
|
|
Annyas and Escajadillo, 1984
|
6
|
N/R
|
Excision of the fistula tract + Esophageal and tracheal wall closure with single layer,
inverted, interrupted sutures + Interposition of a skin graft (n = 6)
|
Successful surgical closure (n = 6)
|
N/R
|
Nasogastric tube removed 8 days after surgery (n = 6)
|
6
|
|
Rosen et al, 1997
|
14
|
Insertion of smaller tubes or cauterization (n = 14)
|
Three-layered closure technique + Interposition of a dermal graft (n = 13)
|
Successful surgical closure (n = 13)Failed TEF surgical closure (n = 1)
|
Hematoma (n = 1)
|
Normal oral intake resumed (n = 13)
|
20.9 ± 14.6 (n = 18)
|
|
Moerman et al, 2004
|
12
|
N/R
|
Excision of the fistula tract + Two-layer esophagoplasty + Two-layer tracheoplasty
(n = 12)
|
Successful surgical closure (n = 6)Failed TEF surgical closure (n = 6)
|
No complications
|
Secondary closure with pectoralis major (n = 2)Secondary closure with forearm free flap (n = 2)New prosthesis (n = 1)
|
N/R
|
|
Mirza et al, 2003
|
1
|
N/R
|
Placement of silicone septal button (n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
N/R
|
N/R
|
|
Lee and Razi, 2004
|
1
|
Prosthesis removal (n = 1)
|
Excision of the fistula tract + Two-layer esophagoplasty + Interposition of a sternocleidomastoid
muscle flap + Two-layer tracheoplasty (n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
Normal oral intake resumed (n = 1)
|
6
|
|
Cavalot et al, 2004
|
8
|
N/R
|
Excision of the fistula tract + Esophageal and tracheal wall closure with single-layer,
inverted, interrupted sutures (n = 5)Excision of the fistula tract + Esophageal and tracheal wall closure with single-layer,
inverted, interrupted sutures + Interposition of a Vicryl mesh (n = 3)
|
Successful surgical closure (n = 8)
|
No complications
|
New tracheoesophageal fistula with successful new prosthesis (n = 4)
|
N/R
|
|
Ünal, 2006
|
1
|
Valve replacement (n = 1)Purse-string suture (n = 1)
|
Excision of the fistula tract + Two-layer esophagoplasty + Two-layer tracheoplasty
(n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
Effective usage of electrolarynx (n = 1)
|
6
|
|
Gehrking et al, 2007
|
9
|
Primary surgical closure (n = 4)Tracheostoma widening (n = 1)Sternocleidomastoid muscle flap (n = 1)Transcervical multilayer fistula closure with Allogenous collagen graft (n = 1)VP replacements (n = 2)Transcervical ML-FC with IHM flap (n = 2)Transtracheostomal FC (tragal perichondrium) (n = 1)GM-CSF injection (n = 1)Hyaluronate 10+ injection (n = 1)Deltopectoral and latissimus dorsi flaps (n = 1)Forearm free flap (discontinued due to poor vessel status) (n = 1)Multiple pharyngoplasties with local flaps (n = 2)Pedicled pectoralis major flap (n = 1)Tracheostoma transposition (n = 1)
|
Esophageal and tracheal wall multi-layer closure + Interposition of a sternocleidomastoid
muscle flap (n = 4)Esophageal and tracheal wall multilayer closure + Collagen allograft (n = 1)Esophageal and tracheal wall multilayer closure + Interposition of local muscle
flap (n = 1)Pharyngectomy + Forearm free flap (n = 3)
|
Successful surgical closure (n = 9)
|
Ulceration and skin necrosis of the suprastomal border without TEF recurrence (n = 1)
|
No recurrent fistula/tumor (n = 3)Free PE passage with/without not curable tumor progression (n = 2)Death due to tumor progression (n = 2)Death due to unrelated causes (n = 1)
|
6.5 ± 7.78 (n = 2)
|
|
Baldwin and Liddington, 2008
|
4
|
Valve removal and sternocleidomastoid flap (n = 1)
|
Two-layer tracheal-esophagoplasty + Forearm free flap (n = 1)One-layer tracheal-esophagoplasty + Deepithelized deltopectoral flap (n = 1)Forearm free flap (n = 1)Pedicled pectoralis major muscle flap (n = 1)
|
Successful surgical closure (n = 4)
|
Infection (n = 1)
|
Percutaneous endoscopic gastrostomy (n = 1)Normal oral intake resumed (n = 1)
|
9 ± 5.2 (n = 3)
|
|
Wreesmann et al, 2009
|
1
|
Prosthesis removal and marginal fat augmentation + Three-layered closure + Sternocleidomastoid
flap coverage (n = 1)
|
Fabrication of delayed bilaminar forearm free flap w/ skin graft + Excision of the
fistula tract + Bilaminar free flap (n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
New phonatory prosthesis placement (n = 1)Normal oral intake resumed (n = 1)
|
12
|
|
Judd and Bridger, 2008
|
5
|
N/R
|
Excision of the fistula tract + Esophageal and tracheal wall closure with interrupted
sutures + Interposition of a sternocleidomastoid fascia flap (n = 5)
|
Successful surgical closure (n = 5)
|
No complications
|
Patient satisfied with results (n = 5)
|
31.2 ± 13.7 (n = 5)
|
|
Schmitz et al, 2009
|
1
|
Pectoralis major myofascial flap (n = 1)
|
Placement of a 5-cm silicone septal button (Micromedics, St Paul, MN) (n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
Oral intake resumed (n = 1)
|
14
|
|
Koch et al, 2010
|
5
|
N/R
|
Excision of the fistula tract + Two-layer esophagoplasty + Resection of the tracheal
fistula + Cephalic repositioning of the trachea (n = 5)
|
Successful surgical closure (n = 4)Failed TEF surgical closure (n = 1)
|
Failed TEF closure requiring a pectoralis major flap (n = 1)
|
Recurrent fistula revision successful (treated with two-layered esophageal sutures + pectoral
major myofascial flap) (n = 1)
|
42 ± 13.5 (n = 5)
|
|
Wong et al, 2011
|
1
|
Collagen injection for primary TEP closure (successful) (n = 1)Sternocleidomastoid flap TEP (failed) (n = 2)
|
Placement of a nasal septal button (Medtronic Xomed, Jacksonville, FL) (n = 1)
|
Successful surgical closure (n = 1)
|
No complications
|
Normal oral intake resumed (n = 1)
|
18
|
|
Geyer et al, 2011
|
2
|
Submucosal circumferential suture (n = 1)
|
Ligation of the fistula tract at two points (n = 1)Ligation of the fistula tract at two points (n = 1) (failed) -> Ligation of the fistula tract at two points (n = 1)
|
Successful surgical closure (n = 1)Failed TEF surgical closure (n = 1) -> Successful surgical closure (n = 1)
|
Failed TEF closure (n = 1)
|
Normal oral intake resumed (n = 2)
|
7 ± 1.41 (n = 2)
|
|
Hu et al, 2011
|
6
|
Prosthesis removal (n = 1)Prosthesis replacement (n = 1)
|
Excision of the fistula tract + Two-layer tracheal-esophagoplasty + Tracheal advancement
technique (n = 6)
|
Successful surgical closure (n = 6)
|
N/R
|
Normal oral intake resumed (n = 1)
|
N/R
|
|
Balasubramanian et al, 2013
|
6
|
N/R
|
Fistula edges are deepithelialized + Single perforator-based deltopectoral flap (n = 6)
|
Successful surgical closure (n = 5)Failed TEF surgical closure (n = 1)
|
Dehiscence (n = 1)Infection (n = 1)Revision surgery (n = 1)
|
N/R
|
N/R
|
|
Mohan and Malata, 2014
|
1
|
Interposition of a pedicled pectoralis major myocutaneous (n = 1)
|
Bilaminar lateral arm flap (n = 1)
|
Successful surgical closure (n = 1)
|
Revision of the esophageal wall (n = 1)
|
Normal oral intake resumed (n = 1)
|
N/R
|
|
Mobashir et al, 2014
|
5
|
Prosthesis removal + Tube feeding + PPI and prokinetics (n = 5)
|
Ligation of the fistula tract at two points (n = 5)
|
Successful surgical closure (n = 5)
|
No compilations
|
Normal oral intake resumed (n = 5)
|
14.4 ± 2.88 (n = 5)
|
|
Unsal et al, 2015
|
4
|
Unspecified conservative methods (n = 4)Prosthesis replacement (n = 1)Sternocleidomastoid muscle flap (n = 1)
|
Placement of a silicone 32 mm septal button (Invotec, Jacksonville, FL) (n = 4)
|
Successful surgical closure (n = 4)
|
Crusting on button (n = 1)
|
Swallowing restoration (n = 4)Esophageal speech (n = 1)
|
16.5 ± 9.47 (n = 4)
|
|
Jaiswal et al, 2015
|
9
|
N/R
|
Sternocleidomastoid musculocutaneous flap transposition (n = 9)
|
Successful surgical closure (n = 8)Failed TEF surgical closure (n = 1)
|
Marginal necrosis of flap (n = 2)Dehiscence (n = 1)
|
Pectoralis major muscle flap (n = 1)
|
N/R
|
|
Wasano et al, 2015
|
4
|
Prosthesis removal (n = 4)Ring expanded prosthesis (n = 1)
|
Excision of the fistula tract + Esophageal and tracheal wall closure with inverted,
interrupted sutures + Interposition of sternocleidomastoid fascia flap (n = 4)
|
Successful surgical closure (n = 4)
|
No complications
|
Normal oral intake resumed (n = 4)
|
11.5 ± 7.05 (n = 4)
|
|
Dewey et al, 2016
|
8
|
Prosthesis removal/replacement + Cauterization of fistulae tract surgical management
(n = 1)
|
Bipaddled radial forearm free flap (n = 5)Bipaddled radial forearm free flap + Pectoralis major flap (n = 3)
|
Successful TEF surgical closure (n = 8)
|
Neopharynx stricture (n = 1)
|
4 postoperative dilations (n = 1)
|
43 ± 37.9(n = 8)
|
|
Huang and Day, 2017
|
1
|
Antimicrobials (n = 1)Primary surgical closure (n = 1)Hyperbaric oxygen therapy (n = 1)
|
Double paddle ulnar perforator free flap (n = 1)
|
Successful TEF surgical closure (n = 1)
|
No complications
|
Normal oral intake resumed (n = 1)
|
3
|
|
Jaiswal et al, 2016
|
1
|
Deltopectoral flap (n = 1)
|
Two-layered closure + Deltopectoral flap (n = 1) + Deltopectoral flap rearrangement + neotracheostoma (n = 1)
|
Failed TEF surgical closure -> Successful surgical closure (n = 1)
|
Failed TEF closure (n = 1)
|
N/R
|
2
|
|
Mutlu et al, 2016
|
4
|
N/R
|
Placement of a silicone 32 mm septal button (Invotec, Jacksonville, FL) (n = 4)
|
Successful TEF surgical closure (n = 3)Failed TEF surgical closure (n = 1)
|
Granulation formation (n = 1)Button failure (n = 1)Transient dysphagia (n = 1)Fungal/bacterial colonization (n = 1)
|
Normal oral intake resumed (n = 1)
|
11 ± 1.0 (n = 3)
|
|
Viñals Viñals et al, 2017
|
1
|
Prosthesis removal + Silastic lamina placement + Silicone septal button placement
(2 × ) + Interpositioning of pectoral flap (n = 1)
|
Gastro-omental Flap + STSG (n = 1)
|
Successful TEF surgical closure (n = 1)
|
No complications
|
Normal oral intake resumed (n = 1)
|
16
|
|
Daya and Pillay, 2018
|
3
|
Radial forearm free flap (n = 1)Free brachioradialis muscle flap (n = 1)Free lateral arm flap (n = 1)
|
Debridement of scarred tissue + Esophageal wall closure + Interposition of pectoralis
major myofascial flap + Esophageal stenting through a surgically controlled fistula
(10 days) + Skin graft + Intubated trachea with endotracheal Portex tube (6 weeks)
(n = 3)
|
Successful TEF surgical closure (n = 3)
|
No complications (n = 3)
|
Normal oral intake resumed (n = 3)
|
10 ± 0.0 (n = 2)
|
|
Yenigun et al, 2019
|
2
|
Prosthesis removal (n = 2)
|
Placement of a butterfly cartilage graft to the trachea posterior wall by suturing
with superior and inferior absorbable suture (n = 2)
|
Successful TEF surgical closure (n = 2)
|
No complications (n = 2)
|
Normal oral intake resumed (n = 2)
|
6 ± 0.0 (n = 2)
|
|
Riva et al, 2019
|
5
|
N/R
|
Cephalic repositioning of the trachea + Semicircular suturing above the tracheal opening
of the fistula + Blunt dissection of the fistula tract without excision + Tracheal
mucosa closure with an everted circular suture (n = 5)
|
Successful TEF surgical closure (n = 4)Failed TEF surgical closure (n = 1)
|
Failed TEF closure (n = 1)
|
Swallowing restoration (n = 4)
|
8 ± 0.0 (n = 4)
|
|
Dwivedi et al, 2019
|
2
|
Radiesse injection (n = 1)Failing conservative measures (n = 2)
|
Excision of the fistula tract + Esophageal wall closure simple interrupted sutures + Fascia
lata autograft interposition + Tracheal wall closure simple interrupted suture (n = 2)
|
Successful TEF surgical closure (n = 1)Failed TEF surgical closure (n = 1)
|
Failed TEF closure requiring a modified single vessel deltopectoral flap (n = 1).
|
N/R
|
24 ± 17(n = 2)
|
|
Gozen et al, 2019
|
7
|
Primary sutures (n = 2)Primary suture + Local flaps (n = 2)Local flaps + Microsurgical reconstruction (n = 1)
|
Excision of the fistula tract + Esophageal wall closure with multilayered primary
suture + Resection of the tracheal fistula + Cephalic repositioning of the trachea
and closure of tracheostomy with skin flaps (n = 7)
|
Successful TEF surgical closure (n = 7)
|
No complications
|
Normal oral intake resumed (n = 7)
|
21.7 ± 8.96(n = 7)
|
|
Neves et al, 2020
|
4
|
N/R
|
Excision of the fistula tract + Esophageal opening closure with continuous sutures + Vertical
incision of the anterior segment of the first tracheal ring + Tracheal opening closure
with sutures + Pectoral skin flap coverage (n = 4)
|
Successful TEF surgical closure (n = 4)
|
No complications
|
New phonatory prosthesis placement (2 years postop) (n = 1)
|
12.5 ± 16.3(n = 2)
|
Abbreviations: GM-CSF, granulocyte-macrophage colony-stimulating factor; IHM, infrahyoid
muscle; N/R, not reported; PE, pharyngoesophageal; PPI, proton-pump inhibitors; STSG,
split-thickness skin graft; TE, tracheoesophageal; TEF, tracheoesophageal fistula;
TEP, tracheoesophageal puncture; VP, voice prosthesis.
Outcomes
Seventeen studies reporting outcomes of 117 patients were included in the quantitative
analysis.[9]
[11]
[25]
[28]
[30]
[32]
[33]
[35]
[38]
[40]
[44]
[46]
[47]
[48]
[49]
[52] The overall incidence of unsuccessful TEP closure was 6% (95% CI 1–13%) ([Fig. 2]). Heterogeneity among studies was not significant (Q statistic 18.28, degrees of freedom = 16, p = 0.31; I
2 = 12.5%, p = 0.308). Subgroup analysis showed an unsuccessful TEP closure rate for silicone
septal button of 8% (95% CI < 1–43%), < 0.1% (95% CI < 1–52%) for ligation of the
fistula, 9% (95% CI < 1–28%) for primary closure, 7% (95% CI < 1–34%) for dermal graft
interposition, 17% (95% CI < 1–64%) for interposition of a deltopectoral flap, < 0.1%
(95% CI < 1–37%) for radial forearm free (RFF) flap, and 2% (95% CI < 1–20%) for interposition
of SCM muscle flap ([Fig. 3]).
Fig. 2 Forest plot presenting the pooled incidence of the overall unsuccessful tracheoesophageal
puncture (TEP) closure rate.
Fig. 3 Forest plot presenting the pooled incidence of unsuccessful tracheoesophageal puncture
(TEP) closure rates among the different surgical techniques employed. SCM, sternocleidomastoid
muscle.
The most-reported technique for TEP occlusion was primary closure. This technique
involved a posterior tracheal wall closure and an anterior esophageal wall closure,
with or without excision of the fistula tract. Closure was performed in a single-layer
fashion with inverted, interrupted sutures or in some cases with a double- and even
triple-layer closure. Regarding the cases in which an unsuccessful TEP closure was
reported with this method, Moerman et al reported a 50% unsuccessful TEP closure rate
in a series of 12 patients in which 83.3% had previous history of radiotherapy.[49] Additionally, Koch et al and Riva et al also presented two cases in which the presence
of previous radiotherapy was determined as a risk factor for wound dehiscence and
TEP recurrence.[30]
[44]
Another important reconstructive alternative was the implementation of SCM muscle
flap, with this technique only one patient had a relapsing TEP.[11] This patient had previous history of radiotherapy and presented with a dehiscent
flap edge during the postoperative period, which ultimately caused recurrence of the
TEF.[11] Other local flaps such as deltopectoral or the pectoralis major flap were recommended
by several authors.[26]
[33]
[39] Similarly, all the failed TEP closures presented in this review using the deltopectoral
flaps were in patients who had previous adjuvant radiotherapy, which was likely the
cause of wound breakdown and the susceptibility to infection.[33]
[39] Conversely, no TEP recurrence was reported in patients managed with a FFF or the
lateral arm free flap despite 94% of patients having previous history of radiotherapy.[10]
[25]
[26]
[27]
[34]
[53]
Ten studies reported the size of the puncture diameter.[9]
[27]
[30]
[38]
[40]
[41]
[44]
[45]
[48]
[50] Remarkably, tracheal wall closure, fistula excision, and esophageal wall closure
with or without interposition of a dermal graft or fascia lata (FL), was the most
common reconstructive technique when defects were of 15 mm or less.[9]
[30]
[45]
[48] Placement of a silicone septal button was proposed in patients with a TE defects
of 15 to 20 mm, an intervention that was successful in five of the six patients reported
in these series.[40]
[50] When the average defect size was greater than 30 mm, surgeons opted to use vascularized
free tissue transfer as their reconstructive method of choice. Wreesmann et al used
a bilaminar flee flap in a defect of 40 mm; Dewey et al employed a bipaddled FFF,
with or without a pectoralis major flap, in defects with an average diameter of 32.5 mm;
and Viñals Viñals et al a gastro-omental free flap in a defect of 50 mm, the greatest
in this review.[27]
[38]
[41] From the aforementioned patients treated with a free flap, all had a successful
TEP closure ([Table 3]).[27]
[38]
[41]
Complications
The presence or absence of complications was reported in 110 patients (75.8%). Complications
following TEP closure occurred in 13 patients (8.8%). The complications included button
failure (n = 1), crusting on button (n = 2), dehiscence (n = 2), fungal/bacterial colonization of surgical site (n = 1), granuloma formation (n = 1), hematoma (n = 1), infection (n = 2), marginal flap necrosis (n = 2), neopharynx stricture (n = 1), transient dysphagia (n = 1), and ulceration and necrosis of the suprasternal border without TEF recurrence.
The patient with button failure (n = 1) was treated with a local rotation flap to restore the stoma. Patients with dehiscence
(n = 2) underwent additional revision surgery, and one required a pectoralis major muscle
flap.
The patient presenting with a hematoma received hyperbaric oxygen therapy, intravenous
antibiotics, and intensive wound care; however, fistula recurrence was observed, and
the patient was discharged with a NG tube. The patient presenting with delayed neopharynx
stricture was treated with serial dilatations. Patients with a failed TEP closure
were treated with deltopectoral flaps (n = 2), pectoralis major muscle flaps (n = 1), and a two-layered esophageal suture with interposition of a pectoralis major
muscle flap (n = 1).
Publication Bias
Funnel plot graphic showed asymmetry and no significant evidence of publication bias
was found (Egger's test, p = 0.183) ([Fig. 4]). Trim-and-fill analysis imputed 17 studies with no impact in the overall outcomes
(observed effect size 0.105, 95% CI –0.073 to 0.283; imputed effect size 0.105, 95%
CI –0.073 to 0.283).
Fig. 4 Funnel plot exhibiting publication bias of the overall unsuccessful tracheoesophageal
puncture (TEP) closure rate.
Discussion
The incidence of leakage around a voice prosthesis secondary to TEP enlargement has
been reported between 1 and 29%.[9]
[45]
[54] Additionally, a 4.5-fold increased risk of TEP enlargement has been reported in
patients who undergo total laryngopharyngectomy compared with patients who are treated
with a total laryngectomy.[45] Since persistent leakage has been acknowledged to result in threefold increase in
aspiration pneumonia with 20 to 30% mortality and 14% chronic dependence on percutaneous
gastrostomy for nutrition, prompt surgical TEP closure is required when conservative
measures fail.[9]
[45] Remarkably, patient request for TEP closure was the most common indication for TEP
closure in simultaneous with enlargement of the fistula, which indicates concerns
regarding the quality of life of patients undergoing voice restoration procedures
that have not been addressed.
When the preoperative risk assessment is high, a silicone septal button can be used
to temporarily obliterate the fistula tract yielding an acceptable recurrence rate
of 8% (95% CI < 1–43%). However, as there is no healing process, this option is per
se inferior to any reconstructive modality.[36]
[50] Artificial materials therefore can provide a temporary solution for patients who
will undergo forthcoming surgeries with autologous tissue or when flap-based reconstructions
of the TEP cannot be performed immediately due to considerable intraoperative time,
suboptimal nutritional status, and multiple comorbidities.[40]
[50] Conversely, the disadvantages of the septal button insertion are that this method
is limited for patients who have a 10- to 20-mm TEP defect and the loss of the TE
speech function, as this reconstructive method does not aim for a formal reconstruction
and subsequent TEP with voice prosthesis insertion.[36]
[50]
Geyer et al reported the dissection and ligation of an intact fistula tract at two
points for TEP closure. This surgical technique was implemented in 2 patients, in
which one case required the same procedure twice due to recurrence.[13] Similarly, Mobashir et al performed a double nonresorbable suture circumferential
ligation of the fistula tract to guarantee a successful closure, but his approach
was through an incision of 2.5 cm above the superior tracheostomy edge to preserve
the stoma integrity.[35] In his cohort, the TEP was effectively closed in 100% of patients. In this setting,
a two-point ligation of the TEF tract when feasible, provides a protective and reliable
(recurrence: 0%, 95% CI < 1–52%) technique to close the fistula of the TEP in a short
operative time. Additionally, as the tract is not divided, there is a hypothetical
lower risk of suture slippage and subsequent infection in the potential space between
the pharynx and trachea.[35]
[46]
To our knowledge, Hosal and Myers introduced the first technique for TEP closure in
which the fistula was transected, and closure of the esophageal and tracheal walls
was performed with inverted sutures without the interposition of autologous tissue.[55] Hu et al reported a method similar to Gozen et al, where trachea and esophagus are
sutured separately, but with the particularity of also performing a tracheal mucosal
resection to prevent overlapping suture lines. This cephalic repositioning of the
trachea provided a healthy membranous tracheal wall that was used as a vascularized
flap to overlie the fistula site.[9] Nonetheless, repeated mucosal resections are only possible for this method if there
is enough tracheal mucosa present.[46]
Neves et al equally transected the tract and separately sutured esophagus and trachea
with the addition of performing a vertical incision across the first tracheal ring
to facilitate a tension-free suture on the posterior tracheal wall.[46] Gozen et al and Neves et al externally reinforced the stoma to avoid stomal stenosis
in radiated patients which may be advantageous to avoid further surgeries.[9]
[46] In this review, primary closure yielded a 9% (95% CI < 1–28%) TEP recurrence rate
which was attributed to the cytotoxic effect of radiotherapy and recanalization of
the tract. In fact, we concluded that this surgical technique should not be considered
as the first choice for patients with previous history of bilateral neck dissection
and radiotherapy.
A butterfly cartilage autograft to enforce TEP closure is an acceptable alternative
that can be performed under local anesthesia and is associated with low morbidity.[43] This technique is elaborately described by Yenigun et al who reported that enteral
feeding was resumed in a short span of time.[43] Likewise, FL autograft is also described as an excellent method for three-layered
fistula closure.[45] The FL is a strong and easily harvestable autograft, capable of providing large
amounts of reliable graft material; however, scar/keloid formation, hematoma, infection,
and chronic pain (from the herniated muscle belly) can occur if proper donor site
closure is not ensured.[45] This method, therefore, should be evaluated before using autologous vascularized
tissue for a three-layer closure in cases where TEP diameter does not exceed 1 cm.[45] Remarkably, it must be mentioned that despite its tensile strength and tissue abundance,
the FL graft is avascular and fails to withstand ongoing local infection and healing
in a postradiotherapy environment, leading to TEP closure failure in patients with
a similar presentation.
Huang and Day established that multilayered closure supersedes a large quantity of
fresh tissue in the form of grafts for reconstruction of communicating wounds.[10] To our knowledge, Lee and Razi was the first to report the interposition of the
SCM muscle in one patient for TEP closure,[51] and Wasano et al proposed the interposition of SCM fascia between the esophagus
and the trachea as an option to decrease the risk of relapse of the TEF. In the series
reported by Wasano et al, excellent results were conveyed despite a 50% preoperative
radiotherapy rate, as all 4 patients achieved resumption of oral intake and had a
successful TEP closure without complications over a period of 11.5 months, perhaps
due to the vascularized nature of a pedicled fascial flap.[37] In the present review, interposition of a SCM flap was highly reliable as it accomplished
a failure rate of 2% (95% CI < 1–20%). Nonetheless, a history of radiotherapy and
especially in bilateral neck dissections, the use of the SCM can be restricted despite
having three sources of perfusion as some blood supply is sacrificed when it is elevated
as a pedicled flap.
Baldwin and Liddington reported the inset of a tunneled deepithelialized deltopectoral
flap between the trachea and the esophagus,[26] while Balasubramanian et al closed the TEP site using a single perforator-based
deltopectoral flap which was sutured directly onto the fistula site and all along
its path. The authors reported complete fistula closure in four patients and one case
of flap dehiscence, resulting probably because of its extended length and the slim
base of the flap, which ultimately compromised the perfusion.[33]
[46] In this setting, the deltopectoral flap may not be the best alternative for a flap-based
reconstruction for TEF closure as it yielded a 17% (95% CI < 1–64%) failure rate.
Also, the use of bulky muscle flaps may compromise the airway and esophageal lumen
and can lead to stomal stricture, potentially requiring further surgery in the form
of stomaplasty.[9]
[44]
[45] Additionally, tissue may be of uncertain quality if neck dissections have been performed
or if the flap was within the radiated field.[32]
[45]
[46]
Microvascular free tissue transfer has asserted itself as the standard of care in
reconstruction of complex head and neck defects due to the advantage of size-specific
tailored flaps and to the availability of chimeric tissue with multilayered components.[10] The RFF flap is a thin, pliable fasciocutaneous flap with a large pedicle considered
ideal by many authors for TEP closure.[10] Gehrking et al performed three FFFs achieving excellent results.[25] Dewey et al described in their series a bipaddled RFF flap created by deepithelialization
of the intervening tissue for TEP closure.[38] Although this flap was assertive and sophisticated for closure of this communicating
defect, the requirement to harvest a bigger flap for deepithelialization of the intermediate
portion and achieve a multilayer closure, resulted in extra bulkiness.[38] Additionally, one patient presented with recurrent strictures of the pharyngoesophageal
segment, which ultimately maintained oral alimentation for 8 years following multiple
dilations.[38] Therefore, the RFF flap is an optimal option for reconstruction of demanding tracheoesophageal
defects exhibiting a 0% (95% CI < 1–37%) TEP recurrence rate, especially in patients
with past medical history of neck dissection and radiotherapy. In this review, previous
history of radiotherapy was reported on 17 out of the 18 patients managed with RFF
flaps and 100% successful rate.
Huang and Day used the ulnar artery perforator free flap (UAPFF) with identifiable
perforators that allowed to separate the fasciocutaneous component into two independent
skin paddles without the aforementioned deepithelialized intermediate portion required
in RFF flaps.[10] The single case reconstructed with this flap had an uneventful recovery. Remarkably,
the UAPFF is commonly less hairy than the RFF flap, making it more tempting for oral
and pharyngeal reconstruction.[10] None of the authors reporting on outcomes on the FFF mentioned the incidence of
recurrence after reconstruction of the TEP site.
Mohan and Malata successfully closed a TEP site with a bilaminar lateral arm free
flap in a previously radiated patient who was initially managed with interposition
of a pedicled pectoralis major myocutaneous flap. The skin paddle provided an adequate
epithelial lining to resurface the mucosal defect in the esophagus and the posterosuperior
edge of the tracheal stoma. The rest of the flap was deepithelialized providing an
interposition tissue and the pedicle length was satisfactory to allow anastomosis
out of the radiated field.[34] Of note, the contemporary incorporation of thin and super-thin perforator flaps
like the superficial circumflex iliac artery perforator flap, thoracodorsal artery
perforator flap, and anterolateral thigh perforator flap has been successfully executed
for the reconstruction of head and neck oncologic defects yielding exceedingly good
results.[56]
[57] Despite the fact we did not find any report that detailed the use of this free flaps,
they can be used for TEP closure without the additional bulkiness of fasciocutaneous
flaps. However, further studies are required.
To our knowledge, no intestinal flaps were reported for the closure of TEPs, but Viñals
Viñals et al implemented a gastro-omental free flap performing the anastomosis beyond
the radiated area in a patient with a previously failed reconstruction using a muscle
flap.[41] The stomach patch was customized to the esophageal defect without the additional
bulk of muscular or fasciocutaneous flaps, and the omentum was placed around the tracheostomy
and interposed between trachea and esophagus creating a three-layer reconstruction.[41] The patient was able to receive a new TEP and voice prosthesis 2 years after reconstruction.[41] In the experience of senior authors (H.C.C. and O.J.M.), enteric flaps are worthwhile
in young patients with long life expectancy and should be considered if other therapeutic
strategies have been exhausted. These flaps also offer immediate fistula closure,
definitive healing, and can be used if wider excisions are performed when locoregional
control of tumors has been unsatisfactory.
Limitations
The incidence of tracheostomy stenosis was not assessed. Comparisons between surgical
methods within independent studies for TEP closure were not reported. The undersized
samples and the inherent properties of retrospective studies reduced the strength
of evidence. Due to the heterogeneity in data report, quality of data, and type of
included studies, it was not possible to obtain the success of TEP closure rate in
radiated versus nonirradiated patients. All included studies were rated 4 using the
OCEBM. Some variables were not reported evenly in all studies.
Conclusion
While several reconstructive options are practical for closure of the TEP site, the
indications for the different modalities cannot be universally established. A critical
assessment of the reconstructive modality should take into consideration previous
surgical history, history of radiation, comorbidities, and defect size. Patients with
no history of radiotherapy and small defects may benefit from fistula excision followed
by tracheal and esophageal wall multilayered closure, with or without cephalic tracheal
repositioning over the TEP site. When the surgical field is compromised with previous
neck dissections and radiation, multilayered reconstruction with interposition of
vascularized tissue in conjunction with fistula excision yields high rates of successful
TEP site closure. Depending on the size of the defect and availability of local tissue,
surgeons may select local flaps or free tissue transfer. In this review, the SCM muscle
flap or fasciocutaneous free flaps demonstrated optimal performance for this purpose.
