Closure of tracheoesophageal fistula with two-layer tracheal-esophagoplasty and tracheal advancement.

INTRODUCTION In properly selected patients, the use of a voice prosthesis placed in a surgically created tracheoesophageal fistula (TEF) is a successful and desirable method of postlaryngectomy vocal rehabilitation. The long-term success rate for tracheoesophageal speech is high, ranging from 70% to 95%. Unfortunately, some patients develop complications that include: migration and progressive enlargement of the puncture, persistent or recurring infection of the fistula site, aspiration pneumonia, aspiration of the prosthesis, vertebral osteomyelitis, and tracheal stomal and esophageal stenosis. The overall complication rate of TEF is 20% to 72%. One common complication of TEF is chronic leakage around or through a tracheal esophageal prosthesis (TEP), which leads to chronic aspiration. This occurs in 7% to 42% of patients. The TEF may enlarge, causing salivary leakage around the prosthesis, or the prosthesis may malfunction with leakage of contents through the prosthesis. If the TEF has become too large, the prosthesis can be removed, allowing spontaneous contracture, and then replaced. Alternatively, a larger diameter TEP can be placed. For a malfunctioning prosthesis, there are a variety of styles and brands that can be trialed to determine which type best suits a patient’s needs. When these measures fail and leakage persists, the medical team often chooses to close the TEF and pursue an alternative method of communication. Only 5% of TEFs require surgical closure. More than 90% respond to conservative measures. Surgical closure of a TEF can be complicated by patient factors such as advanged age, medical comorbidities like diabetes and hypothyroidism, immunosuppression, infection, and mechanical trauma. Additionally, this population has often undergone chemoradiation, which further compromises wound healing. Multiple surgical techniques have been described for the closure of TEFs, which attests to the potential difficulty of this problem. We describe a simple and highly effective technique of TEF closure with a two-layer tracheal-esophagoplasty and tracheal advancement. The patient is an 86-year-old male who underwent a total laryngectomy and partial esophagectomy for esophageal cancer 8 years ago. He suffered persistent leaking around his TEP for over 3 years. He trialed several different brands of voice prosthesis without success, and removed his TEP for extended periods to allow spontaneous closure, also without success. He learned to use an electrolarynx and was satisfied with this mode of communication. His past medical history is significant for multiple comorbidities, including peripheral vascular disease, chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, cardiac pacemaker, and hypertension. Because he failed more conservative measures, he was offered surgical closure of the TEF. A two-layer tracheal-esophagoplasty and tracheal advancement technique was used. The patient had an uncomplicated hospital stay, and a modified barium swallow at 1 week showed no leak or stricture, and the patient advanced to a regular diet. The senior authors have performed this operation on six patients and successfully closed their TEFs.