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CC BY-NC-ND 4.0 · Arch Plast Surg 2022; 49(05): 617-632
DOI: 10.1055/s-0042-1756347
Pediatric/Craniomilofacial/Head & Neck: Review Article

Definitive Closure of the Tracheoesophageal Puncture Site after Oncologic Laryngectomy: A Systematic Review and Meta-Analysis

Joseph M. Escandón    §
1   Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
,
Arbab Mohammad   §
2   Department of Surgery, Aarupadai Veedu Medical College and Hospital, Puducherry, Tamil Nadu, India
,
Saumya Mathews
3   Department of Plastic and Microvascular Services, Tata Memorial Hospital, Mumbai, Maharashtra, India
,
Valeria P. Bustos
4   Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Eric Santamaría
5   Department of Plastic and Reconstructive Surgery, National Cancer Institute, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico
,
Pedro Ciudad
6   Reconstructive and Burn Surgery Department, Arzobispo Loayza National Hospital, Lima, Peru
7   Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
,
Hung-Chi Chen
7   Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
,
Howard N. Langstein
1   Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
,
Oscar J. Manrique 
1   Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, New York
› Author Affiliations Funding None.
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Abstract

Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure.

A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed.

Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1–13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1–43%), 7% (95% CI < 1–34%) for dermal graft interposition, < 1% (95% CI < 1–37%) for radial forearm free flap, < 1% (95% CI < 1–52%) for ligation of the fistula, 17% (95% CI < 1–64%) for interposition of a deltopectoral flap, 9% (95% CI < 1–28%) for primary closure, and 2% (95% CI < 1–20%) for interposition of a sternocleidomastoid muscle flap.

Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.

Keywords

punctures - prosthesis failure - tracheoesophageal fistula - wound closure techniques - TEP closure - laryngectomy - meta-analysis

Disclosures

The authors have no financial interest to declare in relation to the content of this article. All authors have completed the ICMJE uniform disclosure form.


Authors' Contributions

Idea and conceptualization: S.M. and J.M.E.; Research and investigation: A.M. and J.M.E.; Data curation: A.M. and J.M.E.; Analysis: V.P.B., O.J.M., J.M.E.; Funding acquisition: J.M.E.; Methodology: J.M.E.; Project administration: A.M., V.P.B., J.M.E.; Software and simulation: V.P.B. and J.M.E.; Supervision: S.M., O.J.M., H.C.C., E.S., P.C.; Verification: S.M. and O.J.M.; Original draft preparation: all authors; Revision and editing: all authors.


Note

This article was previously presented at the 90th Annual meeting of the American Society of Plastic Surgery (ASPS) in Atlanta, Georgia, October 29th through November 1st, 2021.


Ethical Approval

The present manuscript did not require IRB approval.


§ Both authors contributed equally to this manuscript and are co-first authors.


Supplementary Material



Publication History

Received: 25 August 2021

Accepted: 08 June 2022

Article published online:
23 September 2022

© 2022. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Barauna Neto JC, Dedivitis RA, Aires FT, Pfann RZ, Matos LL, Cernea CR. Comparison between primary and secondary tracheoesophageal puncture prosthesis: a systematic review. ORL J Otorhinolaryngol Relat Spec 2017; 79 (04) 222-229
    CrossrefPubMedGoogle Scholar
  • 2 Blom ED, Singer MI, Hamaker RC. A prospective study of tracheoesophageal speech. Arch Otolaryngol Head Neck Surg 1986; 112 (04) 440-447
    CrossrefPubMedGoogle Scholar
  • 3 Singer MI, Hamaker RC, Blom ED. Revision procedure for the tracheoesophageal puncture. Laryngoscope 1989; 99 (7 Pt 1): 761-763
    CrossrefPubMedGoogle Scholar
  • 4 Erdim I, Sirin AA, Baykal B, Oghan F, Guvey A, Kayhan FT. Treatment of large persistent tracheoesophageal peristomal fistulas using silicon rings. Rev Bras Otorrinolaringol (Engl Ed) 2017; 83 (05) 536-540
    Google Scholar
  • 5 Jacobs K, Delaere PR, Vander Poorten VLM. Submucosal purse-string suture as a treatment of leakage around the indwelling voice prosthesis. Head Neck 2008; 30 (04) 485-491
    CrossrefPubMedGoogle Scholar
  • 6 Parrilla C, Almadori A, Longobardi Y, Lattanzi W, Salgarello M, Almadori G. Regenerative strategy for persistent periprosthetic leakage around tracheoesophageal puncture: is it an effective long-term solution?. Cells 2021; 10 (07) 1695
    CrossrefPubMedGoogle Scholar
  • 7 Périé S, Ming X, Dewolf E, St Guily JL. Autologous fat injection to treat leakage around tracheoesophageal puncture. Am J Otolaryngol 2002; 23 (06) 345-350
    CrossrefPubMedGoogle Scholar
  • 8 Twomey K, Lehn B, Vasani S. Management of leaking tracheoesophageal puncture with hyaluronic acid injection. Head Neck 2018; 40 (07) 1573-1576
    CrossrefPubMedGoogle Scholar
  • 9 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 (06) 1224-1227
    CrossrefPubMedGoogle Scholar
  • 10 Huang AT, Day TA. Double paddle ulnar perforator free flap in reconstruction of through-and-through and fistulous defects of the head and neck. Laryngoscope 2017; 127 (06) 1302-1305
    CrossrefPubMedGoogle Scholar
  • 11 Jaiswal D, Yadav P, Shankhdhar VK, Gujjalanavar RS, Puranik P. Tracheoesophageal puncture site closure with sternocleidomastoid musculocutaneous transposition flap. Indian J Plast Surg 2015; 48 (03) 278-282
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Nomiya T, Teruyama K, Wada H, Nemoto K. Chemoradiotherapy for a patient with a giant esophageal fistula. World J Gastroenterol 2007; 13 (15) 2250-2254
    CrossrefPubMedGoogle Scholar
  • 13 Geyer M, Tan N, Ismail-Koch H, Puxeddu R. A simple closure technique for reversal of tracheoesophageal puncture. Am J Otolaryngol 2011; 32 (06) 627-630
    PubMedGoogle Scholar
  • 14 Shamseer L, Moher D, Clarke M. et al; PRISMA-P Group. Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015; 350: g7647
    CrossrefPubMedGoogle Scholar
  • 15 Moher D, Shamseer L, Clarke M. et al; PRISMA-P Group. Preferred reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4 (01) 1
    Google Scholar
  • 16 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5 (01) 210
    CrossrefPubMedGoogle Scholar
  • 17 Riley RD, Higgins JPT, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342: d549
    CrossrefPubMedGoogle Scholar
  • 18 Studebaker GAA. A “rationalized” arcsine transform. J Speech Hear Res 1985; 28 (03) 455-462
    CrossrefPubMedGoogle Scholar
  • 19 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration. Bristol, United Kingdom: John Wiley & Sons, Ltd; 2008
    CrossrefGoogle Scholar
  • 20 Deeks JJ. Chapter 9: analysing data and undertaking. In: Higgins JPT, Green S. eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration. Bristol, United Kingdom: John Wiley & Sons, Ltd; 2008: 243-296
    Google Scholar
  • 21 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315 (7109): 629-634
    CrossrefPubMedGoogle Scholar
  • 22 Mavridis D, Salanti G. How to assess publication bias: funnel plot, trim-and-fill method and selection models. Evid Based Ment Health 2014; 17 (01) 30
    CrossrefPubMedGoogle Scholar
  • 23 Durieux N, Pasleau F, Howick J. OCEBM Levels of Evidence Working Group. The Oxford; 2011. Levels of Evidence
    Google Scholar
  • 24 Ünal M. Three-layer closure of a tracheoesophageal puncture site: a technical note. Adv Ther 2006; 23 (05) 733-738
    CrossrefPubMedGoogle Scholar
  • 25 Gehrking E, Raap M, Sommer KD. Classification and management of tracheoesophageal and tracheopharyngeal fistulas after laryngectomy. Laryngoscope 2007; 117 (11) 1943-1951
    CrossrefPubMedGoogle Scholar
  • 26 Baldwin CJ, Liddington MI. An approach to complex tracheostomal complications. J Plast Reconstr Aesthet Surg 2008; 61 (04) 408-412
    CrossrefPubMedGoogle Scholar
  • 27 Wreesmann VB, Smeele LE, Hilgers FJM, Lohuis PJFM. Closure of tracheoesophageal fistula with prefabricated revascularized bilaminar radial forearm free flap. Head Neck 2009; 31 (06) 838-842
    CrossrefPubMedGoogle Scholar
  • 28 Judd O, Bridger M. Failed voice restoration: closure of the tracheo-oesophageal fistula. Clin Otolaryngol 2008; 33 (03) 261-264
    CrossrefPubMedGoogle Scholar
  • 29 Schmitz S, Van Damme JP, Hamoir M. A simple technique for closure of persistent tracheoesophageal fistula after total laryngectomy. Otolaryngol Head Neck Surg 2009; 140 (04) 601-603
    CrossrefPubMedGoogle Scholar
  • 30 Koch M, Zenk J, Birk S, Alexiou C, Iro H. Surgical closure of persistent tracheoesophageal fistulas by esophageal suturing and cranial transposition of the trachea. Otolaryngol Head Neck Surg 2010; 143 (06) 843-844
    CrossrefPubMedGoogle Scholar
  • 31 Wong BYW, Kurian M, Chidambaram A. Alternative management of leaking tracheoesophageal fistula after laryngectomy using nasal septal button. Clin Otolaryngol 2011; 36 (01) 97-99
    CrossrefPubMedGoogle Scholar
  • 32 Hu A, Merati A, Meyer TK. Closure of tracheoesophageal fistula with two-layer tracheal-esophagoplasty and tracheal advancement. Laryngoscope 2011; 36 (01) 97-99
    Google Scholar
  • 33 Balasubramanian D, Iyer S, Thankappan K. Tracheoesophageal puncture site closure with single perforator-based deltopectoral flap. Head Neck 2013; 35 (02) E60-E63
    CrossrefPubMedGoogle Scholar
  • 34 Mohan AT, Malata CM. Post-radiation tracheoesophageal fistula following salvage laryngectomy: microsurgical repair using a “bi-laminar” lateral arm flap. Eur J Plast Surg 2014; 37: 683-686
    CrossrefGoogle Scholar
  • 35 Mobashir MK, Basha WM, Mohamed AERS, Anany AM. Management of persistent tracheoesophageal puncture. Eur Arch Otorhinolaryngol 2014; 271 (02) 379-383
    CrossrefPubMedGoogle Scholar
  • 36 Unsal O, Akpinar M, Turk B, Rifki D, Uslu Coskun B. Total closure of enlarged tracheoesophageal puncture with septal button: Long-term results. ORL J Otorhinolaryngol Relat Spec 2015; 77 (05) 268-272
    CrossrefPubMedGoogle Scholar
  • 37 Wasano K, Suzuki N, Kawasaki T. et al. Closure of tracheoesophageal puncture with pedicled fascia flap of the sternocleidomastoid muscle. Auris Nasus Larynx 2015; 42 (04) 318-321
    CrossrefPubMedGoogle Scholar
  • 38 Dewey EH, Castro JR, Mojica J. et al. Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: Report of 8 cases. Head Neck 2016; 38 (Suppl. 01) E172-E178
    CrossrefPubMedGoogle Scholar
  • 39 Jaiswal D, Yadav P, Shankhdhar V, Dalal R. Recurrent tracheoesophageal puncture fistula closure using a previous flap as donor: a case report. Egypt J Otolaryngol 2016; 32 (03) 229
    CrossrefGoogle Scholar
  • 40 Mutlu A, Dasli S, Ozturk M, Topdag M. A simple closure technic for tracheoesophageal puncture failures. J Craniofac Surg 2016; 27 (08) 2149-2150
    CrossrefPubMedGoogle Scholar
  • 41 Viñals Viñals JM, Tarrús Bozal P, Serra-Mestre JM, Bermejo Segú O, Nogués Orpí J. Recurrent tracheoesophageal fistula repair with gastro-omental free flap in an irradiated patient [in Spanish]. Cir Esp 2017; 95 (10) 615-618 (English Ed)
    PubMedGoogle Scholar
  • 42 Daya M, Pillay D. Voice prosthesis related expanding tracheoesophageal puncture repair: microsurgical reconstruction to pedicled pectoralis major muscle flap. S Afr J Surg 2018; 56 (04) 30-33
    CrossrefPubMedGoogle Scholar
  • 43 Yenigun A, Ozturan O, Kulaksiz Y, Aksoy F, Tugrul S. Tracheoesophageal puncture site closure with butterfly cartilage graft. J Craniofac Surg 2019; 30 (03) e257-e259
    CrossrefPubMedGoogle Scholar
  • 44 Riva G, Dagna F, Ricci E, Cavalot AL. Closure of tracheoesophageal puncture after total laryngectomy. Otolaryngol Head Neck Surg 2019; 161 (02) 368-370
    CrossrefPubMedGoogle Scholar
  • 45 Dwivedi RC, Sattar R, Tsiropulous G, Repanos C. Fascia lata graft closure of an enlarged tracheoesophageal puncture (TEP) after laryngectomy/laryngopharyngectomy. Eur Arch Otorhinolaryngol 2019; 276 (08) 2355-2359
    CrossrefPubMedGoogle Scholar
  • 46 Neves JF, Nobre AR, Portugal E, Branquinho F. Surgical closure of tracheoesophageal puncture without a flap interposition. Otolaryngol Head Neck Surg 2020; 163 (03) 618-620
    CrossrefPubMedGoogle Scholar
  • 47 Annyas AA, Escajadillo JR. Closure of tracheoesophageal fistulas after removal of the voice prosthesis. Laryngoscope 1984; 94 (09) 1244-1245
    CrossrefPubMedGoogle Scholar
  • 48 Rosen A, Scher N, Panje WR. Surgical closure of persisting failed tracheoesophageal voice fistula. Ann Otol Rhinol Laryngol 1997; 106 (09) 775-778
    CrossrefPubMedGoogle Scholar
  • 49 Moerman M, Vermeersch H, Heylbroeck P. A simple surgical technique for tracheoesophageal fistula closure. Eur Arch Otorhinolaryngol 2004; 261 (07) 381-385
    CrossrefPubMedGoogle Scholar
  • 50 Mirza S, Head M, Robson AK. Silicone septal button in the management of a large tracheo-oesophageal fistula following primary puncture in a laryngectomee. ORL J Otorhinolaryngol Relat Spec 2003; 65 (02) 129-130
    CrossrefPubMedGoogle Scholar
  • 51 Lee LM, Razi A. Three-layer technique to close a persistent tracheo-oesophageal fistula. Asian J Surg 2004; 27 (04) 336-338
    CrossrefPubMedGoogle Scholar
  • 52 Cavalot AL, De Sanctis A, Palonta F, Preti G, Piumetto E, Albera R. Closure of tracheo-oesophageal fistula following removal of voice prosthesis; a new surgical technique. Acta Otorhinolaryngol Ital 2004; 24 (02) 75-77
    PubMedGoogle Scholar
  • 53 Spaulding SL, Yue LE, O'Malley QF, Sims JR, Urken ML. A novel radial forearm free flap design to treat pharyngoesophageal stenosis in combination with the posterior wall of the trachea. J Surg Oncol 2019; 120 (08) 1446-1449
    CrossrefPubMedGoogle Scholar
  • 54 Hutcheson KA, Lewin JS, Sturgis EM, Risser J. Outcomes and adverse events of enlarged tracheoesophageal puncture after total laryngectomy. Laryngoscope 2011; 121 (07) 1455-1461
    CrossrefPubMedGoogle Scholar
  • 55 Hosal SA, Myers EN. How I do it: closure of tracheoesophageal puncture site. Head Neck 2001; 23 (03) 214-216
    CrossrefPubMedGoogle Scholar
  • 56 Visconti G, Bianchi A, Hayashi A. et al. Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound. Arch Plast Surg 2020; 47 (04) 365-370
    Article in Thieme ConnectPubMedGoogle Scholar
  • 57 Choi DH, Goh T, Cho JY, Hong JP. Thin superficial circumflex iliac artery perforator flap and supermicrosurgery technique for face reconstruction. J Craniofac Surg 2014; 25 (06) 2130-2133
    CrossrefPubMedGoogle Scholar