Primary versus secondary closure of tracheocutaneous fistula in pediatric patients
Christopher H Azbell1, Anna Bakeman1, Jennifer L McCoy2
1Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
Insights
Secondary intention closure of tracheocutaneous fistulas (TCF) is safe and effective in children. This method offers shorter hospital stays compared to primary closure for TCF in pediatric patients with prior tracheostomy.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Wound Healing
Background:
- Persistent tracheocutaneous fistula (TCF) affects up to 50% of pediatric patients post-tracheostomy decannulation.
- Traditional TCF management involved surgical excision and multilayered closure, but secondary intention is increasingly adopted.
- Variations in postoperative care for TCF persist, necessitating comparative outcome analysis.
Purpose of the Study:
- To compare outcomes between primary closure and secondary intention closure after TCF excision in children.
- To evaluate the efficacy of secondary intention closure versus traditional primary closure for TCFs.
- To assess TCF closure in pediatric patients with tracheostomy placed at one year of age or younger.
Main Methods:
- Retrospective chart review of pediatric patients (ages 0-21) undergoing TCF closure.
- Inclusion criteria: tracheostomy placement at or before one year old.
- Statistical analysis included Mann-Whitney U test, Fisher's Exact test, and logistic regression.
Main Results:
- Secondary closure (60.9%) was associated with significantly shorter surgery duration, ICU length of stay, and postoperative length of stay (p < .001).
- No significant differences were observed in cardiac complications, respiratory complications, or need for reoperation between the two methods (p > .05).
- Primary closure correlated with a longer time from decannulation to TCF (p = .010).
Conclusions:
- Secondary intention closure of TCF is a safe and effective option in pediatric patients.
- This approach can lead to reduced hospital stays for children requiring TCF closure.
- Secondary intention closure is as efficacious as primary closure for TCFs in this population.
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.
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