Postoperative Fistula

Prevention of postoperative hemorrhage from the innominate artery following tracheal resection and reconstruction has been discussed in Chapter 13, "Tracheal Fistula to Brachiocephalic Artery." Should a

Fistula Brachiocephalic Vein

figure 27-4 Surgical management of a fistula due to tracheal cuff injury. Exposure is the same as previously described. A, Arterial control is obtained, the artery divided above and below the fistula, and proximal and distal stumps sutured closed. The circumferentially damaged segment of trachea is dissected and excised along with the damaged vessel. B, End-to-end anastomosis of the trachea is completed. Arterial stumps are buried in healthy tissues, and tissues are arranged to fill dead space. The prior stoma remains available for the ventilating tube, if necessary. The cuffmust not be placed in direct contact with the suture line.

figure 27-4 Surgical management of a fistula due to tracheal cuff injury. Exposure is the same as previously described. A, Arterial control is obtained, the artery divided above and below the fistula, and proximal and distal stumps sutured closed. The circumferentially damaged segment of trachea is dissected and excised along with the damaged vessel. B, End-to-end anastomosis of the trachea is completed. Arterial stumps are buried in healthy tissues, and tissues are arranged to fill dead space. The prior stoma remains available for the ventilating tube, if necessary. The cuffmust not be placed in direct contact with the suture line.

hemorrhage occur after tracheal resection and reconstruction by the anterior approach, then an endo-tracheal tube with the cuff tightly inflated is used to occlude the fistula. Exposure must be obtained promptly as described, and control established. In most cases, the damaged artery is best resected and managed as advised earlier. In a rare case, a tiny fistula due to erosion by an adjacent suture may be cleanly debrided and the artery closed with vascular suture material. If this is to be done, the artery must otherwise be in excellent condition and, following arteriorrhaphy, a second layer buttress with a pedicled strap muscle is advisable. This not only helps to buttress the repaired artery but it also interposes healthy muscle between the site of arterial injury and the site of repair of the tracheal anastomosis. Any defect in the anastomosis must also be primarily repaired. The muscle flap also serves to seal this repair.

Even more disastrous, and likely to be promptly fatal, is a late hemorrhage from an artery that has been exposed after separation of a tracheal anastomosis, with placement of a tracheostomy tube or a T tube. If possible, the injured arterial segment is excised, and the sutured stumps are protected by flaps of healthy tissue. This situation may well present an indication for use of pedicled omentum. Most anastomotic separations are due either to devascularization or excessive tension. Further tracheal repair may not be possible. The airway may be managed initially by a properly positioned endotracheal tube that spans the defect, since ventilatory support will likely be needed. Later, the airway is maintained with an extra-long T tube.

Hemorrhage from erosion into the adjacent brachiocephalic artery, at the margin of a mediastinal tracheostomy, requires excision of the injured segment of artery. It seems unwise to attempt to reconstruct the artery in this essentially septic circumstance. A pedicled omentum will be useful. Such surgical catastrophes have been largely eliminated by the precautions described in Chapter 13, "Tracheal Fistula to Brachiocephalic Artery."5

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