Postoperative Fistula

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Early in the development of tracheal reconstruction, postoperative hemorrhage from the brachiocephalic artery occurred too frequently.3,4 Since cuff stenosis often lies at the level of the artery, the vessel was frequently dissected free from scar and the tracheal anastomosis made immediately behind it. Local infection or erosion at this point of confluence could lead to bleeding. Suture material, a foreign body, probably contributes. One surgeon, who formerly used fine wire for an anterior tracheal anastomosis, attributed some fistulas to abrasion by this unyielding material. Anastomotic dehiscence after tracheal reconstruction, most often managed with subsequent intubation, may expose the artery in what is now an infected space.

If tracheal dissection is kept scrupulously close to the trachea and the artery is left undissected with its local tissue investment intact, hemorrhage will almost never follow. When the artery must be dissected because of adherence to tracheal scar, prior tracheal surgery, or in surgery for a neoplasm, it is advisable to place viable tissue, such as an inferiorly based pedicle of sternohyoid muscle or thymus, between the tracheal anastomosis and the overlying artery. The rarity of this complication is seen in its low incidence, occurring in only five (1%) of 503 patients who had tracheal resection and reconstruction for postintubation lesions.5 These instances occurred early in our experience.

Late brachiocephalic hemorrhage has long been the bane of mediastinal tracheostomy and exentera-tion. The artery would become exposed by failure of healing of the skin beneath the mediastinal tra-cheostomy, sometimes abetted by the effects of prior irradiation. This has largely been prevented by omental coverage or, where indicated, by prophylactic division of the brachiocephalic artery, after preoperative imaging and with intraoperative electroencephalographic monitoring (see Chapter 34, "Cervicomediastinal Exenteration and Mediastinal Tracheostomy").6

Innominate arteries or even aortic fistulae have resulted over the years from attempts to use tracheal prostheses made of various foreign materials.3 Fixation points of Gianturco tracheobronchial stents have also produced arterial fistulae. Both demonstrate the all too obvious surgical principle of avoiding prolonged pressure on vascular structures by foreign material.

figure 13-1 Tracheobrachiocephalic artery fistula due to anterior erosion by tracheostomy tube cuff. A, Operative field after division and resection of a fistulous arterial segment. The forceps elevates the proximal brachiocephalic arterial stump. The distal artery is visible to the right of the trachea, which exhibits a sizeable anterior defect. The endotracheal tube is visible in the defect. The brachiocephalic vein is retracted caudad with a Penrose drain.

figure 13-1 (contnued) B, The resected segment of circumferentially damaged trachea is at the left. The anterior fistula is visible. The perforated section of the brachiocephalic artery is at the right. Both arterial ends were sutured closed and protected with thymus. A standard tracheal anastomosis was made.

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