title: Classification and management of tracheoesophageal and tracheopharyngeal fistulas after laryngectomy.
abstract: OBJECTIVE
  Tracheoesophageal fistulas (TEF) and tracheopharyngeal fistulas (TPF) are intentionally created for prosthetic or surgical voice restoration after laryngectomy or can develop after radiotherapy or surgical interventions. If the fistula does not shrink or close spontaneously or does not respond to conservative measures, surgical closure of the fistula is indicated.
  
  
  METHODS
  Retrospective study of 177 patients.
  
  
  METHODS
  Data of 168 laryngectomy patients who needed a voice prosthesis (VP) replacement were obtained. Our experiences with nine severe TEF/TPF were analyzed, and a classification of these fistulas depending on the anatomic and clinical appearance was developed.
  
  
  RESULTS
  TEF/TPF can be divided into five types: high TEF with leakage through the VP (type Ia), high TEF with leakage around the VP (type Ib), enlarged high TEF (type II), deep TEF (type III), TPF (type IV), and TPF associated with pharynx stenosis (type V). Persisting TEF/TPF after unsuccessful attempts at surgical closure in four patients and the surgical solutions and procedures in these rare cases are discussed in detail.
  
  
  CONCLUSIONS
  Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, and in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multilayer sutures of the esophagus and trachea. Persisting TEF/TPF after unsuccessful surgical attempts at revision surgery remain challenging. Our experiences show that tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation, a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.
authors.affiliation: Department of Otorhinolaryngology, Plastic Head and Neck Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. eckard.gehrking@hno.uni-luebeck.de
authors.forename: Eckard
authors.initials: E
authors.lastname: Gehrking
authors.forename: Michael
authors.initials: M
authors.lastname: Raap
authors.forename: Konrad D
authors.initials: KD
authors.lastname: Sommer
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007825:Laryngectomy; D007831:Larynx, Artificial; D008297:Male; D008875:Middle Aged; D010614:Pharynx / Q000601:surgery*; D012189:Retrospective Studies; D014138:Tracheoesophageal Fistula / Q000145:classification* / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome