Delayed Complication of Tracheocutaneous Fistula Closure with Severe Compromising Subcutaneous Emphysema

Tracheocutaneous fistula (TCF) is commonly seen in pediatric patients with long term tracheostomy following decannulation. The fistula may be surgically closed by a variety of techniques. We report a significant complication of TCF excision in a 4 year old male with a history of restrictive lung disease due to a giant omphalocele who had been tracheostomy dependent since infancy. He was decannulated at age 3, and one year after decannulation had a persistent 3mm TCF. He underwent surgery to repair the TCF with excision of the fistula tract and intended closure by secondary intention. On post-operative day 2 the patient rapidly developed profound subcutaneous emphysema of the face, neck, arms and chest, as well as pneumomediastinum. Due to the rapid onset there was concern that swelling may compromise the airway leading to urgent intubation. He was extubated after 2 days as the swelling resolved and discharged from the hospital on post-operative day 7 in stable condition. At follow up he had complete resolution of subcutaneous emphysema as well as complete closure of the TCF. Subcutaneous emphysema is a rare complication of TCF repair. We discuss the main methods of TCF closure with the indications, benefits, and complications of each. Management of subcutaneous emphysema is also discussed along with the lessons learned from this case