Tracheoesophageal Puncture Technique

Deciding between a primary or secondary tracheoesophageal puncture (TEP) can depend on multiple factors. Pou describes that a primary TEP is absolutely contraindicated if the party wall between the trachea and esophagus have been separated, either as a consequence of surgeon technique or secondary to the degree of oncologic resection. Relative contraindications include conditions precluding adequate use of the prosthesis such as poor pulmonary function, poor manual dexterity, or bilateral hearing loss. She notes that preoperative or the need for postoperative radiation are not contraindications to primary TEP. ^[4]

The primary tracheoesophageal puncture (TEP) is performed at the same time as the total laryngectomy. For the purposes of this approach, we are using a technique similar to that used for a Blom-Singer prosthesis. The prosthesis portion of the procedure is performed after the laryngeal specimen has been removed from the patient, leaving an exposed distal trachea with an endotracheal tube in place, posterior pharyngeal mucosa, and an exposed cervical esophagus.

For this portion of the procedure utmost care must be taken to avoid separating the party wall between the esophagus and the trachea. Some describe using absorbable suture to further approximate the posterolateral aspect of the trachea to the anterolateral wall of the esophagus. ^{[4, 24]} When performing the puncture, make the hole sufficiently below the superior aspect of the remaining posterior tracheal wall. This edge makes the superior portion of the stoma, and making a puncture to close to the edge results in the prosthesis angling downwards.

Some device sets, such as the Hermann set, come with a hook that is placed in the esophagus and pierces the esophageal and tracheal wall. This puncture needle is guided over the finger into the esophagus and should be placed between 12 mm and 15 mm below the resected margin of the posterior tracheal wall. ^[5] Other surgeons describe using a blunt instrument such as a right angle clamp to enter the esophagus, and then again making a puncture more than 1 cm below the resected tracheal margin. A stab or horizontal incision should be made over the tips of the right angle. ^{[4, 24]} After creating the puncture, a red rubber catheter or Foley catheter can be placed through the puncture site and fed into the esophagus. This can provide a method of feeding during the initial postoperative period. Alternatively, the prosthesis can be placed immediately and a nasogastric tube can be used for feeding access.

The secondary tracheoesophageal puncture (TEP) is performed after the TL has had time to heal, and some advocate performing the procedure after a radiation course, if prescribed, has been completed. Several techniques are described, both under general or local anesthesia.

Under general anesthesia, the classic method of performing a secondary puncture involves the use of a cervical rigid esophagoscope. The esophagoscope is inserted into the neopharynx and advanced to the level of the party wall and positioned with the bevel facing anteriorly, thus protecting the posterior esophageal wall. Under direct visualization, a needle or trochar can be inserted through the party wall, approximately 8-10 mm below the superior edge of the posterior tracheal wall into the bevel of the esophagoscope.

A catheter or wire is then fed through the puncture site or trochar until it is visualized out of the oral end of the esophagoscope. Deschler et al describe a Teflon catheter that is fed over the puncturing needle. The tract can then be dilated either via a Seldinger technique or via serially larger red-rubber catheters. The final catheter can be then reduced back into the esophagus for future TEP prosthesis placement or the prosthesis itself can be placed. To place the prosthesis, it is secured to the catheter emerging from the mouth, and the catheter is pulled from the stoma, pulling the prosthesis in a retrograde fashion back through the mouth and out the TEP into proper position. ^[25]

Under local anesthesia and after topical anesthesia of the neopharynx, Rabanal and Herranz describe having the patient swallow a hollow tube (such as a No. 8 Portex tube) until it can be seen bulging through the visible posterior tracheal wall. Then a needle is placed approximately 1 cm below the superior edge of the posterior tracheal wall into the hollow tube and a catheter (Drum-Cartridge catheter) is advanced over the needle into the tube until it comes out the mouth. Then the tube and needle are withdrawn, and the hole is consecutively dilated using serially larger catheters. Once a 12 Fr catheter is placed, these authors describe the prosthesis being inserted into the puncture site. ^[26]

Bach et al describe the use of the transnasal esophagoscope to place the puncture under local anesthesia in a clinic setting. The patient's nose is sprayed with oxymetazoline and lidocaine and the patient is asked to dissolve benzonatate capsules in the mouth and then ingest viscous lidocaine (5 mL of 2% lidocaine). Local anesthetic is also injected into the posterior tracheal wall at the site of the puncture. The scope is then passed through the nose into the esophagus. The authors also describe dilating the patient's neopharynx in the office if stenosis is evident.

Under fiberoptic visualization with insufflation of the esophagus, the proposed puncture site is identified using a blunt instrument, and then an 18-gauge needle is advanced through the posterior tracheal wall into the esophageal lumen. Afterwards a cruciate incision is made at the site and dilating catheters are passed through the puncture site into the esophagus. Bach then describes the speech pathologist placing the prosthesis and using the esophagoscope to ensure adequate placement. ^[27]

Generally speaking, in-office placement requires the use of either a trochar or needle to puncture through the party wall into the esophagus, while protecting the posterior esophageal wall. After creating the puncture, the puncture site should be dilated until it is the appropriate size for the prosthesis. The prosthesis can then be placed at the same time as the puncture or can be placed in a delayed fashion. If the prosthesis is going to be delayed, then a red rubber catheter should be left in place to stent the puncture and the visible portion of the catheter should be secured to the neck.

If the voice prosthesis needs to be replaced or if it is being placed for the first time after the puncture, it is often placed in the office by either a speech language pathologist or by an otolaryngologist. Each device manufacturer has a different system for placement of the prosthesis; this chapter will discuss the procedure in generalities.

The systems for replacing the prosthesis involve stenting the puncture site open, placing the new prosthesis into the puncture site with the phalanges bent, and the phalanges then opening into place thus securing the prosthesis across the puncture site. Use an appropriately sized prosthesis to avoid problems with leaking around the puncture site and issues with poor voice production. Many kits come with the phalanges of the prosthesis bent and either secured within the prosthesis applier or by a dissolvable gel cap. By either twisting the prosthesis once it is in position or allowing the gel cap to dissolve, the intraesophageal phalanges open up, thus securing the prosthesis across the puncture site.

After placing the prosthesis, it should be evaluated for a leak. The patient can be asked to sip some water, and the site should be examined by the provider to ensure that the water does not leak around or through the prosthesis. Food coloring in the water can ease detection of a leak.