CPT® Code 31755

1. Indications

The tracheoplasty procedure, specifically tracheopharyngeal fistulization, is indicated for patients who have undergone a laryngectomy. The primary purpose of this procedure is to enable speech production in individuals who have lost their ability to speak due to the removal of the larynx. The following conditions may warrant the performance of this procedure:

• Laryngectomy Patients who have had their larynx removed due to cancer or other significant laryngeal conditions.
• Speech Rehabilitation Individuals seeking to regain the ability to produce speech following laryngectomy.
• Fistula Creation Patients requiring the establishment of a tracheopharyngeal fistula to facilitate communication.

2. Procedure

The procedure for tracheopharyngeal fistulization involves several critical steps, which may vary depending on whether it is performed concurrently with a laryngectomy or as a separate surgical session. The following outlines the procedural steps:

• Step 1: Exposure of the Larynx If the procedure is performed after a laryngectomy, the first step involves careful exposure of the larynx to allow access for the surgical intervention. This is essential for the subsequent steps of the procedure.
• Step 2: Incision in the Cricopharyngeal Muscle An incision is made in the cricopharyngeal muscle, which is then extended vertically into the inferior constrictor muscle. This incision is crucial for accessing the pharyngeal lumen.
• Step 3: Stretching the Muscular Coat The muscular coat of the pharynx and upper esophagus is stretched by placing stay sutures at the edge of the pharyngeal wall. A finger is inserted into the pharyngoesophageal lumen to facilitate the stretching of the muscular coat.
• Step 4: Division of the Muscular Coat The muscular coat is carefully divided while leaving the mucosal layer intact, which is important for maintaining the integrity of the surrounding tissues.
• Step 5: Insertion of the Hollow Metal Tube A hollow metal tube is inserted into the pharyngeal lumen, with the bevel oriented towards the posterior wall of the trachea, to create a passage between the trachea and pharynx.
• Step 6: Trocar and Cannula Insertion A trocar and cannula are inserted through the upper aspect of the posterior tracheal wall and passed through the metal tube into the pharyngeal lumen, facilitating the connection between the two structures.
• Step 7: Catheter Insertion A catheter is inserted through the mouth into the pharynx and through the cannula into the surgical wound, aiding in the establishment of the fistula.
• Step 8: Voice Prosthesis Insertion A voice prosthesis may be inserted to assist with speech production, providing the patient with a means to communicate effectively.
• Step 9: Alternative Techniques Alternatively, a tube may be created using the mucosa of the posterior tracheal wall or muscle flaps or grafts, which is then implanted into the pharynx to establish the fistula.

3. Post-Procedure

Post-procedure care for patients who have undergone tracheopharyngeal fistulization includes monitoring for any complications related to the surgical site, such as infection or improper healing of the fistula. Patients may require follow-up visits to assess the functionality of the fistula and the effectiveness of the voice prosthesis, if applicable. Additionally, speech therapy may be recommended to help patients adapt to their new method of communication and maximize their speech capabilities. Recovery time can vary based on individual circumstances and the complexity of the procedure, but patients are generally advised to follow their physician's post-operative instructions closely to ensure optimal healing and outcomes.