Tracheoesophageal Puncture (TEP)
Considerations
Secondary placement of TEP prosthesis
Preparation
Ensure you have properly size the TE prosthesis to fit the patient's trachea
Start with 20 French 8 mm - fits most patients well
If too small, use 22 French 10 mm
Plan TEP site to allow ease of access while cleaning and changing prosthesis
Check TEP dilator and prosthesis is secured
Equipment
Esophagoscopy / Laryngoscopy tray
Provox kit
Procedure
Once patient is intubated, turn table 90 degrees in preparation for esophagoscopy / laryngoscopy
Apply upper tooth guard
Insert esophagoscope into esophagus
Using non-operative hand, palpate the esophagoscope through the posterior wall of trachea
While palpating, slowly retract esophagoscope until the tip is palpable at TEP insertion site
Rotate esophagoscope 180 degrees so that flange is posterior and providing a safe guard for the trocar
Insert the puncture needle through the TEP site until tip reaches the inner wall of and is visible through the esophagoscope
Optional: Use the Hopkins rod with camera to indirectly visualize the puncture through the esophagoscope
Insert the guidewire through the puncture needle until it is reachable at the cranial end of esophagoscope, and secure
Remove the esophagoscope while keeping guidewire in place
Slide the puncture dilator onto the guidewire from the cranial side, and secure the end of the guidewire to the dilator
Advance the dilator by pulling the guidewire smoothly from the tracheal side until it is showing through the puncture site
Applying counter pressure with your other hand, continue pulling the guidewire to advance the dilator until the prosthesis flange is unfurled and seated in the correct position
Turn the prosthesis into correct position
Cut the safety strap to release the prosthesis from the dilator
Optional: Use the Hopkins rod with camera to document proper placement in the esophagus through the esophagoscope
Sample operative report
Findings:
Status post total laryngectomy on ***
Placed Provox Vega TEP for voice rehabilitation
Procedure in Detail:
@NAME@ was transported to the OR where {HE/SHE:30451} was positioned supine. The laryngectomy stoma was intubated with an armored ETT. Bed turned 90 degrees. Maxillary *** teeth *** gums protected.
Rigid Jesberg esophagoscope placed to the level of the laryngectomy stoma. Puncture completed in the posterior midline stoma wall, 10 mm inferior to the mucocutaneous junction. Guidewire threaded; Puncture trocar and esophagoscope removed. Dilator followed by device placed with tracheal phalanges fully exposed. Device extension secured to skin with steri-strip.
Extubated without issue. Stoma vent replaced. *** Gums *** teeth intact. Transported to PACU without issue.
Post-op
Medications
Nystatin 100,000 unit/mL Oral Susp
Apply the suspension to clean the prosthesis through the stoma 2 times daily; If there is visible fungus, then clean 4 times daily AND SWALLOW 1 TEASPOONFUL (5 ML) ORALLY 2-4 TIMES A DAY
Diet
Resume diet as tolerated
Follow up
ST clinic in 1-2 weeks
HNS clinic PRN
The TEP can be changed by ST or MD every 3 months or earlier as needed
Complications
Damage to teeth / related structures
Leak from the TEP requires replacement
Leak from around the TEP also requires replacement, can be more challenging since there may be an issue with the fit
Fungal colonization is a common nuisance, can be managed with Nystatin but also usually requires replacement