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Ishida K, Hirayama H, Kishi K, Miyawaki T. Long-term surgical and functional outcomes after anterolateral thigh flap and free jejunal transfer reconstruction of circumferential pharyngoesophageal defects. Head Neck 2023; 45:2996-3005. [PMID: 37755124 DOI: 10.1002/hed.27526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/20/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral thigh (ALT) free flap. METHODS We reviewed the medical records of 92 patients with ALT free flaps and 140 who underwent FJ transfer between 2009 and 2022, and compared their surgical outcomes. RESULTS Total flap loss occurred in two (2%) and five (4%) patients in the ALT free flap and FJ transfer groups, respectively. Fistula rates were 5% in both groups. Stricture rates were 21% and 5% in the ALT free flap and FJ transfer groups, respectively (p < 0.01). At the 5-year follow-up evaluation, intelligible speech was achieved by 83% and 28% of patients (p < 0.01) in the ALT free flap and FJ transfer groups, respectively. CONCLUSIONS Each reconstructive method can be further optimized by proficient surgeons with expertise in the available methods and by considering patient-specific factors and available evidence.
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Affiliation(s)
- Katsuhiro Ishida
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruyuki Hirayama
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keita Kishi
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Miyawaki
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
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2
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Kumar V, Kalwani R, Bindu A, Mathews S, Mantri M, Jaiswal D, Shankhdhar VK. Comparison of Functional Outcomes of Intestinal Flaps Vs Tubed Fasciocutaneous Flaps for Circumferential Pharyngoesophageal Defects-an Indian Perspective. Indian J Surg Oncol 2023; 14:668-676. [PMID: 37900626 PMCID: PMC10611640 DOI: 10.1007/s13193-023-01723-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/13/2023] [Indexed: 10/31/2023] Open
Abstract
Pharyngolaryngoesophageal (PLO) reconstruction is a complex and technically demanding procedure. The reconstructive surgeon's concerns include avoiding fistula and stricture formation, as well as restoring normal speech and swallowing. A retrospective observational study with circumferential pharyngo-laryngo-oesophagal defects with aims and objectives of evaluation and comparison of the long-term functional outcomes like speech and swallowing along with the complications of fistula and stricture in two groups of JFF and FC flaps from the data is collected from electronic medical records of Tata Memorial Hospital, Mumbai, from January 2011 to May 2020. A total of 67 patients (52 JFF and 15 fasciocutaneous flaps) were operated on in last 9 years in our institute. The difference in fistula rates and stricture rates between the two groups was not significant (p= 0.98 and 0.947). The difference in 100% oral diet between the two groups was significant (p= 0.019). The difference in speech rehabilitation between the two groups was significant (p= 0.024). The intestinal tubes and fasciocutaneous tubes have comparable outcomes with regard to fistula and stricture formation. Speech outcomes in the form of the ability to have functional speech and voice quality were significantly better with skin-lined tubes. Swallowing outcomes were much better with intestinal tubes, along with early oral alimentation.
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Affiliation(s)
- Vineet Kumar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Rounak Kalwani
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Ameya Bindu
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Saumya Mathews
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Mayur Mantri
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Dushyant Jaiswal
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
| | - Vinay Kant Shankhdhar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012 India
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3
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Shu M, Cheng L, Wu H. A designed ladder-shaped stent for the treatment of refractory hypopharyngeal corrosive strictures. Acta Otolaryngol 2023; 143:704-708. [PMID: 37534459 DOI: 10.1080/00016489.2023.2236147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The treatment of refractory hypopharyngeal corrosive strictures remains challenging nowadays. OBJECTIVES To introduce a designed ladder-shaped stent for the treatment of refractory hypopharyngeal corrosive strictures. MATERIAL AND METHODS Patients with refractory hypopharyngeal corrosive strictures treated in our hospital between 2018 to 2022 were recruited in this study. All the patients had a dysphasia score of 4 and four patients had a tracheostomy preoperatively. A designed ladder-shaped stent was placed in the hypopharyngeal area after laser treatment to maintain the opening. This stent was kept for 3-6 months. All the patients were followed-up for at least 6 months after stent removal. RESULTS Six patients were recruited including two males, three females and one girl. All the patients were tolerable with the stent. There were no immediate or long-term complications. Patients were able to swallow a soft diet after the procedure. No tracheostomy was needed. CONCLUSION This use of a ladder-shaped stent is helpful in the treatment of hypopharyngeal strictures after laser treatment.
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Affiliation(s)
- Min Shu
- Otolaryngology Department of the Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Lei Cheng
- Otolaryngology Department of the Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Haitao Wu
- Otolaryngology Department of the Eye & ENT Hospital of Fudan University, Shanghai, China
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Tamaki A, Zender CA. Free Flap Donor Sites in Head and Neck Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00047-6. [PMID: 37173238 DOI: 10.1016/j.otc.2023.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Microvascular free tissue transfer, also referred to as free flaps surgery, is a reconstructive technique that has become a foundational component of complex head and neck reconstruction. There have been considerable advancements in the field over the last 30 years including the number and variety of free flaps. Each of these free flaps has unique characteristics that must be considered for the defect when selecting a donor site. Here, the authors focus on the most common free flaps used in head and neck reconstruction.
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Affiliation(s)
- Akina Tamaki
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, LKS 5045, Cleveland, OH 44106, USA.
| | - Chad A Zender
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, MSB 6408, Cincinnati, OH 45229, USA
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5
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Hanubal KS, Chheda NN, Dziegielewski PT. Neopharyngeal Stricture following Laryngectomy. Semin Plast Surg 2023; 37:31-38. [PMID: 36776807 PMCID: PMC9911225 DOI: 10.1055/s-0042-1759796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.
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Affiliation(s)
| | - Neil N. Chheda
- Department of Otolaryngology, University of Florida, Gainesville, Florida
| | - Peter T. Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, Florida
- University of Florida Health Cancer Center, Gainesville, Florida
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6
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Salzillo R, Boriani F, Carta F, Tatti M, Atzeni M, Persichetti P, Haywood RM, Puxeddu R, Figus A. Perforator‐based chimeric anterolateral thigh flap U‐shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes. Microsurgery 2022; 43:347-356. [PMID: 36468794 DOI: 10.1002/micr.30991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 11/02/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes. METHODS We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires. RESULTS Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2. CONCLUSIONS The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.
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Affiliation(s)
- Rosa Salzillo
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
- Campus Bio‐Medico University of Rome, Department of Plastic, Reconstructive and Aesthetic Surgery University Hospital Campus Bio‐Medico Rome Italy
| | - Filippo Boriani
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
| | - Filippo Carta
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Melania Tatti
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Matteo Atzeni
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
| | - Paolo Persichetti
- Campus Bio‐Medico University of Rome, Department of Plastic, Reconstructive and Aesthetic Surgery University Hospital Campus Bio‐Medico Rome Italy
| | - Richard M. Haywood
- Norfolk and Norwich University Hospital NHS Foundation Trust, Department of Plastic and Reconstructive Surgery University of East Anglia, Norwich Medical School Norwich UK
| | - Roberto Puxeddu
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Otorhinolaryngology Unit University Hospital Duilio Casula Cagliari Italy
| | - Andrea Figus
- University of Cagliari, Faculty of Medicine and Surgery, Department of Surgical Sciences, Plastic Surgery and Microsurgery Unit University Hospital Duilio Casula Cagliari Italy
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7
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Anterolateral thigh butterfly free flap for reconstruction of laryngopharyngeal defect: surgical considerations. The Journal of Laryngology & Otology 2022; 136:878-881. [DOI: 10.1017/s0022215121004394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackgroundReconstruction of a pharyngoesophageal defect remains a challenging problem, especially with involvement of the neck skin. This study aimed to demonstrate the surgical technique of utilising a butterfly modification of the anterolateral thigh flap.ResultsReconstruction of the pharyngoesophageal defect was accomplished using the butterfly modification of the anterolateral thigh free flap. The flap was tubed on the leg while still being attached to the pedicle, to minimise the ischaemia time.ConclusionButterfly anterolateral thigh free flap allows for multi-layer closure of the neopharynx and can be utilised for reconstruction of pharyngoesophageal and neck skin defects.
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Costantino A, Pace GM, Festa BM, Ferreli F, Malvezzi L, Spriano G, Mercante G, De Virgilio A. Salivary bypass tube in total laryngectomy: Systematic review and meta-analysis. Head Neck 2022; 44:2608-2620. [PMID: 35920404 DOI: 10.1002/hed.27169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/02/2022] [Accepted: 07/21/2022] [Indexed: 11/08/2022] Open
Abstract
The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Gian Marco Pace
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Fabio Ferreli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Luca Malvezzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele MI, Italy.,Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Rozzano MI, Italy
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9
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Costantino A, Festa BM, Ferreli F, Russo E, Malvezzi L, Giannitto C, Spriano G, Mercante G, De Virgilio A. Circumferential pharyngeal reconstruction after total laryngopharyngectomy: A systematic review and network meta-analysis. Oral Oncol 2022; 127:105809. [PMID: 35298936 DOI: 10.1016/j.oraloncology.2022.105809] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/06/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare the functional outcomes of different reconstructive techniques for circumferential pharyngeal reconstruction. METHODS A comprehensive electronic search was performed on PubMed/MEDLINE, Cochrane Library, and Google Scholar databases. Retrospective and prospective studies were included. Two independent reviewers extracted thirty-four studies after applying the eligibility criteria. An arm-based network analysis was conducted using a Bayesian hierarchical model. The main outcomes were pharyngo-cutaneous fistula (PCF) incidence, stenosis incidence and feeding tube dependence (FTD) incidence. Network estimates from outcome variables were presented as absolute risks, odds ratio [OR] with 95% credible intervals (CIs), and ranking probability. RESULTS A total of 1357 patients were included for 5 different interventions (tubed pectoralis muscle myocutaneous flap, t-PMMCF; tubed anterolateral tight flap, t-ALTF; tubed radial forearm free flap, t-RFFF; free jejunal flap, FJF; U-shaped pectoralis muscle myocutaneous flap, u-PMMCF). FJF showed a 92.8% chance of ranking first in terms of pharyngo-cutaneous fistula prevention (absolute risk: 10%), while the highest PCF incidence (42%) was measured for t-PMMCF. u-PMMCF showed the lowest absolute risk (11%) of stenosis incidence (62.2% chance of ranking first). t-PMMCF (5%), FJF (8%), and u-PMMCF (8%) showed similar results in terms of feeding tube dependence, with a 53.2%, 23.1% and 18.9% chance of ranking first, respectively. CONCLUSIONS FJF seems to be the best reconstructive choice after total laryngo-pharyngectomy in terms of PCF, stenosis and FTD incidence. If this reconstructive method is not feasible, a u-PMMCF should be favored over tubed free and pedicled flaps. Further comparative studies are needed to confirm these results.
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Affiliation(s)
- Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Bianca Maria Festa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy.
| | - Fabio Ferreli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Elena Russo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Luca Malvezzi
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Caterina Giannitto
- Radiology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano (MI), Italy
| | - Giuseppe Spriano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy; Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
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10
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Clinical outcomes following pharyngolaryngectomy reconstruction: a 20-year single-centre study. The Journal of Laryngology & Otology 2022; 136:1105-1112. [DOI: 10.1017/s0022215122000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Advanced malignant neoplasms of the larynx and hypopharynx pose many therapeutic challenges. Total pharyngolaryngectomy and total laryngectomy provide an opportunity to cure these tumours but are associated with significant morbidity. Reconstruction of the pharyngeal defect following total pharyngolaryngectomy demands careful consideration and remains an area of debate within surgical discussions.
Methods
This paper describes a systemic analysis of pharyngeal reconstruction following total pharyngolaryngectomy and total laryngectomy, leveraging data collected over a 20-year period at a large tertiary referral centre.
Results
Analysing 155 patients, the results show that circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. In addition, free tissue transfer in larger pharyngeal defects showed lower rates of post-operative anastomosis leak and stricture.
Conclusion
Pharyngeal resection carries a substantial risk of post-operative complications, and free tissue transfer appears to be an effective means of reconstruction for circumferential defects.
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11
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Woods JFC, Woods RSR, Lennon P, Timon C, Kinsella J, Ravi N, Beausang E, Theopold CFP. Analysis of Outcomes of Pharyngo-laryngo-esophagectomy and Reconstruction with Longitudinal Comparison in a Single Institution. J Plast Reconstr Aesthet Surg 2021; 75:1567-1572. [PMID: 34955400 DOI: 10.1016/j.bjps.2021.11.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/14/2021] [Indexed: 11/25/2022]
Abstract
Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ H&N 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.
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Affiliation(s)
- Jack F C Woods
- Department of Surgery, St James's Hospital, Dublin, Ireland.
| | | | - Paul Lennon
- Department of Surgery, St James's Hospital, Dublin, Ireland
| | - Conrad Timon
- Department of Surgery, St James's Hospital, Dublin, Ireland
| | - John Kinsella
- Department of Surgery, St James's Hospital, Dublin, Ireland
| | | | - Eamon Beausang
- Department of Surgery, St James's Hospital, Dublin, Ireland
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12
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Comparison between anterolateral thigh free flap and jejunal flap for tissue reconstruction in patients underwent resection of pharyngoesophageal squamous cell carcinoma after radiotherapy failure: a retrospective study. BMC Surg 2021; 21:389. [PMID: 34727910 PMCID: PMC8561938 DOI: 10.1186/s12893-021-01349-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/15/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with worsening tissue adhesion and necrosis after radiotherapy failure. However, the results of tissue reconstruction and postoperative complications of these two flaps are controversial. The purpose of this study was to compare outcomes between group ALT free flap and group JF in PESCC after radiotherapy failure. METHODS Intraoperative information and postoperative outcomes of patients with PESCC after radiotherapy failure who underwent ALT and JF reconstruction from January 2005 to December 2019 were compared and analyzed. RESULTS The defect size of ALT (Numbers, 34) and JF (Numbers, 31) was 36.19 ± 11.35 cm2 and 35.58 ± 14.32 cm2 (p = 0.884), respectively. ALT and JF showed no significant difference in operation time (p = 0.683) and blood loss (p = 0.198). For postoperative outcomes within 30 days both in recipient site and donor site including wound bleeding, wound dehiscence, wound infection, and pharyngocutaneous fistula, ALT free flap and JF showed similar results. Flap compromise (Numbers, 2 VS.3, p = 0.663), flap take backs (Numbers, 1 VS.1, p = 1.000), partial flap failures (Numbers, 4 VS.2, p = 0.674), and total flap failures (Numbers, 0 VS.0, p = 1.000) showed no difference between the two groups. In addition, no significance was found in hypoproteinemia between the two groups (Numbers, 4 VS.2, p = 0.674). ALT free flap was not statistically different from JF in the incidence of dysphagia at the postoperative 6 months (Numbers of liquid diet, 5VS.5; Numbers of partial tube feeding, 6VS.7; Numbers of total tube feeding, 3VS.1, p = 0.790) and 12 months (Numbers of liquid diet, 8VS.7; Numbers of partial tube feeding, 8VS.7; Numbers of total tube feeding, 5VS.5, p = 0.998). The cause of dysphagia not found to differ between the two groups both in postoperative 6 months (p = 0.814) and 12 months (p = 0.845). CONCLUSION Compared with JF, ALT free flap for PESCC patients after radiotherapy failure showed similar results in postoperative outcomes. ALT free flap may serve as a safe and feasible alternative for PESCC patients after radiotherapy failure.
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13
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Crosetti E, Arrigoni G, Sprio AE, Succo G. "Fistula Zero" Project After Total Laryngectomy: The Candiolo Cancer Institute Experience. Front Oncol 2021; 11:690703. [PMID: 34239804 PMCID: PMC8258249 DOI: 10.3389/fonc.2021.690703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives Pharyngocutaneous fistula (PCF) is a troublesome complication after total laryngectomy. The “Fistula zero” project aims to reduce the number of PCF by following a detailed protocol based on three fundamental key points. Materials and Methods The Fistula zero project included 77 patients who underwent total laryngectomy in the period from January 2019 to December 2020. The protocol consisted of three main aspects: the systematic placement of a Har-El salivary bypass tube, the continuous horizontal watertight pharyngeal suture using a barbed suture, onlay insetting of a pedicled flap in pre-treated patients. Results One case of PCF (1.3%) and three small blind fistulas (3.9%) were observed in this series. The mean length of hospitalization was 18 days. Conclusion Pharyngocutaneous fistula (PCF) prolongs hospitalization and delays adjuvant treatments. Thanks to a strict adherence to the protocol, it was possible to reduce PCF rates, avoiding lengthy hospitalization and additional surgical procedures.
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Affiliation(s)
- Erika Crosetti
- Head and Neck Oncology Unit, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia - IRCCS (FPO-IRCCS), Candiolo, Italy
| | - Giulia Arrigoni
- Head and Neck Oncology Unit, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia - IRCCS (FPO-IRCCS), Candiolo, Italy
| | - Andrea Elio Sprio
- Department of Biomedical and Clinic Sciences, University of Turin, Orbassano, Italy
| | - Giovanni Succo
- Head and Neck Oncology Unit, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia - IRCCS (FPO-IRCCS), Candiolo, Italy.,Department of Oncology, University of Turin, Orbassano, Italy
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Do Salivary Bypass Tubes Reduce the Risk of Pharyngocutaneous Fistula after Laryngopharyngectomy-A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13112827. [PMID: 34204054 PMCID: PMC8201015 DOI: 10.3390/cancers13112827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/30/2021] [Accepted: 06/02/2021] [Indexed: 01/12/2023] Open
Abstract
Simple Summary Salivary bypass tubes (SBT) have been introduced in order to reduce the risk of pharyngocutaneous fistula (PCF) after laryngectomy with pharynx reconstruction. Although the current literature is rather heterogenous, our meta-analysis demonstrates a favorable effect of SBT insertion on PCF formation in patients after laryngopharyngectomies. Abstract To evaluate the effect of salivary bypass tube (SBT) usage on the occurrence of pharyngocutaneous fistula (PCF) in patients after a laryngopharyngectomy, a total of 20 studies, published between 1988 and 2021, were identified including 2946 patients. We performed a meta-analysis assessing the risk of PCF occurrence in patients after SBT application compared to those without. PCF occurred in 26.8% of cases (669/2496) and SBT was applied in 33.0% of patients (820/2483). There was an overall trend towards lower PCF rates when using SBTs (22.2% vs. 35.3%; p = 0.057). We further selected five studies, comprising 580 patients who underwent laryngopharyngectomies, for meta-analysis showing that application of SBT reduced the risk of PCF formation (OR 0.46; 95% CI 0.18–1.18; p = 0.11). The meta-analysis demonstrates a beneficial effect of SBT insertion on PCF formation in patients after laryngopharyngectomy.
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Torrico Román P, García Nogales A, Trinidad Ruíz G. Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy. Am J Otolaryngol 2020; 41:102557. [PMID: 32497952 DOI: 10.1016/j.amjoto.2020.102557] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/04/2020] [Accepted: 05/24/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral centre. SUBJECT AND METHODS A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used. RESULTS There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used. CONCLUSION Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.
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Oh TS, Kwon JG, Jeong WS, Nam SY, Choi SH, Choi JW. A flag-shaped anterolateral thigh free flap for complete circumferential hypopharyngeal reconstruction with dead space obliteration and monitoring flap inset. J Plast Reconstr Aesthet Surg 2019; 72:1785-1794. [DOI: 10.1016/j.bjps.2019.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 02/08/2023]
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Miyamoto S, Nakao J, Higashino T, Yoshimoto S, Hayashi R, Sakuraba M. Clavien-Dindo classification for grading complications after total pharyngolaryngectomy and free jejunum transfer. PLoS One 2019; 14:e0222570. [PMID: 31513680 PMCID: PMC6742376 DOI: 10.1371/journal.pone.0222570] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background The frequency of postoperative complications is used as an indicator of surgical quality; however, comparison of outcomes is hampered by a lack of agreement on the definition of complications and their severity. A standard grading system for surgical complications is necessary to improve the quality of clinical research and reporting in head and neck reconstruction. Methods The aim of this study was to compare postoperative morbidity after microvascular head and neck reconstruction between patients with versus without a history of prior radiation therapy (RT) by using the Clavien–Dindo classification. A group of 274 patients was divided into two cohorts based on the history of prior RT: the RT group included 79 patients and the non-RT group included 195 patients. Postoperative (30-day) complications were compared between the groups with a nonstandardized evaluation system and the Clavien–Dindo classification. Results The grades of complications according to the Clavien–Dindo classification were significantly higher in the RT group than in the non-RT group. The frequency of postoperative complications did not differ significantly between the groups according to the nonstandardized evaluation system. Conclusions The Clavien–Dindo classification could serve as a useful, highly objective tool for grading operative morbidity after microvascular head and neck reconstruction when comparing similar defects and methods of reconstruction. Widespread use of the Clavien–Dindo classification system would allow adequate comparisons of surgical outcomes among different surgeons, centers, and therapies.
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Affiliation(s)
- Shimpei Miyamoto
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
- * E-mail: ,
| | - Junichi Nakao
- Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Takuya Higashino
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Ryuichi Hayashi
- Department of Head and Neck Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Minoru Sakuraba
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
- Department of Plastic and Reconstructive Surgery, Iwate Medical University, Morioka, Japan
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Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study. Eur Arch Otorhinolaryngol 2019; 276:2577-2584. [PMID: 31240457 DOI: 10.1007/s00405-019-05526-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP. METHODS We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital. RESULTS For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively. CONCLUSIONS Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.
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Koh HK, Tan NC, Tan BK, Ooi ASH. Comparison of Outcomes of Fasciocutaneous Free Flaps and Jejunal Free Flaps in Pharyngolaryngoesophageal Reconstruction. Ann Plast Surg 2019; 82:646-652. [DOI: 10.1097/sap.0000000000001776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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20
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Le Bon SD, Rodriguez Ruiz A. Ileal migration of a salivary bypass tube in a dysphagic patient with bipolar disorder. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:229-230. [PMID: 30795942 DOI: 10.1016/j.anorl.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- S D Le Bon
- Service d'oto-rhino-laryngologie et de chirurgie cervico-faciale, hôpital Saint-Pierre, 129, boulevard de Waterloo, 1000 Brussels, Belgium.
| | - A Rodriguez Ruiz
- Service d'oto-rhino-laryngologie et de chirurgie cervico-faciale, hôpital Saint-Pierre, 129, boulevard de Waterloo, 1000 Brussels, Belgium
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Torrico Román P. Digestive Migration and Spontaneous Expulsion of a Montgomery Salivary Derivation Tube. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019. [DOI: 10.1016/j.otoeng.2017.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Routine use of salivary bypass tubes in laryngectomy patients: systematic review. The Journal of Laryngology & Otology 2018; 132:380-384. [PMID: 29444718 DOI: 10.1017/s0022215118000154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pharyngocutaneous fistula is a cause of significant morbidity following laryngectomy. Routine use of salivary bypass tubes during laryngectomy has been proposed to reduce the incidence of fistulae and neopharyngeal strictures. METHOD Following a systematic search of Embase, Medline and Cochrane databases (1946 - current), included articles were assessed for bias according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS Three case-control trials showed reduced pharyngocutaneous fistula rates with the use of salivary bypass tubes; six case series reported widely varied fistula rates. With regards to stricture rates, the largest case-control trial found no improvement with salivary bypass tube use. No fatal adverse events were observed among the 204 patients who received a salivary bypass tube. CONCLUSION Low-level evidence suggests salivary bypass tubes may reduce the incidence of fistula in high-risk patient groups. A robust randomised controlled trial, or large, multicentre cohort studies, are needed to further examine this intervention.
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Torrico Román P. Digestive migration and spontaneous expulsion of a Montgomery salivar derivation tube. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017; 70:55-56. [PMID: 29037422 DOI: 10.1016/j.otorri.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/20/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Pablo Torrico Román
- Servicio de Otorrinolaringología, Hospital Perpetuo Socorro, Complejo Hospitalario Universitario de Badajoz, Badajoz, España.
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Outcomes of Gastro-omental Free Flap Reconstruction for Salvage Laryngopharyngectomy for Pharyngeal and Laryngeal Cancer After Concurrent Chemoradiotherapy. Ann Plast Surg 2017; 79:e20-e24. [DOI: 10.1097/sap.0000000000000298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comment on: Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis. J Plast Reconstr Aesthet Surg 2017; 70:1784-1785. [PMID: 28807591 DOI: 10.1016/j.bjps.2017.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 11/20/2022]
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Piazza C, Bon FD, Paderno A, Grammatica A, Montalto N, Taglietti V, Nicolai P. Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects. Laryngoscope 2017; 127:2731-2737. [PMID: 28573675 DOI: 10.1002/lary.26705] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/06/2017] [Accepted: 04/27/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVES/HYPOTHESIS Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies. STUDY DESIGN Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies. METHODS Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT. RESULTS In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate. CONCLUSIONS First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2731-2737, 2017.
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Affiliation(s)
- Cesare Piazza
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Francesca Del Bon
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Alberto Grammatica
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Nausica Montalto
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Valentina Taglietti
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
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Recurrent head and neck cancer: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S181-S190. [PMID: 27841130 PMCID: PMC4873924 DOI: 10.1017/s002221511600061x] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Recurrent cancers present some of the most challenging management issues in head and neck surgical and oncological practice. This is rendered even more complex by the poor evidence base to support management options, the substantial implications that treatments can have on the function and quality of life, and the difficult decision-making considerations for supportive care alone. This paper provides consensus recommendations on the management of recurrent head and neck cancer. Recommendations • Consider baseline and serial scanning with computed tomography and/or magnetic resonance (CT and/or MR) to detect recurrence in high-risk patients. (R) • Patients with head and neck cancer recurrence being considered for active curative treatment should undergo assessment by positron emission tomography combined with computed tomography (PET-CT) scan. (R) • Patients with recurrence should be assessed systematically by a team experienced in the range of management options available for recurrence including surgical salvage, re-irradiation, chemotherapy and palliative care. (R) • Management of patients with laryngeal recurrence should include input from surgeons with experience in transoral surgery and partial laryngectomy for recurrence. (G) • Expertise in transoral surgery and partial laryngectomy for recurrence should be concentrated to a few surgeons within each multidisciplinary teams. (G) • Transoral or open partial laryngectomy should be offered as definitive treatment modality for highly-selected patients with recurrent laryngeal cancer. (R) • Patients with OPC recurrence should have p16 human papilloma virus status assessed. (R) • Patients with OPC recurrence should be considered for salvage surgical treatment by an experienced team, with reconstructive expertise input. (G) • Transoral surgery appears to be an effective alternative to open surgery for the management of OPC recurrence in carefully selected patients. (R) • Consider elective selective neck dissections in patients with recurrent primaries with N0 necks, especially in advanced cases. (R) • Selective neck dissection (with preservation of nodal levels, especially level V, that are not involved by disease) in patients with nodal (N+) recurrence appears to be as effective as modified or radical neck dissections. (R) • Use salivary bypass tubes following salvage laryngectomy. (R) • Use interposition muscle-only pectoralis major or free flap for suture line reinforcement if performing primary closure following salvage laryngectomy. (R) • Use inlaid pedicled or free flap to close wound if there is tension at the anastomosis following laryngectomy. (R) • Perform secondary puncture in post chemoradiotherapy laryngectomy patients. (R) • Triple therapy with platinum, cetuximab and 5-fluorouracil (5-FU) appears to provide the best outcomes for the management of patients with recurrence who have a good performance status and are fit to receive it. If not fit, then combinations of platinum and cetuximab or platinum and 5-FU may be considered. (R) • Patients with non-resectable recurrent disease should be offered the opportunity to participate in phases I-III clinical trials of new therapeutic agents. (R) • Chemo re-irradiation appears to improve locoregional control, and may have some benefit for overall survival, at the risk of considerable acute and late toxicity. Benefit must be weighed carefully against risks, and patients must be counselled appropriately. (R) • Target volumes should be kept tight and elective nodal irradiation should be avoided. (R) • Best supportive care should be offered routinely as part of the management package of all patients with recurrent cancer even in the case of those who are being treated curatively. (R).
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Hypopharyngeal cancer: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S104-S110. [PMID: 27841124 PMCID: PMC4873926 DOI: 10.1017/s0022215116000529] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With an age standardised incidence rate of 0.63 per 100 000 population, hypopharynx cancers account for a small proportion of the head and neck cancer workload in the UK, and thus suffer from the lack of high level evidence. This paper discusses the evidence base pertaining to the management of hypopharyngeal cancer and provides recommendations on management for this group of patients receiving cancer care.
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Hone RWA, Rahman E, Wong G, Annan Y, Alexander V, Al-Lami A, Varadharajan K, Parker M, Simo R, Pitkin L, Mace A, Ofo E, Balfour A, Nixon IJ. Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis. Eur Arch Otorhinolaryngol 2016; 274:1983-1991. [PMID: 28011997 PMCID: PMC5340845 DOI: 10.1007/s00405-016-4391-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 11/11/2016] [Indexed: 01/12/2023]
Abstract
Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.
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Affiliation(s)
- Robert W A Hone
- Faculty of Medical Science, Post Graduate Medical Institute, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex, UK.
- Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK.
| | - Eqramur Rahman
- Faculty of Medical Science, Post Graduate Medical Institute, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex, UK
| | - Gentle Wong
- Ear, Nose and Throat Department, Brighton and Sussex University Hospital, 177 Preston Rd, Brighton, UK
| | - Yvette Annan
- Ear, Nose and Throat Department, Charing Cross Hospital, Fulham Palace Rd, London, UK
| | - Victoria Alexander
- Ear, Nose and Throat Department, Guy's Hospital, Great Maze Pond, London, UK
| | - Ali Al-Lami
- Ear, Nose and Throat Department, St Georges Hospital, Blackshaw Rd, London, UK
| | - Kiran Varadharajan
- Ear, Nose and Throat Department, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, UK
| | - Michael Parker
- Faculty of Medical Science, Post Graduate Medical Institute, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex, UK
| | - Ricard Simo
- Ear, Nose and Throat Department, Guy's Hospital, Great Maze Pond, London, UK
| | - Lisa Pitkin
- Ear, Nose and Throat Department, Royal Surrey County Hospital, Egerton Rd, Guildford, Surrey, UK
| | - Alasdair Mace
- Ear, Nose and Throat Department, Charing Cross Hospital, Fulham Palace Rd, London, UK
| | - Enyinnaya Ofo
- Ear, Nose and Throat Department, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, UK
| | - Alistair Balfour
- Ear, Nose and Throat Department, St Georges Hospital, Blackshaw Rd, London, UK
| | - Iain J Nixon
- Ear, Nose and Throat Department, St Georges Hospital, Blackshaw Rd, London, UK
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Bearelly S, Heaton CM, Seth R, Daniel Knott P. Laryngopharyngeal Repair in Salvage Laryngectomy. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0125-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ghazali N, Hanna TC, Dyalram D, Lubek JE. The Value of the “Papillon” Anterolateral Thigh Flap for Total Pharyngolaryngectomy Reconstruction: A Retrospective Case Series. J Oral Maxillofac Surg 2016; 74:406-14. [DOI: 10.1016/j.joms.2015.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 11/17/2022]
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Chen X, Zhou H, Zhang YJ, Yin L, Lu MP, Xing GQ, Lin ZP, Cheng L. Applied anatomy of the submental island flap and its clinical application in the repair of defects following hypopharyngeal carcinoma resection. World J Otorhinolaryngol Head Neck Surg 2015; 1:44-49. [PMID: 29204539 PMCID: PMC5698537 DOI: 10.1016/j.wjorl.2015.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 09/17/2015] [Accepted: 09/24/2015] [Indexed: 11/26/2022] Open
Abstract
Objective To explore the feasibility of the submental island flap in the repair of hypopharyngeal defects. Methods We collected wet specimens of fresh cadaveric heads from the Han Chinese adult population for applied anatomy of the submental island flap, and followed five patients with pyriform sinus carcinoma after reconstruction surgery using submental island flaps. Results We found that the average length and width of the submental island flaps were (65.20 ± 11.69) mm and (46.70 ± 6.59) mm, respectively. The skin flap in all five patients survived after surgery, and tracheal tubes and gastric tubes were removed 7–36 days after surgery. Patients were followed up for 24–42 months, pharyngeal flaps grew well, and speech and swallowing functions were satisfactory. Conclusion The submental island flap is a preferred material for the repair of hypopharyngeal defects after hypopharyngeal carcinoma resection, because of good blood supply, easy harvesting, and high survival rate.
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Affiliation(s)
- Xi Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Han Zhou
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Yong-Jie Zhang
- Department of Human Anatomy, School of Basic Medical Sciences, Nanjing Medical University, Nanjing 210029, China
| | - Lin Yin
- Department of Stomatology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Mei-Ping Lu
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Guang-Qian Xing
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Zi-Ping Lin
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
| | - Lei Cheng
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China
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Knopf A, Mansour N, Hofauer B, Bier H, Scherer EQ. Outcome after pharyngeal reconstruction using pectoralis major and radial forearm flap after resection of pharyngeal and laryngeal squamous cell carcinomas. Eur Arch Otorhinolaryngol 2015; 273:2637-42. [PMID: 26345240 DOI: 10.1007/s00405-015-3766-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 08/25/2015] [Indexed: 10/23/2022]
Abstract
The objective of this study is to assess the outcome after pharyngeal reconstruction using pectoralis major and radial forearm flaps in pharyngeal and laryngeal carcinomas. 90 patients who underwent flap surgery due to oro/-hypopharyngeal and laryngeal carcinomas were compared with 404 patients without pharyngeal reconstruction. Differences between the groups were analyzed using the Chi-square, Fisher exact, and the unpaired student's t test. Survival rates were calculated by Kaplan-Meier. Overall survival in oropharyngeal and hypopharyngeal/laryngeal cancer showed comparable results in patients with or without pharyngeal reconstruction (5-year: 53.4 vs. 64.2 %, p = 0.23; 5-year: 51.8 vs. 62.4 %, p = 0.94), while the survival time after flap surgery was significantly decreased (5-year: 44.8 vs. 62.4 %, p < 0.02; 5-year: 30.3 vs. 64.2 %, p = 0.07). Subgroup analysis attributed the worse survival after flap surgery to patients who underwent flap surgery due to functional deficits or recurrent disease (p = 0.002). In these patients, the median survival after flap surgery was 26 (hypopharyngeal/laryngeal cancer) or 13 months (oropharyngeal cancer) and associated with a significant increase in severe complications and hospitalization time (p < 0.0001). The hospitalization time correlated with the history of prior radiotherapy and the extent of surgery (r = 0.26; r = 0.3; p < 0.0001). Flap surgery in primary oropharyngeal and hypopharyngeal/laryngeal cancer showed an unaltered overall survival when compared with patients without reconstruction. Patients with recurrent disease or functional deficits demonstrated a significant decrease in survival combined with an increase of severe complications.
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Affiliation(s)
- Andreas Knopf
- Otorhinolaryngology, Head and Neck Surgery, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Naglaa Mansour
- Otorhinolaryngology, Head and Neck Surgery, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Benedikt Hofauer
- Otorhinolaryngology, Head and Neck Surgery, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Henning Bier
- Otorhinolaryngology, Head and Neck Surgery, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Elias Q Scherer
- Otorhinolaryngology, Head and Neck Surgery, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Functional Outcome Analysis After Anterolateral Thigh Flap Reconstruction of Pharyngoesophageal Defect. Ann Plast Surg 2015; 75:174-9. [DOI: 10.1097/sap.0000000000000073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zelken JA, Kang CJ, Huang SF, Liao CT, Tsao CK. Refinements in flap design and inset for pharyngoesophageal reconstruction with free thigh flaps. Microsurgery 2015; 37:112-118. [DOI: 10.1002/micr.22432] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/13/2015] [Accepted: 05/15/2015] [Indexed: 01/04/2023]
Affiliation(s)
- Jonathan A. Zelken
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Jan Kang
- Department of Otolaryngology; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Shiang-Fu Huang
- Department of Otolaryngology; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chun-Ta Liao
- Department of Otolaryngology; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Kan Tsao
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
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Szewczyk M, Pazdrowski J, Golusiński P, Golusiński W. Delayed reconstruction of the upper digestive tract in a patient following total pharyngolaryngectomy with resection of the cervical oesophagus. Rep Pract Oncol Radiother 2015; 20:243-7. [PMID: 25949230 DOI: 10.1016/j.rpor.2014.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/27/2014] [Accepted: 11/20/2014] [Indexed: 11/19/2022] Open
Abstract
Carcinoma of the hypopharynx is an uncommon disease, with an annual incidence of approximately 1 in 100,000. Post-cricoid carcinoma is more common in women and is not usually associated with tobacco and alcohol abuse. Reconstruction of large pharyngeal defects following surgery for squamous cell carcinoma is complex and often requires microvascular free tissue transfer to achieve the best oncological and functional outcomes. The most common complications of such procedures include fistulas and strictures of the neopharynx. Here, we describe a case of a female patient admitted to the Head and Neck Department at our hospital to undergo delayed reconstruction following pharyngolaryngectomy and removal of the cervical oesophagus. Several complications occurred during post-operative care, including stricture and skin dehiscence. At present, the patient is able to swallow saliva and is currently being prepared to return to a normal diet.
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Affiliation(s)
- Mateusz Szewczyk
- Department of Head and Neck Surgery, Poznan University of Medical Sciences Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
| | - Jakub Pazdrowski
- Department of Head and Neck Surgery, Poznan University of Medical Sciences Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
| | - Paweł Golusiński
- Department of Head and Neck Surgery, Poznan University of Medical Sciences Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland ; Department of Biology and Enviromental Studies, Poznan University of Medical Sciences, Dluga 1/2, 61-848 Poznan, Poland
| | - Wojciech Golusiński
- Department of Head and Neck Surgery, Poznan University of Medical Sciences Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
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Choice of flap affects fistula rate after salvage laryngopharyngectomy. Sci Rep 2015; 5:9180. [PMID: 25776941 PMCID: PMC4361877 DOI: 10.1038/srep09180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/19/2015] [Indexed: 11/13/2022] Open
Abstract
Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.
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Tan NC, Lin PY, Kuo PJ, Tsai YT, Chen YC, Nguyen KT, Kuo YR. An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction. Microsurgery 2014; 35:345-9. [PMID: 25430852 DOI: 10.1002/micr.22359] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/12/2014] [Accepted: 11/14/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral thigh (ALT) flap, and the jejunum flap. This study was to objectively compare three different flaps for pharyngeal reconstruction during the past 10 years. Stricture and fistula were assessed using esophagogram and esophagoscopy. METHODS Forty-five patients with pharyngeal reconstructions had esophagram and esophagoscopy done postoperatively to assess for strictures and fistulas. These patients were divided into three groups based on pharyngeal reconstruction by ALT, RFF, and jejunal flaps. From the results of the esophagogram and esophagoscope, the presence of a fistula or stricture was compared and analyzed. RESULTS There was only one ALT flap failure. The rate of fistula was 33%, 50%, and 30% in the ALT, RFF, and jejunal flap group respectively. The fistula rate revealed no significant difference between ALT, RFF, jejunal flap groups (P = 0.63). The rate of stricture was 38.1%, 57.1%, and 0% in the ALT, RFA, jejunal flap groups respectively. The stricture rate in jejunal flap group revealed significant decrease (P = 0.0093). CONCLUSION Jejunal flap has a significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps.
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Affiliation(s)
- Ngian Chye Tan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Surgical Oncology, National Cancer Centre, Singapore
| | - Pao-Yuan Lin
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yun-Ta Tsai
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Yur-Ren Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Advantages and limitations of free and pedicled flaps in reconstruction of pharyngoesophageal defects. Curr Opin Otolaryngol Head Neck Surg 2014; 22:407-13. [DOI: 10.1097/moo.0000000000000081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mayanagi S, Onitsuka T, Nakagawa M, Sato H, Kitagawa Y, Tsubosa Y. The use of short segment free jejunal transfer as salvage surgery for cervical esophageal and hypopharyngeal cancer. World J Surg 2014; 38:144-9. [PMID: 24081534 PMCID: PMC3868873 DOI: 10.1007/s00268-013-2229-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy. Methods We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates. Results The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %. Conclusions Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.
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Affiliation(s)
- Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan,
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Herzog M, Lorenz KJ, Glien A, Greiner I, Plontke S, Plößl S. Treatment of tracheopharyngeal and tracheo-oesophageal fistulas following laryngectomy and fistula classification based on individual silicone casts. Eur Arch Otorhinolaryngol 2014; 272:2961-8. [PMID: 25178413 DOI: 10.1007/s00405-014-3246-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
Persistent tracheopharyngeal (TPF) and tracheo-oesophageal (TEF) fistulas after laryngectomy create a therapeutic challenge. The current classification of TPFs and TEFs is based on clinical experience without detailed anatomical information. In this study, casts of TPFs/TEFs were obtained from 16 patients; these were the first steps in manufacturing customised prostheses. Fistulas were classified according to the shape and dimension of the tracheopharyngeal and tracheo-oesophageal silicone casts and prostheses as well as on epithetic requirements. Four different types of fistulas were classified: Type A, a fistula with a straight axis between the neopharynx and oesophagus; Type B, a fistula with a stenosis of the neopharynx but a straight axis; Type C, the axis between the neopharynx and oesophagus is flexed anteriorly; and Type D, neighbouring structures are absent creating a large defect. This classification system might improve the manufacturing processes of customised prostheses in individual cases with challenging tracheopharyngeal and tracheo-oesophageal fistulas.
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Affiliation(s)
- Michael Herzog
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin-Luther-University, Halle-Wittenberg, 06120, Halle (Saale), Germany,
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Punthakee X, Zaghi S, Nabili V, Knott PD, Blackwell KE. Effects of salivary bypass tubes on fistula and stricture formation. JAMA FACIAL PLAST SU 2014; 15:219-25. [PMID: 23519300 DOI: 10.1001/jamafacial.2013.791] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Stricture and fistula formation are two of the most common long-term complications of free flap reconstruction of hypopharyngeal defects. OBJECTIVE To examine the effects of salivary bypass tubes (SBTs) on fistula and stricture formation after free flap reconstruction of hypopharyngeal defects. DESIGN Retrospective cohort study. SETTING Academic tertiary care medical center. PARTICIPANTS A total of 103 consecutive patients who underwent hypopharyngeal free flap reconstruction. INTERVENTION Use of salivary bypass tube. MAIN OUTCOME MEASURE Fistula and stricture formation. RESULTS The overall fistula and stricture rates were 14.6% and 27.2%, respectively. Subgroup analysis revealed fistula rates of 7.4% in patients who received SBTs and 22.4% in those who did not (P = .048). However, no statistically significant difference between the two groups was shown with multivariate analysis. The unadjusted stricture rate was 30.6% without vs 24.1% with SBT placement (P = .51). CONCLUSIONS AND RELEVANCE Univariate analysis showed that SBT placement significantly reduced the risk of fistula in this population. Larger multicenter studies are needed to further explore the benefits of SBT use in preventing fistula and stricture formation. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Xerxes Punthakee
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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Abstract
The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.
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Durmus K, Kakarala K, Old M, Teknos T, Ozer E. Anterolateral thigh butterfly free flap reconstruction for peristomal recurrence following laryngectomy: Our experience in six patients. Clin Otolaryngol 2013; 38:339-42. [DOI: 10.1111/coa.12124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 11/28/2022]
Affiliation(s)
- K. Durmus
- Department of Otolaryngology-Head and Neck Surgery; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Comprehensive Cancer Center; the Ohio State University; Columbus; OH; USA
| | - K. Kakarala
- Department of Otolaryngology-Head and Neck Surgery; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Comprehensive Cancer Center; the Ohio State University; Columbus; OH; USA
| | - M.O. Old
- Department of Otolaryngology-Head and Neck Surgery; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Comprehensive Cancer Center; the Ohio State University; Columbus; OH; USA
| | - T.N. Teknos
- Department of Otolaryngology-Head and Neck Surgery; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Comprehensive Cancer Center; the Ohio State University; Columbus; OH; USA
| | - E. Ozer
- Department of Otolaryngology-Head and Neck Surgery; Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Comprehensive Cancer Center; the Ohio State University; Columbus; OH; USA
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Atkinson R, Ho K. Inverted V-shaped modification in pharyngolaryngo-oesophageal reconstructions. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-013-0829-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy. PLoS One 2013; 8:e53985. [PMID: 23320112 PMCID: PMC3540016 DOI: 10.1371/journal.pone.0053985] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/05/2012] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma. MATERIALS/METHODS A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated. RESULTS 33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively). CONCLUSION Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.
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Perez-Smith D, Wagels M, Theile DR. Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases. J Plast Reconstr Aesthet Surg 2012; 66:9-15. [PMID: 22995669 DOI: 10.1016/j.bjps.2012.08.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 08/22/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Jejunal Free Flap (JFF) was first described by Seidenberg in 1957 for the reconstruction of pharyngolryngectomy defects. Historically, its outcome profile has been better than alternative reconstructions. Recently, the use of tubed Fasciocutaneous Free Flaps (FCFF) has been increasing as series reporting outcomes superior or equivalent to JFF are published. Our experience with JFF has been more positive than recently published reports suggest. This study aims to provide an accurate and up-to-date assessment of outcomes in JFF reconstruction of pharyngolaryngectomy defects and to compare these results to those of contemporary alternative techniques. METHODS 368 Consecutive free jejunum reconstructions were performed for pharyngolaryngectomy defects between 1977 and 2010. All patients had been assessed by a multidisciplinary Head and Neck Clinic prior to surgery. A systematic review of recent literature pertaining to pharyngolaryngectomy reconstruction outcomes was undertaken for comparison with our dataset. RESULTS 70.9% of tumours in this series were T-grade 3 or 4. Perioperative mortality was 3.8% and flap failure occurred in 2.98%. The incidence of anastomotic leak was 8.2% and stricture occurred in 10.9%. A full oral diet was maintained by 91.6% of patients by day 12 on average. 70.6% underwent primary tracheo-oesophageal puncture and of these 78.1% had effective speech. CONCLUSIONS Overall, our data compares favourably with other series. The strengths of the JFF reconstruction are the capacity to maintain an oral diet, low stricture and leak rates and the versatility to reconstruct long segment defects. We have observed variability in leak rates throughout the study period, which may be operator dependant. The gap between outcomes for FCFF and JFF reconstructions has narrowed but the latter remains our reconstruction of choice for pharyngolaryngectomy defects.
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Affiliation(s)
- Diana Perez-Smith
- Department of Plastic and Reconstructive Surgery, The Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD 4102, Australia.
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López F, Obeso S, Camporro D, Fueyo A, Suárez C, Llorente JL. Outcomes following pharyngolaryngectomy with fasciocutaneous free flap reconstruction and salivary bypass tube. Laryngoscope 2012; 123:591-6. [PMID: 22951963 DOI: 10.1002/lary.23695] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Reconstruction of the pharyngoesophageal defects is one of the most challenging for head and neck surgeons. We evaluated our experience in the hypopharyngeal reconstruction using a fasciocutaneous free flap in conjunction with a Montgomery salivary bypass tube (MSBT). STUDY DESIGN Retrospective review. METHODS The charts of 55 patients who had undergone hypopharynx reconstruction using either a radial forearm free flap (RFFF) (24) or an anterolateral thigh (ALT) flap (31) with MSBT were reviewed. There were 40 circumferential and 15 near-circumferential defects. Outcomes analyzed included fistula and stricture rates and swallowing function. RESULTS Pharyngocutaneous fistula occurred in 9% of patients (16% using RFFF and 3% using ALT), and strictures occurred in 5% (8% using RFFF and 3% using ALT). Of patients reconstructed with this technique, 95% were able to resume oral alimentation. CONCLUSIONS The use of fasciocutaneous free flaps in conjunction with the MSBT is a useful tool for pharyngoesophageal reconstruction.
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Affiliation(s)
- Fernando López
- Department of Otorhinolaryngology and Head and Neck Surgery, Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Asturias, Spain.
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Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy. Curr Opin Otolaryngol Head Neck Surg 2012; 20:77-88. [PMID: 22327791 DOI: 10.1097/moo.0b013e328350a5cc] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW The present review is focused on the main reconstructive options currently used after partial or circumferential resection of the hypopharynx and cervical esophagus. The advantages and disadvantages of pectoralis major myocutaneous (PMMC) pedicled flap, fasciocutaneous free flaps as radial forearm and anterolateral thigh (ALT), and visceral free grafts like jejunum and gastro-omental are overviewed. RECENT FINDINGS For partial hypopharyngeal defects with limited extension to the cervical esophagus, no specific pedicled or free flap is deemed superior over others: the patient's body habitus and surgeon's preference remain the most important factors affecting the reconstructive choice. In contrast, after circumferential hypopharyngectomy, pharyngocutaneous fistula (PCF) and stricture rates of PMMC are higher than those obtained by free flaps. In the most recent series applying ALT and jejunum, PCF and stricture occurrence is comparable, whereas reduced mortality, overall complication rate, and donor-site morbidity of ALT and its better swallowing and speech outcomes have contributed to make this option progressively more popular. On the other hand, gastro-omental seems to offer an unparalleled amount of highly vascularized tissue to manage the difficult situation of salvage surgery after chemoradiation, even though complication rates remain not negligible and this technique has not been widely adopted. SUMMARY The reconstructive armamentarium of head and neck surgeons involved in hypopharyngeal and cervical esophagus reconstruction should encompass every option described herein in order to appropriately deal with specific clinical needs and patient requirements. However, fasciocutaneous free flaps (especially ALT) seem to play an ever greater role in restoration of pharyngoesophageal continuity.
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Maciejewski A, Krakowczyk Ł, Szymczyk C, Wierzgoń J, Grajek M, Dobrut M, Szumniak R, Jędrzejewski P, Ulczok R, Półtorak S. Salvage surgery of recurrence after laryngectomy--when should the alt free flap be modified? Med Sci Monit 2012; 18:CS31-6. [PMID: 22460099 PMCID: PMC3560816 DOI: 10.12659/msm.882606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Reconstruction of the pharynx and cervical esophagus has significantly progressed in the last 2 decades. A revolution in microvascular surgery has provided numerous choices for primary restoration, or in secondary reconstructions necessary for recurrences or complications of primary surgery. The goals of reconstruction after laryngopharyngoesophagectomy are to provide continuity of the alimentary tract, to protect major blood vessels, to heal the primary wound, and to restore the swallowing and breathing functions with minimal donor site and neck morbidity and deformation. CASE REPORT We present 3 cases with complex defects of the laryngopharynx, cervical esophagus and trachea and anterior neck skin following central neck exenteration safely reconstructed with a single anterolateral thigh flap. No postoperative complications occurred in any of the 3 cases of reconstructions, each using a single anterolateral thigh flap. CONCLUSIONS This approach significantly simplified the reconstruction, with quick recovery, short hospital stay and excellent functional and aesthetic results.
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Affiliation(s)
- Adam Maciejewski
- Department of Oncologic and Reconstructive Surgery, Centre of Oncology, M. Sklodowska-Curie Memorial Institute, Gliwice, Poland.
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