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Gao K, Guo W, Shang Y, Liu G, Zhai X, Li H, Shi M, Tong X. Surgical treatment of carotid blowout syndrome after radiotherapy for head and neck malignant tumors: a single-center experience. Neurosurg Rev 2023; 46:293. [PMID: 37924361 DOI: 10.1007/s10143-023-02193-z] [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: 09/17/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Abstract
To explore the treatments for and manifestations of carotid blowout syndrome (CBS) and to further explore the critical role of high-flow bypass combined with parent artery isolation. The clinical data of nine patients with radiotherapy-related CBS who were admitted to our hospital from March 2020 to March 2023 were retrospectively analyzed. Relevant literature was reviewed. From March 2020 to March 2023, nine CBS patients were admitted to Tianjin Huanhu Hospital, including eight males and one female. Digital subtraction angiography was performed for all the patients; all the pseudoaneurysms were located at the petrous segment of the internal carotid artery. A balloon occlusion test was performed on four patients, which was tolerated by all patients. CT and MRI scans showed seven cases of osteonecrosis combined with infection and two cases of tumor recurrence. Emergency permanent parent artery occlusion was performed on six patients, aneurysm embolization was completed in one case, covered stent implantation was performed in one patient, and three cases were treated by cerebral bypass surgery (including two patients with failed interventional treatment). Rebleeding was found in two patients, and no rebleeding was found in the bypass group. Paralysis was found in three patients, and asymptomatic cerebral infarction without permanent neurologic impairment was found in three patients. Two patients died due to tumor progression. Emergency occlusion surgery is lifesaving in the acute phase of CBS. Endovascular therapy cannot prevent the progression of pseudoaneurysms or lower the recurrence rate of bleeding events. High-flow bypass combined with parent artery isolation is a safe and effective method that may facilitate further surgical treatment. Further research is warranted.
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Affiliation(s)
- Kaiming Gao
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Wenqiang Guo
- Department of Neurosurgery, Qilu Hospital of Shandong University (Qingdao), 758 Hefei Road, Shibei District, Qingdao, Shandong, 266035, China
| | - Yanguo Shang
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Gang Liu
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Xiang Zhai
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Haiyan Li
- Department of Otorhinolaryngology, Tianjin Huanhu Hospital, Tianjin, China
- Department of Otorhinolaryngology, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China
| | - Minggang Shi
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
| | - Xiaoguang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
- Department of Neurosurgery, Tianjin Central Hospital for Neurosurgery and Neurology, Tianjin, China.
- Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute, Tianjin, China.
- Tianjin Key Laboratory of Cerebral Vascular and Neural Degenerative Diseases, Tianjin, China.
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Haga Y, Yasunaga Y, Araki J, Nakao J, Mori H, Nakagawa M, Mukaigawa T. Perioperative Factors Aggravating Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Center Retrospective Analysis Using the Clavien-Dindo Classification. Ann Plast Surg 2023; 91:84-89. [PMID: 37450865 DOI: 10.1097/sap.0000000000003627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Pharyngocutaneous fistula formation represents a major postoperative complication following total laryngectomy. We aimed to investigate the risk factors for pharyngocutaneous fistula development after total laryngectomy and to identify factors that lead to severe cases of pharyngocutaneous fistula. METHODS Patients who underwent total laryngectomy between January 2013 and February 2021 were included in the study and were divided into 2 groups: Those with and without pharyngocutaneous fistula. The severity of pharyngocutaneous fistula was graded using the Clavien-Dindo classification. RESULTS Patients with pharyngocutaneous fistula experienced longer operative time, greater intraoperative blood loss, greater decrease in perioperative hemoglobin level, and longer postoperative hospitalization. Unlike in lower-severity cases, patients with grade IIIb pharyngocutaneous fistula underwent preoperative radiotherapy or chemoradiotherapy; preoperative treatment was thus a risk factor for higher severity of pharyngocutaneous fistula (odds ratio, 35; P = 0.004). CONCLUSION Salvage laryngectomy was found to be a predictor of severe pharyngocutaneous fistula development. Prolonged operative time, increased intraoperative blood loss, and decreased postoperative hemoglobin level were found to be predictors of postlaryngectomy pharyngocutaneous fistula formation.
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Affiliation(s)
| | - Yoshichika Yasunaga
- From the Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi
| | - Jun Araki
- From the Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi
| | - Junichi Nakao
- From the Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi
| | - Hiroaki Mori
- From the Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Nagaizumi
| | | | - Takashi Mukaigawa
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
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3
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Kim DH, Kim SW, Hwang SH. Predictive Value of Risk Factors for Pharyngocutaneous Fistula After Total Laryngectomy. Laryngoscope 2023; 133:742-754. [PMID: 35769042 DOI: 10.1002/lary.30278] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/02/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy. METHODS The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool. RESULTS A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84). CONCLUSION Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon Saint Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Feng K, Hu J, Huang Q, Cai W, Zhuang Z, Liu H, Hou J, Liu X, Wang C. Risk factors and nomogram for predicting carotid blowout syndrome based on computed tomography angiography. Oral Dis 2021; 28:2131-2138. [PMID: 33772979 DOI: 10.1111/odi.13859] [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: 01/11/2021] [Revised: 03/03/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify independent factors for head and neck cancer (HNC) patients with carotid blowout syndrome (CBS) and construct a nomogram to predict risk of CBS preoperatively based on computed tomography angiography (CTA) imaging. SUBJECT AND METHODS From January 2010 to July 2020, 73 HNC patients who had surgery in hospitalization and underwent CTA examination for head and neck region were included in this study. Vascular alterations and the relationship between carotid artery (CA) and tumor were evaluated in CTA. Clinical and CTA imaging features were distinguished by logistic regression analysis and used to perform receiver operating curve analysis. Nomogram was created to predict risk of CBS and assessed by concordance index (C-index) and calibration curve. RESULTS Three independent risk factors were identified, including radical neck dissection, CA surrounded by tumor, and CA invaded by tumor without clear boundary. Area under curve of the combination of 3 variables was 0.836 (95% CI, 0.72-0.952, p < 0.001). The C-index of nomogram was 0.84 (95% CI, 0.73-0.94), and the calibration plot showed a good fitting between prediction and observation. CONCLUSIONS We established a useful nomogram based on CTA imaging, which showed a satisfied efficacy for evaluating risk of CBS in HNC patients preoperatively.
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Affiliation(s)
- Kun Feng
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jing Hu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiuyu Huang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Weixin Cai
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Zehang Zhuang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Haichao Liu
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Jinsong Hou
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
| | - Xiqiang Liu
- Department of Oral and Maxillofacial Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cheng Wang
- Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China
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Sallustro M, Abualhin M, Faggioli G, Pilato A, Dall'Olio D, Simonetti L, Astarita F, Amorosa L, Gargiulo M. Multistep and Multidisciplinary Management for Post-irradiated Carotid Blowout Syndrome in a Young Patient With Oropharyngeal Carcinoma: A Case Report. Ann Vasc Surg 2020; 67:565.e1-565.e5. [PMID: 32209410 DOI: 10.1016/j.avsg.2020.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/08/2020] [Accepted: 02/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carotid blowout syndrome is a severe complication of head and neck cancer, associated with high mortality and morbidity. METHODS We present a case of acute hemorrhage from the carotid artery of a 59-year-old man with a history of chemoradiotherapy for lingual base and oropharyngeal squamous cell carcinoma. The case was managed by a staged multidisciplinary approach of open arterial reconstruction, after initial endovascular hemorrhage control using stent graft. RESULTS The patient was discharged to home with patent carotid artery, no sign of infection or bleeding, and autonomous ambulation. A CT/PET scan performed 6 months later confirmed healing and absence of tumor recurrence. CONCLUSIONS A multidisciplinary approach involving vascular surgeons, ENT surgeons, plastic and maxillofacial surgeons is particularly appropriate in the management of carotid blowout syndrome to warrant a durable and effective repair of all the anatomical structures involved.
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Affiliation(s)
- Marianna Sallustro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy.
| | - Mohammad Abualhin
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - GianLuca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - Alessandro Pilato
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
| | - Danilo Dall'Olio
- Department of Otorhinolaryngology, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Luigi Simonetti
- Interventional and Urgency Radiology and Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Fabio Astarita
- Department of Otorhinolaryngology, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Luca Amorosa
- Department of Maxillofacial Surgery, Maggiore Hospital, Azienda AUSL, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Policlinico Sant'Orsola- Malpighi, Bologna, Italy
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6
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Li S, Huang Z, Chen W, Pan C, Huang Z. Risk factors for postoperative hemorrhage in patients with oral squamous cell carcinoma: A retrospective study. Head Neck 2019; 41:2093-2099. [PMID: 30706556 DOI: 10.1002/hed.25659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 12/22/2018] [Accepted: 01/04/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Shihao Li
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Zixian Huang
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Weiliang Chen
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Chaobin Pan
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Zhiquan Huang
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
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7
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Ahn D, Lee GJ, Sohn JH. Ultrasonographic swallowing examination for early detection of neopharyngeal fistula after salvage total laryngectomy: A preliminary study. Head Neck 2019; 41:1804-1808. [PMID: 30676670 DOI: 10.1002/hed.25617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 11/01/2018] [Accepted: 12/11/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The current study investigated the feasibility of ultrasonographic swallowing examination (USSE) for the evaluation of neopharynx and early detection of neopharyngeal fistula after salvage total laryngectomy. METHODS A prospective case series-based study involving 16 patients who underwent salvage total laryngectomy was conducted. USSE was performed on postoperative days 5-7, and oral diet initiation was determined based on the USSE results. RESULTS Fistula of the neopharynx was detected in four patients (25%) via USSE, as was the specific site of the fistula. In these patients, oral diet was delayed and immediate interventions including ultrasound-guided fluid aspiration and compression dressing were applied, and all fistulas were subsequently closed. In the remaining 12 patients with no neopharyngeal fistula on USSE, an oral diet was started immediately and no fistula occurred. CONCLUSIONS USSE is a promising method for neopharynx evaluation and early detection of neopharyngeal fistula after salvage total laryngectomy.
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Affiliation(s)
- Dongbin Ahn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Gil Joon Lee
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jin Ho Sohn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, South Korea
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Suárez C, Fernández-Alvarez V, Hamoir M, Mendenhall WM, Strojan P, Quer M, Silver CE, Rodrigo JP, Rinaldo A, Ferlito A. Carotid blowout syndrome: modern trends in management. Cancer Manag Res 2018; 10:5617-5628. [PMID: 30519108 PMCID: PMC6239123 DOI: 10.2147/cmar.s180164] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.
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Affiliation(s)
- Carlos Suárez
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain,
| | | | - Marc Hamoir
- Department of Head and Neck Surgery, Head and Neck Oncology Program, King Albert II Cancer Institute, St Luc University Hospital, Brussels, Belgium
| | | | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Carl E Silver
- Department of Surgery, University of Arizona, Phoenix, AZ, USA
| | - Juan P Rodrigo
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain, .,Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group Padua, Italy
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Chiesa Estomba CM, González García JA, Sistiaga Suarez JA, Arrizabalaga IT, Larruscain Sarasola E, Altuna Mariezcurrena X. Efficacy of the Myofascial Pectoralis Major Flap in the Reduction of Salivary Fistulas After Salvage Total Laryngectomy. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018. [DOI: 10.1016/j.otoeng.2017.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Chiesa Estomba CM, González García JA, Sistiaga Suarez JA, Thomas Arrizabalaga I, Larruscain Sarasola E, Altuna Mariezcurrena X. Efectividad del colgajo de músculo pectoral mayor miofascial en la reducción de fístulas salivares tras laringectomía total de rescate. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018; 69:99-104. [DOI: 10.1016/j.otorri.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/26/2017] [Accepted: 06/01/2017] [Indexed: 12/01/2022]
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11
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Meyer A, Gross N, Teng M. AHNS Series: Do you know your guidelines? Perioperative antithrombotic management in head and neck surgery. Head Neck 2017; 40:182-191. [PMID: 29044795 DOI: 10.1002/hed.24927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/20/2017] [Indexed: 12/16/2022] Open
Abstract
Head and neck surgeons are commonly faced with surgical patients who have underlying medical problems requiring antithrombotic therapy. It is difficult to achieve a balance between minimizing the risk of thromboembolism and hemorrhage in the perioperative period. Data from randomized, controlled trials are limited, and procedure-specific bleed rates are also difficult to pinpoint. The decision is made more difficult when patients with moderate-to-high risk for thromboembolic events undergo procedures that are high risk for bleeding. This is true for many head and neck oncologic surgeries. Furthermore, although elective procedures may be delayed for optimization of antithrombotic medication, emergent procedures cannot. Head and neck surgery often represents the most challenging of all these circumstances, given the potential risk of airway compromise from bleeding after head and neck surgery.
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Affiliation(s)
- Annika Meyer
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neil Gross
- MD Anderson Cancer Center, Head and Neck Surgery, Houston, Texas
| | - Marita Teng
- Department of Otolaryngology - Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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12
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Wulff NB, Kristensen CA, Andersen E, Charabi B, Sørensen CH, Homøe P. Risk factors for postoperative complications after total laryngectomy following radiotherapy or chemoradiation: a 10-year retrospective longitudinal study in Eastern Denmark. Clin Otolaryngol 2016; 40:662-71. [PMID: 25891761 DOI: 10.1111/coa.12443] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the rates of and risk factors for postoperative complications following total laryngectomy in patients treated with radiotherapy or chemoradiation. DESIGN Retrospective longitudinal study. SETTING Tertiary medical centres. PARTICIPANTS A total of 143 patients undergoing total laryngectomy for squamous cell carcinoma of the larynx or hypopharynx. MAIN OUTCOME MEASURES Overall postoperative complications and fistula formation. RESULTS Overall postoperative complications, fistula formation, wound infection, bleeding and wound necrosis within one year after total laryngectomy occurred in 56.6%, 42.3%, 31.0%, 11.3% and 9.2% of patients, respectively. Stenosis of the pharynx/oesophagus and stoma shrinkage within five years after surgery were each seen in 18.2% of cases. In 66.7% of cases, conservative treatment of the fistulas was chosen. Rehospitalisations within five years occurred for 44.8% with a median rate of 1.5 (range 1-11). Smoking status (P = 0.005 and 0.013) and chronic obstructive pulmonary disease (COPD) (P = 0.013 and 0.011) were significant risk factors for both overall postoperative complications and fistula formation in uni- and multivariate analysis. Tumour localisation in the hypopharynx was associated with overall postoperative complications (P = 0.036). Residual tumour or cancer recurrence was associated with late-onset fistulas (P < 0.001). CONCLUSION The frequencies of postoperative complications after total laryngectomy were comparable with similar international studies, although fistula formation rate is increasing in Denmark. We suggest optimising treatment of COPD and to further encourage to smoking cessation. We propose that development of fistulas >2 months after surgery prompts immediate biopsies. Additionally, we suggest standardised registration of surgical techniques to identify variables affecting the frequency of postoperative complications.
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Affiliation(s)
- N B Wulff
- Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - C A Kristensen
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - E Andersen
- Department of Oncology, Herlev Hospital, University Hospital of Copenhagen, Denmark
| | - B Charabi
- Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - C H Sørensen
- Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - P Homøe
- Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Denmark.,Department of Otorhinolaryngology and Maxillofacial Surgery, Køge University Hospital, Denmark
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13
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Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy. The Journal of Laryngology & Otology 2016; 130:860-4. [DOI: 10.1017/s0022215116008501] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:This study aimed to assess the utility of onlay pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage total laryngectomy.Methods:A retrospective analysis was performed of 172 patients who underwent salvage laryngectomy for recurrent carcinoma of the larynx or hypopharynx between 1999 and 2014. One hundred and ten patients underwent primary closure and 62 patients had pectoralis major myofascial flap onlay.Results:The overall pharyngocutaneous fistula rate was 43 per cent, and was similar in both groups (primary closure group, 43.6 per cent; onlay flap group, 41.9 per cent; p = 0.8). Fistulae in the onlay flap group healed faster: the median and mean fistula duration were 37 and 55 days, respectively, in the primary closure group and 20 and 25 days, respectively, in the onlay flap group (p = 0.008).Conclusion:Use of an onlay pectoralis major myofascial flap did not decrease the pharyngocutaneous fistula rate, although fistula duration was shortened. A well-designed randomised-controlled trial is needed to establish parameters for its routine use in clinical practice.
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14
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Hyperbaric oxygen therapy as an alternative to surgery for non-healing pharyngocutaneous fistula. Eur Arch Otorhinolaryngol 2016; 273:3857-3861. [PMID: 27016920 DOI: 10.1007/s00405-016-4002-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
Abstract
The aim of the study is to examine the utilization of hyperbaric oxygen treatment (HBOT) as an alternative to surgical treatment for non-healing postoperative phayngocutaneous fistula (POPCF). A retrospective study was conducted between 2012 and 2014 of referred patients who had failed conservative treatment for POPCF at other medical centers. Reevaluation at our department was followed by therapeutic management including daily HBOT. Eight male patients with a mean age of 62.3 years were included. The average period of conservative treatment was 1 month before admittance to our department. All patients were managed with HBOT and local debridement. Closure of the POPCF was proved by a barium swallow test in seven patients (87.5 %). HBOT is recommended for patients who have failed conservative treatment for POPCF post-laryngectomy, due to a high rate of successful (87.5 %) closure and should be considered as an alternative to surgical treatment.
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Serbanescu-Kele C, Halmos G, Wedman J, van der Laan B, Plaat B. Early feeding after total laryngectomy results in shorter hospital stay without increased risk of complications: a retrospective case-control study. Clin Otolaryngol 2015; 40:587-92. [DOI: 10.1111/coa.12420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 11/28/2022]
Affiliation(s)
- C.M.C. Serbanescu-Kele
- Department of Otorhinolaryngology; Head and Neck Surgery; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - G.B. Halmos
- Department of Otorhinolaryngology; Head and Neck Surgery; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - J. Wedman
- Department of Otorhinolaryngology; Head and Neck Surgery; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - B.F.A.M. van der Laan
- Department of Otorhinolaryngology; Head and Neck Surgery; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - B.E.C. Plaat
- Department of Otorhinolaryngology; Head and Neck Surgery; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
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Hsueh WD, Hwang PH, Abuzeid WM. Perioperative Management of Antithrombotic Therapy in Common Otolaryngologic Surgical Procedures: State of the Art Review. Otolaryngol Head Neck Surg 2015; 153:493-503. [PMID: 26307580 DOI: 10.1177/0194599815600409] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/23/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The perioperative management of patients undergoing otolaryngologic procedures is increasingly complicated by the use of newer antithrombotic agents. Furthermore, with advances in anesthesia and surgical technique, otolaryngologists are presented with the challenge of operating on patients with advanced comorbid diseases. The objective of this review is to provide evidence-based recommendations on perioperative antithrombotic management for common otolaryngologic procedures. DATA SOURCES PubMed/MEDLINE. REVIEW METHODS Selected literature on patient-specific thromboembolic risk, rate of bleeding complications in otolaryngologic procedures, and the interruption of antithrombotic therapy is reviewed and interpreted by expert opinion. CONCLUSIONS By stratifying patients into either low thromboembolic risk (≤ 5%) or high thromboembolic risk (> 5%) and interpreting this in the context of procedural bleed risk and potential clinical consequences in the event of a bleed, otolaryngologists can make evidence-based decisions to determine the appropriate perioperative management of antithrombotic therapy. IMPLICATIONS FOR PRACTICE When the perioperative management of antithrombotic therapy is being decided, 3 critical factors must be considered systematically: the patient's inherent thromboembolic risk, the risk and potential consequences of bleeding related to the procedure, and the timing of interruption of thromboembolic therapy.
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Affiliation(s)
- Wayne D Hsueh
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
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17
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Dedivitis RA, Aires FT, Cernea CR, Brandão LG. Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors. Head Neck 2015; 37:1691-7. [PMID: 24958209 DOI: 10.1002/hed.23804] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pharyngocutaneous fistula (PCF) is the most common surgical complication after total laryngectomy. Controversy still remains regarding the multiple risk factors implicated. The purpose of this study was to evaluate the potential risk factors for PCF. METHODS The strategy for our literature survey included research in MEDLINE up to December 2013. The risk factors analyzed were age, sex, smoking habit, alcohol use, comorbidity, preoperative hemoglobin level, blood transfusion, preoperative tracheotomy, previous radiotherapy and chemoradiotherapy, primary tumor site, T classification, cartilage invasion, tumor grade, surgical margins, suture material, second layer of suture, reconstruction, tracheoesophageal prosthesis, and neck dissection. RESULTS The electronic search resulted in 311 studies from which 63 met the inclusion criteria. CONCLUSION Chronic obstructive pulmonary disease (COPD), previous hemoglobin <12.5g/dL, blood transfusion, previous radiotherapy or chemoradiotherapy, advanced primary tumors, supraglottic subsite, hypopharyngeal tumor site, positive surgical margins, and the performance of neck dissection were risk factors for PCF.
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Affiliation(s)
- Rogério Aparecido Dedivitis
- Department of Head and Neck Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Claudio Roberto Cernea
- Department of Head and Neck Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lenine Garcia Brandão
- Department of Head and Neck Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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18
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Süslü N, Senirli RT, Günaydın RÖ, Özer S, Karakaya J, Hoşal AŞ. Pharyngocutaneous fistula after salvage laryngectomy. Acta Otolaryngol 2015; 135:615-21. [PMID: 25762119 DOI: 10.3109/00016489.2015.1009639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Preoperative chemoradiotherapy (CRT) was associated with a significantly higher rate of pharyngocutaneous fistula (PCF). OBJECTIVE PCF is the most frequent complication following total laryngectomy. Although organ-preserving radiotherapy (RT) or CRT offer good locoregional control, many patients still require salvage laryngectomy. The aim of this study was to evaluate the factors that predispose patients to PCF, with a focus on preoperative RT, induction chemotherapy (ICT), and CRT. METHODS This was a retrospective case series; 151 patients who underwent TL were reviewed. Preoperative RT, ICT, CRT, and some surgical parameters were analyzed as potential risk factors. RESULTS The overall PCF rate was 13%. CRT was the only preoperative treatment that had a significant effect on PCF (35.3%, p = 0.004, odds ratio (OR) = 10.75). Surgery extended to the pharynx (p = 0.005, OR = 8.34) and vacuum drain duration (p = 0.012, OR = 5.16) were observed to be associated with PCF.
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Affiliation(s)
- Nilda Süslü
- Department of Otorhinolaryngology-Head and Neck Surgery
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19
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Olszański W, Zasławska K, Pomarańska M, Tryka E, Piechnik B, Andrzejczak A, Swietlicki M, Trzaskowska E, Wawrzecka A, Klatka J. [Complications of surgical treatment in patients with laryngeal and hypopharyngeal cancer]. Otolaryngol Pol 2013; 67:6-10. [PMID: 23374657 DOI: 10.1016/j.otpol.2012.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 02/23/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Surgical treatment of patients with laryngeal or/and hypopharyngeal cancer is combined with potential risk of complications either local and general. The aim of the study was to evaluate the occurrence of them in the large cohort of patients with mentioned localization of cancer. MATERIAL AND METHODS The group of 447 patients, treated between 2000-2005 in Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin were analyzed retrospectively. There were 412 men and 35 women. 426 patients underwent surgical removal of the tumour without any reconstruction procedure. In 21 (4.7%) patients we performed reconstructions of the pharyngeal defect implementing pectoralis major muscle flap. Complications were classified into general and local. Furthermore, according to the time we classified sequel of the treatment into recent (those during the first 7 days after surgery) and late. Statistical analysis of variables was performed using χ² test. RESULTS Uncomplicated treatment were accomplished in 78.6% of patients. Local complications occur in 65 (14.5%) and general in 31 (6.9%) individuals. Pharyngo-cutaneous fistula was the most often occurring local sequel which constituted 50.8% of all local complications. Fistula developed in 33 (7.4%) cases. Cardiovascular and pulmonary diseases were the most often among general complications. They occur at the same rate of 25.8% of all general complications cases. Five patients (1.1%) died due to complications developed during the postoperative period. CONCLUSIONS We noticed 10.6% local complications in our group of patients whereas only 2.5% of treated persons developed general sequel. The pharyngo-cutaneous fistula was the most often occurring local complication. It has been treated surgically in 15 (45.5%) patients. Whereas cardiovascular and pulmonary diseases were the most often general complications and they occur in above half of all cases with general complications.
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Affiliation(s)
- Witold Olszański
- Katedra i Klinika Otolaryngologii i Onkologii Laryngologicznej Uniwersytetu Medycznego w Lublinie, 20-954 Lublin, Poland.
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Kapila S, Rozen WM, Huang T, Wu T, Fairbank S. Determining between chyle leak and anastomotic leak after esophageal reconstruction: the utility of methylene blue dye. Laryngoscope 2012; 122:779-80. [PMID: 22344866 DOI: 10.1002/lary.21732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 12/21/2010] [Accepted: 01/04/2011] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS Two common complications of esophagectomy and immediate reconstruction comprise thoracic duct injury leading to chyle leak and anastomotic leakage. These can delay optimized nutrition, speech, and swallowing rehabilitation, and thus are important to identify and treat accordingly. When either chyle leak or anastomotic leak are clinically suspected, differentiation between the two can be very difficult clinically. As both complications may result in an increase in drain output once oral intake has occurred, an effective, quick, and accurate tool is required to determine whether this increase in drain output is related to an anastomotic leak or with a increase activity in chyle production. STUDY DESIGN Retrospective descriptive study. METHODS Description of the use of oral methylene blue dye as a safe, simple, and quick clinical bedside test. RESULTS When ingested orally, an anastomotic leak will lead to blue dye staining the neck drain output immediately (within seconds to minutes). A chyle leak may also result in blue staining of the drain output; however, this is not an immediate phenomenon, and rather, based on the bioavailability of methylene blue this would take a minimum of 1 hour, and more likely up to 4 hours, as the dye is absorbed into mesenteric lymphatics and travels via the thoracic duct. CONCLUSIONS With no documented contraindications or side effects from its oral use (in the absence of hypersensitivity reactions), methylene blue is an inexpensive and freely available test in the postoperative setting of esophageal reconstruction.
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Affiliation(s)
- Shivam Kapila
- Department of Plastic and Reconstructive Surgery, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
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21
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Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas. Eur Arch Otorhinolaryngol 2009; 266:1799-805. [DOI: 10.1007/s00405-009-0946-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 02/26/2009] [Indexed: 10/21/2022]
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Ganly I, Patel SG, Matsuo J, Singh B, Kraus DH, Boyle J, Wong R, Shaha AR, Shah JP. Analysis of postoperative complications of open partial laryngectomy. Head Neck 2009; 31:338-45. [PMID: 19073010 DOI: 10.1002/hed.20975] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ian Ganly
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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23
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Wakisaka N, Murono S, Kondo S, Furukawa M, Yoshizaki T. Post-operative pharyngocutaneous fistula after laryngectomy. Auris Nasus Larynx 2008; 35:203-8. [PMID: 17826021 DOI: 10.1016/j.anl.2007.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 04/22/2007] [Accepted: 06/26/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Although organ-preserving radiotherapy or chemoradiotherapy has offered good locoregional control, many patients still experience recurrent disease requiring salvage laryngectomy. The pharyngocutaneous fistula (PCF) is a common and troublesome complication in the early post-operative period after laryngectomy. Here, we evaluated the cause of PCF after laryngectomy, with special emphasis on radiotherapy and/or chemotherapy. PATIENTS AND METHODS A total of 63 consecutive patients undergoing salvage total laryngectomy for squamous cell carcinoma of the larynx at Kanazawa University Hospital from 1990 to 2005 were reviewed. Forty of the 63 had received primary total laryngectomy (PL). Ten patients underwent radiotherapy alone (SL-RT) and 13 patients underwent concurrent chemoradiotherapy (SL-CRT) followed by salvage laryngectomy. RESULTS Overall, 17 of the 63 patients (27.0%) developed PCF after laryngectomy. Fisher's exact test showed a significant increase of PCF formation in SL-CRT (7/13, 53.8%) compared with PL (7/40, 17.5%) (p=0.0252). There were non-significant increases of PCF formation both in SL-CRT (7/13, 53.8%) compared with SL-RT (3/10, 30.0%) (p=0.4015), and also in SL-RT (3/10, 30.0%) compared with PL (7/40, 17.5%) (p=0.3969). The Mann-Whitney U-test showed that the duration of PCF was significantly longer for SL-CRT PCF (121.2+/-95.0 days) compared with those for PL (39.0+/-55.3 days) (p=0.0298) or SL-RT (28.0+/-16.2 days) (p=0.0325). However, we did not find a significant difference in the duration of PCF with respect to PL (39.0+/-55.3 days) and SL-RT (28.0+/-16.2 days) (p=0.4367). CONCLUSIONS Although radiotherapy or chemotherapy has only a limited impact on PCF formation, concurrent chemoradiotherapy significantly increases PCF formation. The addition of chemotherapy to irradiation delays PCF closure.
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Affiliation(s)
- Naohiro Wakisaka
- Division of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa 920-8640, Japan
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Early oral feeding following total laryngectomy. The Journal of Laryngology & Otology 2008; 123:333-8. [PMID: 18501033 DOI: 10.1017/s0022215108002557] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine whether, in a developing world context, early oral feeding after laryngectomy is safe, cost-effective and appropriate. STUDY DESIGN A prospective study of early oral feeding after laryngectomy, compared with retrospective, historical delayed feeding controls. METHOD Forty patients underwent total laryngectomy for advanced carcinoma of the larynx with or without hypopharyngeal involvement, not requiring tongue base resection or myocutaneous flaps, and were commenced on oral feeding on the second post-operative day. Thirty-nine laryngectomy patients previously managed in the same unit who had received conventional, delayed oral feeding served as controls. RESULTS Pharyngocutaneous fistulae developed in 20 per cent of the early feeding patients, compared with 15.4 per cent of the delayed oral feeding controls (p = 0.592). For patients who did not develop fistulae, hospitalisation was shorter in the early oral feeding group (p = 0.007). CONCLUSION Early oral feeding for laryngectomy patients is recommended, both in developed and developing countries.
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Jeong WJ, Jung EJ, Hah JH, Kwon TK, Wu HG, Heo DS, Sung MW, Kim KH. Preliminary results of pre-radiation neck dissection in head and neck cancer patients undergoing organ preservation treatment. Acta Otolaryngol 2007:121-7. [PMID: 17882582 DOI: 10.1080/03655230701625001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
CONCLUSION Pre-RT ND in patients with HNSCC undergoing organ preservation treatment is safe, advantageous, poses no additional morbidity owing to the elective neck dissection, and may possibly improve survival outcomes. OBJECTIVE Establish the role of pre-radiation neck dissection (pre-RT ND) in patients with head & neck squamous cell carcinoma (HNSCC) undergoing organ preservation treatment. MATERIALS AND METHODS Fourteen patients with histologically confirmed HNSCC in stages III approximately IV with proven regional metastasis were enrolled in the organ preservation approach incorporating pre-RT ND at a tertiary referral center between May 1998 and August 2004. Site matched patients treated with organ preservation intent in the conventional fashion were used as controls. Data were collected for their diagnosis, management, treatment outcome, and follow up. RESULTS Disease free survival was significantly better for the pre-RT ND group. There was no significant difference in overall survival, pattern of recurrence, and primary organ preservation rate between the two groups. No significant morbidity owing to neck dissection was noted in patients who underwent neck dissection. Although the delivery of radiation to the primary site was delayed for patients in the pre-RT ND group, it did not influence the major outcomes.
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Affiliation(s)
- Woo-Jin Jeong
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea
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Liu SA, Tung KC, Cheng CC, Chiu YT. The impact of different closure materials on pharyngeal wound healing: an experimental animal study. Eur Arch Otorhinolaryngol 2007; 265:227-31. [PMID: 17724603 DOI: 10.1007/s00405-007-0431-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 08/13/2007] [Indexed: 10/22/2022]
Abstract
The formation of pharyngo-cutaneous fistula (PCF) is controversial and various predisposing factors have been proposed. This study aimed to compare different suture materials in the closure of pharyngeal wounds in experimental animals. Fifty-two Sprague-Dawley rats were divided into three groups. Artificial pharyngotomy was performed and was then repaired with Vicryl, polypropylene, and Vicryl plus fibrin glue, respectively. Outcome measurements included gross wound inspection and histological examination. There was a significant difference in the rates of PCF formation between group I and group II (Fisher's exact test, p = 0.046). In addition, minimal inflammatory response was found in the polypropylene group when compared to the other groups. The fibrin glue-treated group had the highest fibroblast activity and collagen deposition. Polypropylene produced minimal tissue reaction, which facilitated the healing process. Therefore, proper selection of suture material can probably reduce the rate of PCF but should not be substituted for proper aseptic and meticulous surgical techniques.
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Affiliation(s)
- Shih-An Liu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan
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27
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Arosarena OA. Perioperative Management of the Head and Neck Cancer Patient. J Oral Maxillofac Surg 2007; 65:305-13. [PMID: 17236939 DOI: 10.1016/j.joms.2005.10.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 07/22/2005] [Accepted: 10/08/2005] [Indexed: 11/19/2022]
Affiliation(s)
- Oneida A Arosarena
- Department of Otolaryngology, Temple University, Philadelphia, PA 19140, USA.
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Yom SS, Machtay M, Biel MA, Sinard RJ, El-Naggar AK, Weber RS, Rosenthal DI. Survival Impact of Planned Restaging and Early Surgical Salvage Following Definitive Chemoradiation for Locally Advanced Squamous Cell Carcinomas of the Oropharynx and Hypopharynx. Am J Clin Oncol 2005; 28:385-92. [PMID: 16062081 DOI: 10.1097/01.coc.0000162422.92095.9e] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients who have received definitive radiation therapy (RT) for a nonlaryngeal T3/4 head and neck squamous cell carcinoma have a limited opportunity for post-RT surgical salvage. The authors reviewed the practice of planned post-RT restaging to determine its impact on the success of early surgical salvage. METHODS A retrospective review was performed for patients with resectable T3/4 cancers of the oropharynx and hypopharynx treated with RT +/- chemotherapy who underwent planned restaging clinically, radiographically (CT or MRI), and by direct laryngoscopy with biopsy at 4 to 8 weeks post-RT. Chemotherapy was given as induction, concurrently, or both. Neck dissection was performed at time of restaging in patients with primary tumor control and initial N2/N3 neck disease or persistent lymphadenopathy. RESULTS A total of 54 patients had a median follow-up of 34.7 months (range, 7.6-97.8 months). Forty-two patients (78.8%) achieved a complete response (CR) at the primary site immediately after RT. Six developed late local failure at 9 to 61 months, of whom 2 were successfully salvaged. The ultimate 2-year local control among patients with initial CR was 94.8%. The 2-year organ preservation, disease-free survival, and overall survival (OS) rates were was 92.5%, 87%, and 90%, respectively. Twelve patients did not achieve initial CR. Two patients with bulky stage IV disease had unresectable cancers. Ten underwent immediate surgical salvage and 7 achieved local control (1 of whom developed distant metastases) whereas 3 had continued local failure. For patients without initial CR, the 2-year ultimate local control rate was 46.7% and OS was 46.8%. For all patients, overall 2-year local control, organ preservation, and OS rates were 85.6%, 75.6%, and 81.8% respectively. The rate of local failure-free organ preservation was 71.5%. CONCLUSION For patients with T3/4 resectable nonlaryngeal head and neck cancers, planned clinical, radiographic, and pathologic restaging at 1 to 2 months after definitive RT provides the opportunity for early surgical salvage in those who fail at the primary site. This practice produces improved overall local control and survival rates compared with the literature reports for delayed attempted salvage with timing based on the findings of routine postradiation clinical surveillance. Future efforts may focus on the improved selection of patients who would be most likely to require early surgical intervention.
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Affiliation(s)
- Sue S Yom
- Department of Radiation Oncology, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ganly I, Patel S, Matsuo J, Singh B, Kraus D, Boyle J, Wong R, Lee N, Pfister DG, Shaha A, Shah J. Postoperative complications of salvage total laryngectomy. Cancer 2005; 103:2073-81. [PMID: 15816049 DOI: 10.1002/cncr.20974] [Citation(s) in RCA: 201] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The objectives of the current study were to report the incidence of postoperative complications for salvage total laryngectomy (STL) compared with primary total laryngectomy (PTL) and to identify patient and tumor-related factors predictive of postoperative complications. METHODS A sample of 183 patients who had received a total laryngectomy were identified from an existing database of 662 patients treated for squamous cell carcinoma of the larynx. PTL and STL were performed in 113 and 70 patients, respectively. Initial therapy in the patients who required salvage surgery included radiotherapy (RT) in 32 (46%) and chemoradiotherapy (CTRT) in 38 (54%). Postoperative complications were recorded for each group and categorized into local, swallowing, airway, and systemic complications. Postoperative complication rates for STL after RT and CTRT were compared with those after PTL by univariate analysis. Patient and tumor-related predictors of complications were identified by univariate and multivariate analyses. RESULTS The overall mortality rate was 0.5%. Forty percent of all patients developed a postoperative complication after total laryngectomy. Local complications, which were the most frequent, occurred in 52 (28%) patients. Pharyngocutaneous fistula occurred in 31 (17%) patients. Statistical analysis showed that there was a greater number of patients with local wound (45% vs. 25%, P = 0.02) and fistula complications (32% vs. 12%, P = 0.012) in the STL-CTRT group compared with the primary laryngectomy group. Multivariate analysis showed that primary CTRT was an independent predictor of local complications and pharyngocutaneous fistula. CONCLUSIONS Salvage laryngectomy was more frequently associated with postoperative complications after CTRT compared with PTL. Problems related to local wound healing, especially the development of pharyngocutaneous fistula, constituted the most common postoperative complication in these patients. Multivariate analysis showed that primary CTRT was an independent predictor of local wound complications and pharyngocutaneous fistula.
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Affiliation(s)
- Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Grau C, Johansen LV, Hansen HS, Andersen E, Godballe C, Andersen LJ, Hald J, Møller H, Overgaard M, Bastholt L, Greisen O, Harbo G, Hansen O, Overgaard J. Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA. Head Neck 2003; 25:711-6. [PMID: 12953306 DOI: 10.1002/hed.10237] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE In 1998, the Danish Society for Head and Neck Oncology decided to conduct a nationwide survey at the five head and neck oncology centers with the aim of evaluating the surgical outcome of salvage laryngectomy after radiotherapy with special emphasis on identifying factors that could contribute to the development of pharyngocutaneous fistulae. PATIENTS A total of 472 consecutive patients undergoing postirradiation salvage laryngectomy in the period July 1, 1987-June 30, 1997 were recorded at the five head and neck oncology centers in Denmark. Age ranged from 36 to 84 years, median 63 years, 405 men and 67 women. Primary tumor site was glottic larynx (n = 242), supraglottic larynx (n = 149), other larynx (n = 45), pharynx (n = 27), and other (n = 9). All patients had received prior radiotherapy. RESULTS Median time between radiotherapy and laryngectomy was 10 months (range, 1-348 months). A total of 89 fistulae lasting at least 2 weeks were observed, corresponding to an overall average fistulae risk of 19%. The number of performed laryngectomies per year decreased linearly (from 58 to 37), whereas the annual number of fistulae increased slightly (from 7 to 11), which meant that the corresponding estimated fistulae risk increased significantly from 12% in 1987 to 30% in 1997. Other significant risk factors for fistulae in univariate analysis included younger patient age, primary advanced T and N stage, nonglottic primary site, resection of hyoid bone, high total radiation dose, and large radiation fields. Multiple logistic regression analysis of these parameters suggested that nonglottic tumor site, late laryngectomy period (1987-1992 vs 1993-1997), and advanced initial T stage were independent prognostic factors for fistulae risk. Surgical parameters like resection of thyroid/tongue base/trachea or radiotherapy parameters like overall treatment time or fractions per week did not influence fistulae risk. CONCLUSIONS The risk of fistulae is especially high in patients initially treated with radiotherapy for nonglottic advanced stage tumors. A significant decrease in the number of performed salvage laryngectomies over the 10 years was seen. Over the same time period, the annual number of fistulae remained almost constant. The resulting more than doubling of fistulae rate could thus in part be explained by less surgical routine.
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Affiliation(s)
- Cai Grau
- Department of Oncology, Aarhus University Hospital, 8000 Aarhus C, Denmark.
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Wiseman S, Hicks W, Loree T, Al-kasspooles M, Rigual N. Fibrin glue-reinforced closure of postlaryngectomy pharyngocutaneous fistula. Am J Otolaryngol 2002; 23:368-73. [PMID: 12430130 DOI: 10.1053/ajot.2002.126318] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pharyngocutaneous fistulization is a dreaded and devastating complication of laryngectomy. Although the specific risk factors are controversial, a history of prior radiation therapy has generally been accepted to be a major risk factor for developing this complication. We present a case of a postlaryngectomy pharyngocutaneous fistula developing in a previously irradiated patient that was successfully managed by incorporating fibrin glue into the surgical closure. We also discuss the underlying theoretical basis for this approach by reviewing the relevant literature.
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Affiliation(s)
- Sam Wiseman
- Division of Head and Neck Surgery, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY 14263, USA
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Herranz J, Sarandeses A, Fernández MF, Barro CV, Vidal JM, Gavilán J. Complications after Total Laryngectomy in Nonradiated Laryngeal and Hypopharyngeal Carcinomas. Otolaryngol Head Neck Surg 2000; 122:892-8. [PMID: 10828805 DOI: 10.1016/s0194-59980070020-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To study the complications of total laryngectomy, we evaluated 471 previously untreated patients who underwent total laryngectomy between 1980 and 1997. This series consisted of 358 patients with primary carcinoma of the larynx and 113 with carcinoma of the hypopharynx. Concurrent neck dissection was performed in 85% of patients. Complications were studied in relation to age, T and N stage, previous tracheostomy, neck dissection, margins, reconstruction, tracheoesophageal puncture, and surgeon. Complication treatment and hospitalization were also evaluated. The overall complication rate was 30.7%, with 29.2% major and 6.5% minor complications. The mortality rate was 0.6% (3/471). Pharyngocutaneous fistula was the most frequent wound complication (21%), followed by wound infection (4.2%) and hemorrhage (2.3%). Pneumonia (1.4%) and embolism (0.4%) were the most frequent medical complications. Hypopharyngeal tumors, neck dissection, and extended procedures had a significantly higher rate of complications. Complication causes, prevention, and treatment are discussed.
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Affiliation(s)
- J Herranz
- Department of Otorhinolaryngology, Hospital Juan Canalejo, La Coruña, Spain
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Wenisch C, Werkgartner T, Sailer H, Patruta S, Krause R, Daxboeck F, Parschalk B. Effect of preoperative prophylaxis with filgrastim in cancer neck dissection. Eur J Clin Invest 2000; 30:460-6. [PMID: 10809907 DOI: 10.1046/j.1365-2362.2000.00643.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cancer surgery is known to lead to a deterioration in host defence mechanisms and an increase in susceptibility to infection after operation. Filgrastim enhances important antimicrobial functions of neutrophils including chemotaxis, phagocytosis and oxidative killing mechanisms. METHODS The effects of additional (all patients received perioperative 3 ' 25 mg kg-1 cefotiam and 1 ' 20 mg kg-1 metronidazole) preoperative prophylaxis with filgrastim (5 microg kg-1 12 h prior to surgery plus 5 microg kg-1 0 h prior to surgery) on neutrophil phagocytosis and reactive oxygen radical production and postoperative infections in 24 patients undergoing cancer neck dissection were studied. Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labelled Escherichia coli and Staphylococcus aureus by flow cytometry. Reactive oxygen generation after phagocytosis was estimated by determining the amount of dihydrorhodamine 123 converted to rhodamine 123, intracellularly. RESULTS In the filgrastim-treated patients a higher neutrophil phagocytic capacity was seen intraoperatively, and 1-5 days postoperative, but not prior to surgery. Reactive oxygen radical production was significantly higher in filgrastim-treated patients prior to surgery, intraoperative and postoperative (1-5 days). 2/12 (17%) patients had postoperative infections in the filgrastim group and 9/12 (75%) patients had infections in the placebo group (P < 0.001). In particular, wound infections were recorded more often in the placebo group (1/12 vs. 6/12; P = 0.004). CONCLUSION We conclude that filgrastim enhances perioperative neutrophil function and could be useful in the prophylaxis of postoperative wound infections in patients undergoing cancer neck dissection.
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Affiliation(s)
- C Wenisch
- University Hospital of Vienna, Vienna, Austria.
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Abstract
The quest for improved fractionation and combined modality regimens in head and neck cancer has also yielded progressively higher rates of toxicity. Time compression of dose delivery in accelerated fractionation has produced high rates of severe mucositis including the early stoppage of two randomized trials. The addition of chemotherapy has introduced systemic toxicity and can exacerbate local tissue reactions when used concurrent with radiotherapy. Mucositis is recognized as the principal impediment to efforts at further treatment intensification. The development and utilization of standardized toxicity grading criteria and accepted reporting standards has lagged toxicity production, impeding a full appreciation of the true extent of both acute and late toxicity. Objective data regarding acute and chronic effects on organ function are also sorely lacking. A better characterization of the frequency, severity, and duration of the various toxicities encountered in head and neck cancer will also allow the rational development of toxicity interventions. New methods are needed to summarize the global or aggregate toxicity of a treatment program. Further research into the assessment and analysis of toxicity is not only crucial to improvements in quality of life (QOL), but perhaps, improved rates of disease control as well.
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Affiliation(s)
- A Trotti
- Division of Radiation Oncology, H. Lee Moffitt Cancer Center at the University of South Florida, Tampa, FL, USA.
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Khan A, Spiro JD, Dowsett R, Greenberg BR. Sequential chemotherapy and radiotherapy for organ preservation in advanced resectable nonlaryngeal head and neck cancer. Am J Clin Oncol 1999; 22:403-7. [PMID: 10440200 DOI: 10.1097/00000421-199908000-00017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although there is no definite survival advantage to the use of sequential induction chemotherapy (CT) followed by radiotherapy (RT) in advanced resectable laryngeal cancer, this approach does succeed in preserving the larynx in many of these patients. The authors performed this study to analyze their results using a similar approach for patients with advanced resectable cancer located outside the larynx who would have required a total laryngectomy for oncologic or functional reasons. A retrospective study was performed at a single institution that included all patients with advanced resectable nonlaryngeal head and neck cancer treated with induction CT between January 1990 and August 1995. A total of 19 patients were included, with primary cancers located in the oropharynx in 14 patients, the hypopharynx in four, and the oral cavity and oropharynx in one. Eight patients had clinical stage III disease, and 11 patients had stage IV disease. Our treatment protocol consisted of two cycles of induction CT with cisplatin and 5-fluorouracil, followed by a third cycle of CT and subsequent RT in patients who achieved at least a clinical partial response (PR) after two courses of induction CT. Eighteen of 19 patients were evaluable for response. Overall, 13 patients (72%) had a major response (PR or CR) to induction CT at the primary site, and eight patients (57%) had a major response to chemotherapy in the neck. With a mean follow-up of 53 months (range, 24-71 months), the disease-specific survival was 57% for those patients with cancer of the oropharynx and oral cavity. In the subset of patients with hypopharynx cancer, 3 of 4 patients died of cancer despite achieving major response to induction CT. Organ preservation using sequential CT and RT for advanced resectable nonlaryngeal head and neck cancer is feasible, and the results in our experience with cancer of the oropharynx were similar to those reported for primary laryngeal cancer. Our limited experience using this protocol for cancer of the hypopharynx has been disappointing.
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Affiliation(s)
- A Khan
- Department of Medicine, University of Connecticut Health Center, Farmington 06030, USA
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Redaelli de Zinis LO, Ferrari L, Tomenzoli D, Premoli G, Parrinello G, Nicolai P. Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy. Head Neck 1999; 21:131-8. [PMID: 10091981 DOI: 10.1002/(sici)1097-0347(199903)21:2<131::aid-hed6>3.0.co;2-f] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Pharyngocutaneous fistula is the most common complication following total laryngectomy. The present study was designed to determine the incidence and predisposing factors and to describe the management of the complication. METHODS The records of 246 consecutive patients who underwent total laryngectomy for squamous cell carcinoma were reviewed. We evaluated 23 factors potentially predisposing to fistula formation (age, sex, smoking and drinking habits, hypertension, diabetes, chronic bronchitis, chronic congestive heart failure, anesthesiologic risk, cholinesterase level, pre- and postoperative hemoglobin and albumin levels, previous treatment, previous tracheotomy, site of origin of the tumor, surgical procedure, concurrent neck dissection, suture material, status of surgical margins, clinical stage, and histologic grade) using the chi-squared test and logistic regression analysis. RESULTS A pharyngocutaneous fistula developed in 16% of patients within a mean time of 11 days from surgery. Spontaneous closure with local wound care was achieved in 70% of cases. Ten patients required surgical closure by direct suture of the pharyngeal mucosa; a deltopectoral flap and a pectoralis major myocutaneous flap were used in one case each. The mean healing time was 39+/-46 days in the group of patients requiring surgical closure, compared with 19+/-12 days in the group in which spontaneous closure occurred. The definitive model of logistic regression analysis showed that pharyngolaryngectomy, chronic congestive heart failure, and postoperative hemoglobin level lower than 12.5 g/dL carried respectively a two-, five-, and ninefold increase in the risk of fistula development. The model, with a specificity of 81%, is fairly good in identifying patients with a low risk of fistula. CONCLUSIONS The results observed in the group of patients under analysis corroborated the relevance of factors such as the extension of laryngectomy and postoperative hemoglobin level on fistula occurrence. However, chronic congestive heart failure, which is an expression of disturbance of the organism, emerged for the first time as an additional statistically significant risk factor for pharyngocutaneous fistula formation. Our experience confirmed that most fistulas can be successfully managed with conservative treatment. Except for the rare cases in which large defects are present, direct suture is appropriate when conservative treatment has failed.
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