Using a linear stapler for pharyngeal closure in total laryngectomy

Stapler versus conventional pharyngeal repair after total laryngectomy: a randomized clinical trial

OBJECTIVES

The aim of the current study was to evaluate the functional outcomes of stapler pharyngeal closure after total laryngectomy by the incidence of PCT and assessment of swallowing after surgery. In addition, the study aimed to evaluate the oncological outcomes in terms of patients' survival rates.

METHODS

This randomized clinical trial was conducted on 58 patients with advanced laryngeal carcinoma who underwent total laryngectomy. Patients were randomly assigned to two groups according to the method of pharyngeal repair after laryngectomy: manual closure group (n = 28), and stapler group (n = 30). Functional and oncological outcomes were assessed and compared.

RESULTS

The incidence of pharyngocutaneous fistula was significantly less in the stapler group. Additionally, operative time was significantly shorter and swallowing function was better in the stapler group compared to the manual group. There was no statistically significant difference between groups regarding survival rates.

CONCLUSION

The stapler is a reliable method for pharyngeal closure after total laryngectomy if the limits of its indications regarding the primary tumor are considered. Stapler closure decreases the incidence of PCF and decreases the surgical time. Good swallowing outcomes are achieved without compromising the oncological outcomes.

Stapler Assisted Total Laryngectomy: A Prospective Randomized Clinical Study

Closure of the pharyngeal defect after total laryngectomy had been traditionally performed with manual suturing techniques that invert the mucosal edge this technique though effective, yet it is time-consuming. Recently the use of stapling devices to successfully close the pharyngeal defect after total laryngectomy has been advocated to shorten the operative time, especially in the high-risk cancer patients where a prolonged operative time is not preferred. The present study aimed at comparing stapler assisted total laryngectomy to suture closure total laryngectomy in a prospective randomized manner. This is a prospective clinical study conducted on 60 patients undergoing total laryngectomy at Alexandria Main University Hospital, Egypt. Patients with tumor extension to the hypopharynx or base of the tongue were excluded from the study. The surgical time is reduced with shorter hospital stays and no increase in postoperative complications rate. The use of the stapler is technically easy to perform and as equally as effective as the traditional neopharyngeal suturing techniques in patients undergoing total laryngectomy.

Partial penile amputation using a thoracoabdominal stapler in nine dogs

Objectives

To describe a novel technique for partial anatomic penile amputation using a thoracoabdominal stapler in dogs and to report any associated short‐term peri‐operative complications and clinical outcomes associated with the procedure.

Materials and methods

Medical records from a tertiary referral hospital were reviewed for dogs undergoing penile amputation and scrotal urethrostomy between October 2007 and December 2019. Data collected included patient signalment, clinical signs on presentation, indication for penile amputation, surgical technique, duration of surgery, post‐operative complications, and short‐term outcome.

Results

Nine dogs were included in the study. Indications for surgery were for treatment of chronic paraphimosis and priapism (n = 3), recurrent urethral prolapse (n = 2), balanoposthitis (n = 1), masses arising from the penis, prepuce, and/or urethra (n = 2), and penile trauma (n = 1). All dogs underwent a scrotal urethrostomy followed by a partial penile amputation with a thoracoabdominal stapler. All dogs suffered mild post‐operative haemorrhage from the urethrostomy stoma. On recovery from general anaesthesia, 2/9 dogs were painful and another 2/9 dogs were dysphoric. Two dogs experienced incisional complications with mild swelling around the urethrostomy stoma. One dog experienced an infection of the penile amputation site 21 days after surgery. The short‐term outcomes for this procedure were excellent in 8/9 dogs. These outcomes were based on owner assessment of comfort and monitoring throughout the recovery period, manual palpation of the surgical site at the time re‐evaluation, and surgeon visualization of successful voluntary urination 14–35 days after surgery.

Clinical significance

Use of a thoracoabdominal stapler is effective in achieving partial anatomic penile amputation in dogs.

Total laryngectomy and permanent tracheostomy in six dogs

The objective of this report is to describe the surgical technique for total laryngectomy and outcome in six dogs. Laryngeal cancer is an uncommon and challenging clinical problem. Total laryngectomy can provide local disease control but is uncommonly performed. Detailed procedural descriptions are limited and similarly limited information is available regarding patient outcome. Institutional medical records were searched for dogs treated with total laryngectomy. Six dogs were identified. The procedure resulted in postoperative quality of life similar to permanent tracheostomy alone. Surgical margin status was evaluated in five of six cases and was complete in those five. All dogs survived to discharge from the hospital. Complications were mostly related to tracheostomy occlusion or collapse which is recognized as a complication associated with permanent tracheostomy. Patient quality of life was acceptable. Local recurrence was suspected in one dog. Recurrence was not observed in the case with unknown margin status.

Platelet-rich fibrin: an autologous biomaterial for healing assistance of pharyngeal repair in total laryngectomy

OBJECTIVES

The aim of this study was to evaluate the potential role of platelet-rich fibrin (PRF) application on the pharyngeal repair on decreasing the incidence of pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

This randomized controlled clinical trial was conducted on 67 patients with advanced laryngeal carcinoma who underwent total laryngectomy, over 2 years in the Otorhinolaryngology Department, Mansoura University Hospitals, Egypt. Patients were randomly assigned into two groups: PRF group (n = 35) and control group (n = 32). Risk factors for development of PCF as well as the incidence of PCF were studied in both groups.

RESULTS

There was no statistically significant difference between groups regarding demographic data, medical comorbidities, basal hemoglobin and albumin levels, data related to the tumor (location, grade and TNM staging) and surgical details (preoperative tracheotomy and neck dissection). However, regarding the incidence of PCF, there was a statistically significant difference between groups as shown in Table 2. PCF was detected in 2/35 patients (5.7%) in the PRF group and in 10/32 patients (31.3%) in the control group (p = 0.004).

CONCLUSION

PRF application on the pharyngeal repair after total laryngectomy enhances the healing process and consequently decreases the incidence of PCF.

Pharyngeal closure after a total laryngectomy: mechanical versus manual technique

OBJECTIVE

To verify the main advantages and drawbacks of mechanical suturing for pharyngeal closure after total laryngectomy versus a manual suturing technique.

METHODS

A retrospective review was carried out of 126 total laryngectomies performed between 2008 and 2018. Manual closure was performed in 80 cases (63.5 per cent) and mechanical suturing was performed in 46 cases (36.5 per cent).

RESULTS

Mechanical suturing was used significantly more frequently in patients with: glottic tumours (p = 0.008), less local tumour extension (p = 0.017) and less pre-operative morbidity (p = 0.014). There were no significant differences in the incidence of pharyngocutaneous fistula between the manual suture group (16.3 per cent) and the mechanical suture group (13.0 per cent) (p = 0.628). None of the patients treated with mechanical suturing had positive surgical margins. Cancer-specific survival for the mechanical suture group was higher than that for the manual suture group (p = 0.009).

CONCLUSION

Mechanical suturing of the pharynx after total laryngectomy is an oncologically safe technique if used in suitable cases.

The Comparative Analysis of Suture versus Linear Stapler Pharyngeal Closure in Total Laryngectomy: A Prospective Randomized Study

Objective

The aim of this study was to prospectively evaluate and compare the outcomes in patients undergoing pharyngeal closure with the linear stapler and suture techniques after total laryngectomy.

Methods

Forty-one patients who needed total laryngectomy for laryngeal cancer were enrolled in the study. Patients were randomized into two groups according to the pharyngeal closure technique: the linear stapler group (Group A) and the suture closure group (Group B). Rate of pharyngocutaneous fistula (PCF), nasogastric tube (NGT) removal time and pharyngeal closure time were analyzed and compared between the two groups.

Results

PCF developed in three patients in Group A (14.3%) and in seven patients in Group B (35%). Although the rate of PCF was lower in Group A, this did not represent a statistical difference (p:0.129). Median NGT removal time was 12 days (IQR=3) and 19.5 days (IQR=1) in Groups A and B, respectively. Median NGT removal time was not statistically different between the two groups (p:0.642). All patients were able to swallow liquids and solids without difficulty. Median pharyngeal closure time was 3 minutes (IQR=1) and 37.5 minutes (IQR=9) in Groups A and B, respectively. Median pharyngeal closure time was significantly lower in Group A (p:0.00).

Conclusion

The linear stapler technique in total laryngectomy is a reliable, safe, easy-to-apply and time-saving method. Closure with linear stapler significantly reduces pharyngeal closure time without adverse effect on NGT removal times and PCF rates.

Total Laryngectomy with Horizontal Mechanical Closure of the Pharyngoesophagectomy: Evaluation of the Effectiveness in Elderly Patients

Introduction  The main modalities of surgical treatment for laryngeal cancer include transoral laser microsurgery (TLM), open preservation surgery, and total laryngectomy (TL). In the elderly, for the presence of comorbidities, the surgical approach more appropriate in many cases remains TL. The use of a stapler for the closure of the esophagus has been introduced to reduce surgical time and postoperative complications such as pharyngocutaneous fistula (PCF).

Objective  In the present study, we have evaluated the effectiveness of the use of the horizontal mechanical pharyngoesophageal closure in patients who underwent TL.

Methods  This nonrandomized study was performed on consecutive patients with histopathologically proven squamous cell endolaryngeal carcinoma. The TL was performed using a linear stapler to mechanically suture the pharyngotomy using the semiclosed technique.

Results  A total of 33 patients underwent TL, and 13 of them underwent neck dissection. A total of 15 patients (45.4%) were ≤70 years old, and 18 were > 70 years old. Analyzing the results in relation to age, patients > 70 years old showed tumors at an earlier stage than those aged ≤70 years old. Furthermore, in this group there was a greater number of patients who had comorbidities ( p  = 0.014). In total, we had 2 (6%) cases of PCF in 6.6% in the group ≤70 years old, and in 5.5% of the group > 70 years old ( p  = 1.00).

Conclusions  The use of the stapler for the horizontal closure of the pharyngoesophagectomy in the patients subjected to TL is proven to be useful and safe even when used in elderly patients.

Magnifying endoscopy with narrow-band imaging to assist the linear stapler closure of the pharynx during total laryngectomy

OBJECTIVE

This study aimed to present a novel technique for stapler-assisted laryngectomy under direct visualization using a videoendoscope with narrow-band imaging (NBI-endoscopy).

METHODS

A case series of five consecutive patients were treated with stapler-assisted total laryngectomy from December 2014 to March 2016. The technique involved monitoring the stapler closure of laryngopharyngeal cavity under NBI-endoscopic vision, triple checking of neo-pharynx cavity by an endoscopic view inside and transillumination verification outside, air leakage test, and guiding the insertion of feeding tube under direct visualization. The main evaluation of this study was pharyngocutaneous fistula, surgical margin, and oral feeding time.

RESULTS

All the patients healed well without a pharyngocutaneous fistula. The mean of surgical time, oral feeding, and hospitalization time were 40 min, 6 days, and 8 days, respectively.

CONCLUSION

This study demonstrated a technique simple to learn and associated with decreased complication rates, which could be safe and efficient for stapler-assisted laryngectomy.

Management of pharynx fistula after upper digestive tract instrumentation

Pharynx fistula is a pathological state that can pose serious problems for both physician and patient and can lead up to the death of the patient in complicated cases. The authors describe a series of guidelines for the management of the pharynx fistula regarding the complications of the instrumentation of the upper digestive tract. Most of the cases that are addressed to our clinic can be treated with a conservative approach and a nutrition therapy plan tailored to each case. In selected cases surgery is the method of choice for therapy. The management of the pharynx fistula can be well managed in a multidisciplinary approach using resources from the E.N.T. and H.N.S. department and more important from the ICU department.

Outcomes of mechanical stapling for postlaryngectomy open pharyngotomy closure

OBJECTIVES/HYPOTHESIS

A total laryngectomy (TL) is performed as a primary or salvage therapy for laryngeal carcinoma. Pharyngotomy closure after TL is typically performed using manual sutures. Automatic stapling devices are routinely used in thoracoabdominal surgery, but have not been widely accepted for use in pharyngotomy closure. Previously described closed stapling techniques of pharyngeal closure do not allow direct evaluation of surgical margins and are limited to endolaryngeal disease. We describe an open technique for pharyngotomy closure using a mechanical stapling device.

STUDY DESIGN

Retrospective review.

METHODS

A review was conducted of 16 total laryngectomies performed from May 2008 to August 2015 utilizing an Ethicon Endopath ETS Compact-Flex 45 stapler.

RESULTS

Sixteen patients (15 male, one female), mean age 69 years, received open TL (14 salvage, two primary) with endostapler pharyngeal closure and primary tracheoesophageal puncture (TEP). Surgical time averaged 218 minutes. Median time to swallowing was 4 days (range, 2-240 days) and mean hospital stay 6 days (range, 3-10 days). Fistula incidence was 31% (5/16) overall and 36% (5/14) in the postradiation patients.

CONCLUSIONS

Mechanical stapling is a simple method for postlaryngectomy open pharyngotomy closure. This technique allows evaluation of margins, easy primary TEP, and the opportunity for early swallowing and shorter hospital stays. In addition, it can be performed for closure of salvage laryngectomies with rates of fistula formation similar to that found in the literature using suture closure techniques. Future studies are necessary to compare oncological results and surgical complications between the open and closed stapling techniques and to traditional suture closure.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:605-610, 2017.

Primary tracheoesophageal puncture and cricopharyngeal myotomy in stapler-assisted total laryngectomy

OBJECTIVE

To evaluate the utility of the hybrid tracheoesophageal puncture procedure in stapler-assisted laryngectomy.

METHODS

Patients who underwent total laryngectomy at a single institution from 2009 to 2015 were reviewed. The interventions assessed were surgical creation of a tracheoesophageal puncture and placement of a voice prosthesis. The outcomes measured included voicing ability and valve failure.

RESULTS

Thirty-nine patients underwent total laryngectomy or pharyngolaryngectomy. Of these, nine underwent stapler-assisted laryngectomy; seven of the nine patients underwent concurrent stapler-assisted laryngectomy, cricopharyngeal myotomy and a hybrid tracheoesophageal puncture procedure. These seven patients were the focus of this review. Successful voicing and oral alimentation was achieved in all patients. Mean time to phonation was 30 days (range, 7-77 days) and mean time to first valve change was 90 days (range, 35-117 days).

CONCLUSION

Primary tracheoesophageal puncture with concurrent voice prosthesis placement and cricopharyngeal myotomy is easily performed with stapler-assisted laryngectomy. The hybrid tracheoesophageal puncture procedure is a simple method that enables a single operator to achieve primary tracheoesophageal puncture and valve placement; in addition, it facilitates concurrent cricopharyngeal myotomy.

Modified Continuous Mucosal Connell Suture for the Pharyngeal Closure After Total Laryngectomy: Zipper Suture

Objectives

Pharyngocutaneous fistula is a serious complication after total laryngectomy, and there are some risk factors stated in the literature. The surgical suture techniques are not studied so much. The aim of this study is to evaluate the effectiveness of 'modified continuous mucosal Connell suture' on the incidence of pharyngocutaneous fistula after total laryngectomy.

Methods

This is a retrospective case series study based at a tertiary center with 31 patients who underwent total laryngectomy between July 2011 and December 2013. Pharyngocutaneous fistula formation after total laryngectomy was evaluated with the patients who underwent modified continuous mucosal Connell suture for pharyngeal repair.

Results

Pharyngocutaneous fistula was observed in only one patient (3.2%) who had a history of previous radiotherapy, and it was spontaneously healed within 6 days by conservative treatment.

Conclusion

We defined a new suture technique for the pharyngeal repair after total laryngectomy. This technique is a simple modification of continuous mucosal Connell suture. We named it as zipper suture. It is effective in the prevention of pharyngocutaneous fistula for pharyngeal reconstruction after total laryngectomy.