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Wang Z, Ma W, Wang X, Zeng Q, Hu G. Pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction. Eur Arch Otorhinolaryngol 2023; 280:4641-4647. [PMID: 37395759 DOI: 10.1007/s00405-023-08069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Total laryngeal and hypopharyngeal resection remained to be the mainly treatment option for advanced hypopharyngeal cancer, which resulted in complicated reconstructive challenge for circumferential hypopharyngeal defect. The pedicled thoracoacromial artery compound flaps included Thoracoacromial artery perforator (TAAP) flap and pectoralis major myocutaneous (PMMC) flap. This study is to evaluate the clinical application of the pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction. METHODS From May 2021 to April 2022, four hypopharyngeal cancer patients with circumferential hypopharyngeal defects were reconstructed by the pedicled thoracoacromial artery compound flaps. All patients were males. Patient age ranged from 35 to 62 years (average, 50 years). The Shoulder function were evaluated by SPADI. The average follow-up was 10.25 months (range from 4 to 18 months). RESULTS All of the pedicled thoracoacromial artery compound flaps in our study survived. The defect length between tongue base and cervical esophagus ranged from 8 to 10 cm after total laryngeal and hypopharyngeal resection. The TAAP flap size ranged from 6 × 7 cm to 7 × 10 cm, and the PMMC flap size ranged from 6 × 7 cm to 9 × 12 cm. The pedicle length of TAAP and PMMC flaps varied, respectively, from 5 to 8 cm (mean 6.5 cm) and 7 cm to 11 cm (mean 8.75 cm). The mean time of TAAP and PMMC flaps harvest was, respectively, 82 min and 39 min. All patients were able to resume soft diet in the fourth week of postoperation, but one patient was operated by gastrostomy in the second month of postoperation because of pharyngeal cavity stenosis, and the patient successfully resumed oral soft diet by endoscopic balloon dilation after postoperation radiotherapy. All patients have resumed oral feeding at last. There were mild dysfunction for our patients according to SPADI during the mid-long follow-up. CONCLUSIONS The pedicled thoracoacromial artery compound flaps have stable blood supply and provide adequate muscle coverage for greater protection during radiotherapy, and the microsurgical skills have no requirement. Therefore, the compound flaps provide a good choice for the reconstruction of circumferential hypopharyngeal defect, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.
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Affiliation(s)
- Zhihai Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Ma
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiaoqiang Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Quan Zeng
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Guohua Hu
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Hanubal KS, Chheda NN, Dziegielewski PT. Neopharyngeal Stricture following Laryngectomy. Semin Plast Surg 2023; 37:31-38. [PMID: 36776807 PMCID: PMC9911225 DOI: 10.1055/s-0042-1759796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stricture formation is a serious complication following pharyngeal reconstruction. These strictures can be life-threatening and can severely impact quality of life. In this article, the existing literature on surgical risk factors linked to neopharyngeal stricture formation is reviewed. Intraoperative preventative measures reconstructive surgeons should consider are also discussed. Finally, this article will describe the evaluation and management of pharyngoesophageal strictures, including the challenges and options when dealing with refractory strictures.
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Affiliation(s)
| | - Neil N. Chheda
- Department of Otolaryngology, University of Florida, Gainesville, Florida
| | - Peter T. Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, Florida
- University of Florida Health Cancer Center, Gainesville, Florida
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Clinical outcomes following pharyngolaryngectomy reconstruction: a 20-year single-centre study. The Journal of Laryngology & Otology 2022; 136:1105-1112. [DOI: 10.1017/s0022215122000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Advanced malignant neoplasms of the larynx and hypopharynx pose many therapeutic challenges. Total pharyngolaryngectomy and total laryngectomy provide an opportunity to cure these tumours but are associated with significant morbidity. Reconstruction of the pharyngeal defect following total pharyngolaryngectomy demands careful consideration and remains an area of debate within surgical discussions.
Methods
This paper describes a systemic analysis of pharyngeal reconstruction following total pharyngolaryngectomy and total laryngectomy, leveraging data collected over a 20-year period at a large tertiary referral centre.
Results
Analysing 155 patients, the results show that circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. In addition, free tissue transfer in larger pharyngeal defects showed lower rates of post-operative anastomosis leak and stricture.
Conclusion
Pharyngeal resection carries a substantial risk of post-operative complications, and free tissue transfer appears to be an effective means of reconstruction for circumferential defects.
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Bacterial colonization of Montgomery salivary bypass tubes after hypopharyngeal reconstruction in head and neck cancer patients. Eur Arch Otorhinolaryngol 2019; 277:1149-1154. [PMID: 31848731 PMCID: PMC7072055 DOI: 10.1007/s00405-019-05768-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/09/2019] [Indexed: 12/24/2022]
Abstract
Background Hypopharyngeal reconstruction after salvage pharyngolaryngectomy results in high postoperative morbidity. The use of salivary bypass tubes can reduce pharyngocutaneous fistula (PCF) formation. The influence of bacterial colonization has not been described in literature. Methods Bacterial swipes from 26 consecutive patients reconstructed after laryngopharyngectomy in combination with Montgomery salivary bypass tubes (MSBT) were analyzed in regards to PCF formation. Results PCF occurred in 2 untreated primary and in 9 salvage laryngopharyngectomies, respectively. Bacterial colonization showed high rates of gram-negative pathogens and drug resistance to standard Ampicillin treatment. Type of bacteria was not associated with fistula formation. Antibiotic resistance was found in 6 out 11 patients (54%) with PCF. Conclusions We identified high rates of antibiotic-resistant Gram-negative pathogens on MSBT. Although not statistically significant, PCF were found more frequently in drug-resistant patients. Bacterial colonization of hypopharyngeal reconstructions should therefore be taken into account for perioperative prophylaxis.
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Oh TS, Kwon JG, Jeong WS, Nam SY, Choi SH, Choi JW. A flag-shaped anterolateral thigh free flap for complete circumferential hypopharyngeal reconstruction with dead space obliteration and monitoring flap inset. J Plast Reconstr Aesthet Surg 2019; 72:1785-1794. [DOI: 10.1016/j.bjps.2019.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 02/08/2023]
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Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study. Eur Arch Otorhinolaryngol 2019; 276:2577-2584. [PMID: 31240457 DOI: 10.1007/s00405-019-05526-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP. METHODS We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital. RESULTS For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively. CONCLUSIONS Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.
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Koh HK, Tan NC, Tan BK, Ooi ASH. Comparison of Outcomes of Fasciocutaneous Free Flaps and Jejunal Free Flaps in Pharyngolaryngoesophageal Reconstruction. Ann Plast Surg 2019; 82:646-652. [DOI: 10.1097/sap.0000000000001776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Outcomes of Gastro-omental Free Flap Reconstruction for Salvage Laryngopharyngectomy for Pharyngeal and Laryngeal Cancer After Concurrent Chemoradiotherapy. Ann Plast Surg 2017; 79:e20-e24. [DOI: 10.1097/sap.0000000000000298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Piazza C, Bon FD, Paderno A, Grammatica A, Montalto N, Taglietti V, Nicolai P. Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects. Laryngoscope 2017; 127:2731-2737. [PMID: 28573675 DOI: 10.1002/lary.26705] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/06/2017] [Accepted: 04/27/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVES/HYPOTHESIS Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies. STUDY DESIGN Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies. METHODS Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT. RESULTS In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate. CONCLUSIONS First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2731-2737, 2017.
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Affiliation(s)
- Cesare Piazza
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Francesca Del Bon
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Alberto Paderno
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Alberto Grammatica
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Nausica Montalto
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Valentina Taglietti
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, Brescia, Italy
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Scaglioni MF, Lin TS, Chen YC, Tsai YT, Yang CH, Wu CC, Kuo PJ, Hsieh CH, Yang JCS. The free inverted omega-shaped flap for circumferential hypopharyngeal reconstruction with simultaneous neck skin defect. Microsurgery 2016; 38:51-59. [PMID: 27062074 DOI: 10.1002/micr.30056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem. METHODS From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy. RESULTS The average flap size was 29 × 8 cm (range: 25-31 × 6-10 cm2 ). An average of 2.6 perforators was included in each flap (2-4 perforators/flap). All flaps survived. One venous thrombosis was noted and salvaged after thrombolectomy and vein graft. The mean follow-up period was 25 months. The fistula rate was 21.4% (three patients). One fistula never healed because of early recurrence; one fistula healed after surgical intervention; and one fistula need a loco-regional flap for secondary reconstruction. Three postoperative strictures were noted (21.4%). CONCLUSION For the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:51-59, 2018.
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Affiliation(s)
- Mario F Scaglioni
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsan-Shiun Lin
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yun-Ta Tsai
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hsiang Yang
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Chung Wu
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Johnson Chia-Shen Yang
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Modification of the anterolateral thigh free flap design for reconstruction after laryngo-pharyngoesophagectomy. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016. [DOI: 10.1007/s00238-015-1074-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Farhadieh RD, Morrison WA. Pharyngeal reconstruction. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Choice of flap affects fistula rate after salvage laryngopharyngectomy. Sci Rep 2015; 5:9180. [PMID: 25776941 PMCID: PMC4361877 DOI: 10.1038/srep09180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/19/2015] [Indexed: 11/13/2022] Open
Abstract
Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.
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Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2013; 20:17-23. [PMID: 23598761 DOI: 10.1177/229255031202000103] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The anterolateral thigh (ALT) flap is widely used in reconstruction. Its advantage over other flaps is its purported minimal donor site morbidity. The present systematic review summarizes the types of complications and their incidence with this flap. A secondary objective is to delineate factors that influence these complications and make recommendations to avoid them. METHOD Two independent assessors undertook a systematic review of the literature using multiple databases. All patients with ALT flap reconstruction for any defect were included. Donor site complications including lateral thigh paresthesia, musculoskeletal dysfunction, hypertrophic scarring, wound breakdown, infection, donor site pain, seroma, hematoma, compartment syndrome and muscle necrosis were extracted from identified articles and tabulated. Based on the number of pooled events and the number of cases performed, an incidence rate was calculated. RESULTS Forty-two relevant articles were identified that included 2324 flaps. Of the 2324 flaps, the majority were fasciocutaneous (n=737), and 1303 of the flaps were used in head and neck reconstruction. The incidence of complications were: lateral thigh paresthesia (24.0%); musculoskeletal dysfunction (4.8%); hypertrophic scarring or wound dehiscence (4.8%); donor site pain (3.3%); seroma (2.4%); infection (2.2%); hematoma (0.7%); compartment syndrome (0.09%); and partial muscle necrosis (0.09%). CONCLUSION Lateral thigh paresthesia is the most common complication. Severe complications such as compartment syndrome and muscle necrosis can occur, but are rare. Preservation of the lateral cutaneous nerve of the thigh, femoral motor nerve branches and deep fascia decreases the risk of complications. The degree of vastus lateralis disruption did not show a significant impact on musculoskeletal dysfunction.
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Affiliation(s)
- Jessica Collins
- Department of Surgery, Division of Plastic and Reconstructive Surgery
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Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy. PLoS One 2013; 8:e53985. [PMID: 23320112 PMCID: PMC3540016 DOI: 10.1371/journal.pone.0053985] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 12/05/2012] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma. MATERIALS/METHODS A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated. RESULTS 33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively). CONCLUSION Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.
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López F, Obeso S, Camporro D, Fueyo A, Suárez C, Llorente JL. Outcomes following pharyngolaryngectomy with fasciocutaneous free flap reconstruction and salivary bypass tube. Laryngoscope 2012; 123:591-6. [PMID: 22951963 DOI: 10.1002/lary.23695] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Reconstruction of the pharyngoesophageal defects is one of the most challenging for head and neck surgeons. We evaluated our experience in the hypopharyngeal reconstruction using a fasciocutaneous free flap in conjunction with a Montgomery salivary bypass tube (MSBT). STUDY DESIGN Retrospective review. METHODS The charts of 55 patients who had undergone hypopharynx reconstruction using either a radial forearm free flap (RFFF) (24) or an anterolateral thigh (ALT) flap (31) with MSBT were reviewed. There were 40 circumferential and 15 near-circumferential defects. Outcomes analyzed included fistula and stricture rates and swallowing function. RESULTS Pharyngocutaneous fistula occurred in 9% of patients (16% using RFFF and 3% using ALT), and strictures occurred in 5% (8% using RFFF and 3% using ALT). Of patients reconstructed with this technique, 95% were able to resume oral alimentation. CONCLUSIONS The use of fasciocutaneous free flaps in conjunction with the MSBT is a useful tool for pharyngoesophageal reconstruction.
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Affiliation(s)
- Fernando López
- Department of Otorhinolaryngology and Head and Neck Surgery, Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Asturias, Spain.
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Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy. Curr Opin Otolaryngol Head Neck Surg 2012; 20:77-88. [PMID: 22327791 DOI: 10.1097/moo.0b013e328350a5cc] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW The present review is focused on the main reconstructive options currently used after partial or circumferential resection of the hypopharynx and cervical esophagus. The advantages and disadvantages of pectoralis major myocutaneous (PMMC) pedicled flap, fasciocutaneous free flaps as radial forearm and anterolateral thigh (ALT), and visceral free grafts like jejunum and gastro-omental are overviewed. RECENT FINDINGS For partial hypopharyngeal defects with limited extension to the cervical esophagus, no specific pedicled or free flap is deemed superior over others: the patient's body habitus and surgeon's preference remain the most important factors affecting the reconstructive choice. In contrast, after circumferential hypopharyngectomy, pharyngocutaneous fistula (PCF) and stricture rates of PMMC are higher than those obtained by free flaps. In the most recent series applying ALT and jejunum, PCF and stricture occurrence is comparable, whereas reduced mortality, overall complication rate, and donor-site morbidity of ALT and its better swallowing and speech outcomes have contributed to make this option progressively more popular. On the other hand, gastro-omental seems to offer an unparalleled amount of highly vascularized tissue to manage the difficult situation of salvage surgery after chemoradiation, even though complication rates remain not negligible and this technique has not been widely adopted. SUMMARY The reconstructive armamentarium of head and neck surgeons involved in hypopharyngeal and cervical esophagus reconstruction should encompass every option described herein in order to appropriately deal with specific clinical needs and patient requirements. However, fasciocutaneous free flaps (especially ALT) seem to play an ever greater role in restoration of pharyngoesophageal continuity.
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Hussein ITM, Cheng E, Ganaie SS, Werle MJ, Sheema S, Haque A, Mir MA. Autophagic clearance of Sin Nombre hantavirus glycoprotein Gn promotes virus replication in cells. J Virol 2012; 86:7520-9. [PMID: 22553339 PMCID: PMC3416297 DOI: 10.1128/jvi.07204-11] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 04/24/2012] [Indexed: 11/20/2022] Open
Abstract
Hantavirus glycoprotein precursor (GPC) is posttranslationally cleaved into two glycoproteins, Gn and Gc. Cells transfected with plasmids expressing either GPC or both Gn and Gc revealed that Gn is posttranslationally degraded. Treatment of cells with the autophagy inhibitors 3-methyladenine, LY-294002, or Wortmanin rescued Gn degradation, suggesting that Gn is degraded by the host autophagy machinery. Confocal microscopic imaging showed that Gn is targeted to autophagosomes for degradation by an unknown mechanism. Examination of autophagy markers LC3-I and LC3-II demonstrated that both Gn expression and Sin Nombre hantavirus (SNV) infection induce autophagy in cells. To delineate whether induction of autophagy and clearance of Gn play a role in the virus replication cycle, we downregulated autophagy genes BCLN-1 and ATG7 using small interfering RNA (siRNA) and monitored virus replication over time. These studies revealed that inhibition of host autophagy machinery inhibits Sin Nombre virus replication in cells, suggesting that autophagic clearance of Gn is required for efficient virus replication. Our studies provide mechanistic insights into viral pathogenesis and reveal that SNV exploits the host autophagy machinery to decrease the intrinsic steady-state levels of an important viral component for efficient replication in host cells.
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Affiliation(s)
- Islam T M Hussein
- Department of Microbiology, Molecular Genetics and Immunology, University of Kansas Medical Center, Kansas City, KS, USA
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Chan JYW, Chow VLY, Chan RCL, Lau GISK. Oncological outcome after free jejunal flap reconstruction for carcinoma of the hypopharynx. Eur Arch Otorhinolaryngol 2011; 269:1827-32. [PMID: 22094906 PMCID: PMC3365236 DOI: 10.1007/s00405-011-1836-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/03/2011] [Indexed: 11/17/2022]
Abstract
It has been a common practice among the oncologist to reduce the dosage of adjuvant radiotherapy for patients after free jejunal flap reconstruction. The current aims to study potential risk of radiation to the visceral flap and the subsequent oncological outcome. Between 1996 and 2010, consecutive patients with carcinoma of the hypopharynx requiring laryngectomy, circumferential pharyngectomy and post-operative irradiation were recruited. Ninety-six patients were recruited. TNM tumor staging at presentation was: stage II (40.6%), stage III (34.4%) and stage IV (25.0%). Median follow-up period after surgery was 68 months. After tumor ablation, reconstruction was performed using free jejunal flap (60.4%), pectoralis major myocutaneous (PM) flap (31.3%) and free anterolateral thigh (ALT) flap (8.3%). All patients underwent adjuvant radiotherapy within 6.4 weeks after surgery. The mean total dose of radiation given to those receiving cutaneous and jejunal flap reconstruction was 62.2 Gy and 54.8 Gy, respectively. There was no secondary ischaemia or necrosis of the flaps after radiotherapy. The 5-year actuarial loco-regional tumor control for the cutaneous flap and jejunal flap group was: stage II (61 vs. 69%, p = 0.9), stage III (36 vs. 46%, p = 0.2) and stage IV (32 vs. 14%, p = 0.04), respectively. Reduction of radiation dosage in free jejunal group adversely affects the oncological control in stage IV hypopharyngeal carcinoma. In such circumstances, tubed cutaneous flaps are the preferred reconstructive option, so that full-dose radiotherapy can be given.
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Affiliation(s)
- Jimmy Yu Wai Chan
- Division of Head and Neck Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong Li Ka Shing Faculty of Medicine, 102 Pokfulam Road, Hong Kong SAR, China.
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Chan YW, Ng RWM, Liu LHL, Chung HP, Wei WI. Reconstruction of circumferential pharyngeal defects after tumour resection: reference or preference. J Plast Reconstr Aesthet Surg 2011; 64:1022-8. [PMID: 21481656 DOI: 10.1016/j.bjps.2011.03.021] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 02/18/2011] [Accepted: 03/03/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reconstruction of circumferential hypopharyngeal defects is often challenging. The aim of the study is to examine the result of our experience and to formulate improved management guidelines. METHOD Between 1980 and 2009, all patients who have circumferential pharyngectomy were recruited. Data were recorded prospectively for analysis. RESULTS A total of 202 patients were recruited. Majority had primary tumour in the hypopharynx (n=165), and the remaining patients had recurrent laryngeal carcinoma. Radiotherapy was given preoperatively in 72 patients and postoperatively in 108 patients. A pectoralis major (PM) flap was used in 92 (45.5%) patients, a free anterolateral thigh (ALT) flap in 24 (11.9%) patients and a free jejunal flap in 86 (42.6%) patients. Early fistula rate was 23.9% in the PM flap group, 12.5% in the ALT group and 4.6% in the jejunum group. Late anastomotic stricture rate was 27.2% in the PM flap group, 12.5% in the free ALT group and 2.3% in the jejunum group. Early fistula formation significantly increased the risk of subsequent anastomotic stricture (p=0.023). In patients with no stricture, 61.9% of them in the jejunal group were able to resume solid diet, compared with 35.8% and 38.1% in the PM and ALT groups. After PM flap harvesting, 34.8% of the chest wall defects could not be closed primarily, which were best repaired using the lateral thoracic flap. The donor-site morbidity of ALT and jejunal flap was low. CONCLUSION In suitable patients, free jejunal flap reconstruction of circumferential pharyngectomy defects achieves the best functional outcome with minimal donor-site morbidity.
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Affiliation(s)
- Yu Wai Chan
- Division of Head and Neck Surgery, Department of Surgery, University of Hong Kong Li Ka Shing Faculty of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China.
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Fujiwara T, Shih HS, Chen CC, Tay SKL, Jeng SF, Kuo YR. Interdigitation of the distal anastomosis between tubed fasciocutaneous flap and cervical esophagus for stricture prevention. Laryngoscope 2011; 121:289-93. [DOI: 10.1002/lary.21289] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2010] [Indexed: 11/10/2022]
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