Pharyngoesophageal Reconstruction with the Anterolateral Thigh Flap: A Clinical and Functional Outcomes Study

Edge De-epithelialization for Reducing Pharyngocutaneous Fistula in Patch Free Flap Reconstructions for Salvage Total Laryngectomy Defects: A Case-Control Study

BACKGROUND

The leakage of saliva through the deep neck region from a pharyngocutaneous fistula could cause devastating complications, including vascular ruptures leading to mortality. While a partial pharyngoesophageal defect is created after total laryngectomy, a patch pattern of hypopharyngeal reconstruction is required, for which a fasciocutaneous free flap is usually applied. If radiotherapy fails to cure pharyngeal cancer, salvage total laryngectomy (STL) is needed. However, postradiation tissues tend not to heal well, and the incidence of pharyngocutaneous fistula therefore increases. We proposed an edge-epithelialization method to address this problem and conducted a retrospective study for comparison.

METHODS

The inclusion criteria were patients with head and neck cancer who underwent total laryngectomy that immediately required patch free flap reconstruction at a single medical center (January 2012-December 2021). Receipt of presurgical radiotherapy, hospitalization duration, and the presence of postoperative complications were recorded.

RESULTS

The included patients were separated into two groups: Group A (edge de-epithelialization not adopted) (n = 79) and Group B (edge de-epithelialization adopted) (n = 51). Forty-four and twenty-two patients in Groups A and Group B, respectively, received preoperative radiotherapies and simultaneous STL and fasciocutaneous free flap reconstructions. The incidence of pharyngocutaneous fistula was significantly lower in Group B (p = 0.0145). This phenomenon was the same for patients who underwent preoperative radiotherapy only (p = 0.0470) but not for patients who did not receive preoperative radiotherapy (p = 0.2363).

CONCLUSIONS

Edge de-epithelialization is an effective method for reducing pharyngocutaneous fistula formation in patch free flap reconstructions after STLs.

Associations between hypopharyngeal defect closure and quality of life in long-term total laryngectomy survivors

BACKGROUND

Few studies have examined health-related quality of life (HRQOL) outcomes in long-term total laryngectomy survivors in relation to the type of hypopharyngeal defect.

METHODS

A cross-sectional study was performed in long-term total laryngectomy survivors, treated between 2000 and 2020. The primary outcome was HRQOL, assessed using the FACE-Q Head and Neck Cancer Module, in relation to the type of hypopharyngeal closure (primary closure, partial or circumferential reconstruction).

RESULTS

Seventy-nine survivors were included with a median follow-up of 92.1 months (IQR 75.6-140.2 months). Patients requiring partial hypopharyngeal reconstruction (n = 18) scored significantly worse than patients with primary closure (n = 51) on 4 of 13 FACE-Q domains: functional domains of eating (p = 0.03), speech (p = 0.05), and swallowing (p = 0.03), and the psychological domain of speaking-related distress (p = 0.02). No statistically significant differences were found between the circumferential hypopharyngeal defect reconstruction group (n = 10). Stricture occurrence was the only clinical factor associated with worse eating, speaking, swallowing, eating-related distress, and cancer worry in multivariable analyses.

CONCLUSION

Several functional and psychological domains were significantly worse following partial hypopharyngeal reconstruction than in patients who received primary closure. Efforts to reduce stricture rates to enhance reconstructive outcomes following total laryngectomy merit further research.

Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy

PURPOSE

Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy.

PATIENTS AND METHODS

Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects.

RESULTS

The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation.

CONCLUSIONS

Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.

Profunda Artery Perforator Flap Tongue Reconstruction: An Effective and Safe Alternative to the Anterolateral Thigh Flap

BACKGROUND

The anterolateral thigh (ALT) perforator flap is a workhorse flap for tongue reconstruction. The authors present an alternative option using the profunda artery perforator (PAP) flap for glossectomy reconstruction compared with the ALT flap.

METHODS

A retrospective review was conducted of 65 patients who underwent subtotal or total glossectomy reconstruction between 2016 and 2020 (46 ALT versus 19 PAP flaps). Flap volume was assessed using computed tomography scans at two different time points. Quality of life and functional outcomes were measured using the MD Anderson Symptom Inventory for Head and Neck Cancer.

RESULTS

Patients receiving a PAP flap had significantly lower body mass index compared with those receiving an ALT flap (22.7 ± 5.0 versus 25.8 ± 5.1; P = 0.014). Donor-site and recipient-site complications were similar, as was the mean flap volume 7 months after surgery (30.9% for ALT versus 28.1% for PAP; P = 0.93). Radiation and chemotherapy did not appear to have a significant effect on flap volume change over time. The most frequently reported high-severity items in MD Anderson Symptom Inventory for Head and Neck Cancer were swallowing/chewing and voice/speech for both cohorts. Patients who had reconstruction with a PAP flap had significantly better swallowing function ( P = 0.034).

CONCLUSIONS

Both the PAP and ALT flaps appear to be safe and effective choices for subtotal and total tongue reconstruction. The PAP flap can serve as an alternative donor site, especially in patients with low body mass index and thin lateral-thigh thickness undergoing reconstruction of extensive glossectomy defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of outcomes between circumferential and near-circumferential pharyngoesophageal reconstruction using anterolateral thigh flap

A leftover narrow strip of the posterior pharyngeal wall may form after laryngopharyngectomy, and whether to retain it during reconstruction remains debated owing to the differing views on the incidence of leakage and strictures. This study aimed to ascertain whether this remnant posterior pharyngeal wall is advantageous or disadvantageous to surgeons performing pharyngoesophageal reconstruction. We reviewed the data of patients with circumferential or near-circumferential pharyngoesophageal defects following oncological laryngopharyngectomy who underwent reconstructive surgery utilizing the anterolateral thigh flap. They were then categorized into two groups: circumferential and near-circumferential. Thereafter, their demographics, operative findings, and postoperative outcomes were compared. Forty patients (20 in each group) with an average age of 57.2 ± 6.7 years (range: 40-72) were enrolled in the study. All flaps except one survived. During a mean follow-up of 41.1 ± 24.6 (range: 6-95) months, the stricture rate was significantly lower in the near-circumferential group (one vs. nine [from 17 patients who had resumed oral intake postoperatively] patients in the near-circumferential and circumferential groups, respectively, p = 0.002). Oral intake was viable in all patients with near-circumferential defects but only in 11 patients with circumferential defects (p = 0.003). The near-circumferential group had fewer strictures and better tolerance of oral nutrition, supporting the incorporation of the residual posterior pharyngeal wall via near-circumferential reconstruction instead of discarding it to facilitate circumferential reconstruction.

Reconstruction of subtotal pharyngolaryngectomy using a fasciocutaneous free flap with cartilage graft: A case series of 17 patients

INTRODUCTION

Subcricoid-hemilaryngopharyngectomy (SCHLP) with a reconstruction using a fasciocutaneous free flap armed with cartilage graft (FFACG) aims to avoid permanent tracheostomy while still maintaining the laryngopharyngeal functions. The purpose of this study is to report the outcome of this surgical approach.

MATERIALS AND METHODS

Retrospective study including 17 men operated between 2001 and 2019. Specific survival rate included death caused by cancer or SCHLP complications. Complications, functional and oncological outcomes were evaluated retrospectively.

RESULTS

There were no locoregional recurrences. One patient died due to inhalation pneumonia 3 years after surgery. Tracheostomy was closed in 13 patients (76.5%). Mean decannulation time was at six [1-14] months after surgery.

CONCLUSION

SCHPL with FFACG could avoid total pharyngolaryngectomy with good oncologic results. However, tracheotomy is extended and deglutition recovery is long with high risk of aspirations. These complications justify that such surgery should be realized only on selected patients by experienced surgical teams. Expertise of the surgical team is critical.

Comparison of Functional Outcomes of Intestinal Flaps Vs Tubed Fasciocutaneous Flaps for Circumferential Pharyngoesophageal Defects-an Indian Perspective

Pharyngolaryngoesophageal (PLO) reconstruction is a complex and technically demanding procedure. The reconstructive surgeon's concerns include avoiding fistula and stricture formation, as well as restoring normal speech and swallowing. A retrospective observational study with circumferential pharyngo-laryngo-oesophagal defects with aims and objectives of evaluation and comparison of the long-term functional outcomes like speech and swallowing along with the complications of fistula and stricture in two groups of JFF and FC flaps from the data is collected from electronic medical records of Tata Memorial Hospital, Mumbai, from January 2011 to May 2020. A total of 67 patients (52 JFF and 15 fasciocutaneous flaps) were operated on in last 9 years in our institute. The difference in fistula rates and stricture rates between the two groups was not significant (p= 0.98 and 0.947). The difference in 100% oral diet between the two groups was significant (p= 0.019). The difference in speech rehabilitation between the two groups was significant (p= 0.024). The intestinal tubes and fasciocutaneous tubes have comparable outcomes with regard to fistula and stricture formation. Speech outcomes in the form of the ability to have functional speech and voice quality were significantly better with skin-lined tubes. Swallowing outcomes were much better with intestinal tubes, along with early oral alimentation.

The use of chimeric-superthin anterolateral thigh flap in reconstruction of laryngopharyngoesophagectomy defects of hypopharyngeal cancer

INTRODUCTION

Due to 3D defects after resection of hypopharyngeal cancers, free flaps have become as first option for reconstruction and the anterolateral thigh flap (ALT) has been chosen frequently for soft tissue defects. Chimerization of the skin island of the ALT is also possible which can result in reconstruction of multiple defects simultaneously and monitorization of buried flaps. However, ALT can be bulky in some patients. The superthin ALT is well established by some authors especially for extremities but there is no study about the use of this modification in pharyngoesophageal defects. We present our experience of using chimeric-superthin ALT for pharyngoesophageal reconstructions.

PATIENTS AND METHODS

Between 2019 and 2022, six patients (one female and five male) underwent hypopharyngeal tumor resection and experienced chimeric-superthin ALT flap reconstructions. Patients' ages were ranged between 53 and 71 (mean: 64) years old. The type of tumor was squamous cell carcinoma (SCC) for all patients. Three patients had total and three patients had 75% of pharyngoesophageal defects. Defect size was between 10 × 7 cm and 12 × 8.5 cm (mean: 87.08 cm2 ). All flaps were harvested as 5 mm thickness with two skin perforators. All flaps were divided into two individual skin islands as chimeric fashion. One of the skin islands was used for esophageal reconstruction and the other was used for both flap monitorization and tensionless closure of anterior neck skin.

RESULTS

Total flap size was between 18 × 9 cm and 21 × 11 cm (mean: 200 cm2 ). In two patients, anastomoses were performed to pectoral branch of thoracoacromial vessels. Neck vessels were chosen as recipient for remaining patients. Wound dehiscence occurred in two patients between the neck skin and monitor island and was re-sutured without any problems. There was no partial or total flap necrosis and all flaps survived. The follow up period was between 4 and 9 months (mean: 5.6). All patients had a successful functional outcome as swallowing.

CONCLUSION

The superthin-chimeric ALT flap is a useful option when classical ALT is bulky in defects of hypopharyngeal cancer.

Latissimus Dorsi and DIEP Flaps for Pharyngeal Reconstruction: A Novel Indication

Aims

Complex pharyngeal defects after tumor resection remain a challenging dilemma for reconstructive plastic surgeons. They often benefit from pedicled or free flaps reconstruction to maintain continuity of the aerodigestive tract and protect the great vessels. While pedicle pectoralis major myocutaneous flaps or supraclavicular flaps have been described, microvascular free flaps have largely replaced the use of pedicle flaps.

Materials and methods

We describe our experience with subtotal and total pharyngeal reconstruction utilizing tubed DIEP (n = 2) and latissimus dorsi free flaps (n = 2). All four patients were smokers and received prior radiation.

Results

All patients were able to resume a regular diet and did not suffer any recipient or donor site complications. There were no fistula or total flap losses.

Conclusion

In our experience, DIEP and latissimus dorsi free flaps can serve as a valid alternative to radial forearm, jejunal and anterolateral thigh flaps for pharyngeal reconstruction.

Pharyngeaoesophageal Reconstruction

Pharyngoesophageal reconstruction is one of the most challenging reconstructive dilemmas that demands extensive planning, meticulous surgical execution, and timely management of postoperative complications. The main goals of reconstruction are to protect critical blood vessels of the neck, to provide alimentary continuity, and to restore functions such as speech and swallowing. With the evolution of techniques, fasciocutaneous flaps have become the gold standard for most defects in this region. Major complications include anastomotic strictures and fistulae, but most patients can tolerate an oral diet and achieve fluent speech after rehabilitation with a tracheoesophageal puncture.

Neopharyngeal Stricture following Laryngectomy

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.

Is Supraclavicular Artery Island flap (SAI) a viable alternative to Free Tissue Transfer (FTT) in head and neck reconstruction? A systematic review and meta-analysis

PURPOSE

The aim of this study is to compare the outcomes of Supraclavicular Artery Island (SAI) Flap versus Free Tissue Transfer for head and neck reconstruction.

METHODS

We performed a systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database according to the PRISMA guidelines. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed.

RESULTS

Eight studies, reporting a total of 402 patients and same number of flaps, 165 of which underwent reconstruction using supraclavicular artery island flap and 237 reconstructed with free tissue transfer were identified. No statistically significant differences were observed regarding major complications, total flap necrosis, partial flap necrosis, post operative fistula formation, donor site dehiscence, recipient site dehiscence and total flap area.

CONCLUSION

Supraclavicular artery island flap and free tissue transfer seem to be comparable when used in head and neck reconstruction.

A modified tracheal transection approach for cervical esophageal lesion treatment: A report of 13 cases

Background

Surgical interventions for tumors in the cervical esophageal region are complicated and laryngeal function is frequently sacrificed. Therefore, we attempted the tracheal transection approach to resect the tumor while preserving laryngeal function.

Methods

Three patients with papillary thyroid cancer (PTC), six with cervical esophageal cancer (CEC), and four with CEC mixed with thoracic esophageal cancer (TEC) were enrolled. The esophagus was exposed after the trachea was transected between the second and third tracheal rings. CEC/TEC: Resection of the esophagus or/and a portion of the hypopharynx with acceptable safety margins and repair with free jejunum or tubular stomach. PTC: Suture the small esophageal incision immediately after removing the tumor. The tracheal dissection was repaired with interrupted sutures throughout the entire layer after the esophageal lesion was resected. The status of the recurrent laryngeal nerve (RLN) determined whether a tracheotomy was necessary.

Results

All 13 patients had effective esophageal lesion excision, with six of them requiring intraoperative tracheotomy. Postoperative complications included a tracheoesophageal fistula (one case, 7.7%), postoperative RLN paralysis (two cases, 15.4%), and aspiration (three cases, 23.1%). Except for two patients with distant metastases, there was no recurrence in the remaining patients after 5-92 months of follow-up.

Conclusion

The tracheal transection approach, as a new surgical technique, can retain laryngeal function while ensuring appropriate exposure and satisfactory surgical resection. Before surgery, the feasibility of this approach must be carefully assessed. The RLN should be protected during the procedure. The operation is both safe and effective, with a wide range of applications.

Reconstruction of hypopharyngeal defects with anterolateral thigh free flap: A single-center retrospective analysis

INTRODUCTION

Reconstruction of expanded hypopharyngeal defects following laryngo-hypopharyngectomy for surgical treatment of primary is still a challenge for head and neck surgeons. Tradiotionally, jejunal or radial forearm flaps are the common reconstructive choice. Recently, the anterolateral thigh (ALT) free flap has served for pharyngoesophageal reconstruction. The goal of this work is to describe a retrospective analysis about a five-year single-center experience in the reconstruction of post-operative hypopharyngeal defects with ALT free flap.

METHODS

A single-center retrospective study was performed, including patients treated for patients who underwent tumor surgery involving hypopharynx with ALT free flap reconstruction from 2015 to 2020. Exclusion criteria were paediatric (0-18 years) patients, and the absence of follow-up.

RESULTS

The study included 23 adult patients. The mean size of the flap was 90 cm² (range 60-130 cm²). The mean time required to harvest the antero-lateral tight flap was 70 min (range 35-120 min). The median age was 46.3 years (SD 15.81, range: 19-84 years), with a gender female prevalence (F = 48, M = 33). Mean follow-up was 77.7 months (min 4-max 361, SD 72.46). One patient (4.4 %) showed a hypopharyngeal stenosis.

CONCLUSION

ALT free flap represents a successful and versatile reconstructive option for hypopharyngeal defects extended to oropharynx and/or larynx following total laryngectomy with circumferential or partial hypopharyngectomy, regardless of the functional and aesthetic results, with minimal donor-site complication.

The Impact of Postoperative Radiotherapy on Dietary Function of Head and Neck Cancer Patients after Pharyngoesophageal Reconstruction with Free Jejunal Flap

This study investigated the impact of postoperative radiotherapy (PORT) on dietary function in patients who underwent pharyngoesophageal defect reconstruction using a free jejunal flap. A retrospective chart review of 36 patients who underwent circumferential pharyngoesophageal defect reconstruction using a free jejunal flap was performed. The European Organization for the Research and Treatment of Cancer head and neck cancer module questionnaire was used. Five items related to dietary function were selected and analyzed for changes in scores before and after PORT. Both the PORT and non-PORT groups showed improved dietary function before surgery, and no significant changes were noted at 3 and 12 months postoperatively. Repeated measures ANOVA showed that PORT had no significant impact on dietary function. In univariate analysis, no variable was a significant predictor of the score at 12 months, postoperatively. Previous radiotherapy and neck dissection had a close statistically significant relation. The multivariate analysis showed that neoadjuvant chemotherapy, previous radiotherapy, and neck dissection were significant predictors of the score at 12 months, postoperatively. PORT did not show a significant effect on the 12 months postoperative score. Free jejunal flap is an effective pharyngoesophageal defect reconstruction method that does not cause any dietary function disruption after PORT.

Comparison between anterolateral thigh free flap and jejunal flap for tissue reconstruction in patients underwent resection of pharyngoesophageal squamous cell carcinoma after radiotherapy failure: a retrospective study

BACKGROUND

Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with worsening tissue adhesion and necrosis after radiotherapy failure. However, the results of tissue reconstruction and postoperative complications of these two flaps are controversial. The purpose of this study was to compare outcomes between group ALT free flap and group JF in PESCC after radiotherapy failure.

METHODS

Intraoperative information and postoperative outcomes of patients with PESCC after radiotherapy failure who underwent ALT and JF reconstruction from January 2005 to December 2019 were compared and analyzed.

RESULTS

The defect size of ALT (Numbers, 34) and JF (Numbers, 31) was 36.19 ± 11.35 cm² and 35.58 ± 14.32 cm² (p = 0.884), respectively. ALT and JF showed no significant difference in operation time (p = 0.683) and blood loss (p = 0.198). For postoperative outcomes within 30 days both in recipient site and donor site including wound bleeding, wound dehiscence, wound infection, and pharyngocutaneous fistula, ALT free flap and JF showed similar results. Flap compromise (Numbers, 2 VS.3, p = 0.663), flap take backs (Numbers, 1 VS.1, p = 1.000), partial flap failures (Numbers, 4 VS.2, p = 0.674), and total flap failures (Numbers, 0 VS.0, p = 1.000) showed no difference between the two groups. In addition, no significance was found in hypoproteinemia between the two groups (Numbers, 4 VS.2, p = 0.674). ALT free flap was not statistically different from JF in the incidence of dysphagia at the postoperative 6 months (Numbers of liquid diet, 5VS.5; Numbers of partial tube feeding, 6VS.7; Numbers of total tube feeding, 3VS.1, p = 0.790) and 12 months (Numbers of liquid diet, 8VS.7; Numbers of partial tube feeding, 8VS.7; Numbers of total tube feeding, 5VS.5, p = 0.998). The cause of dysphagia not found to differ between the two groups both in postoperative 6 months (p = 0.814) and 12 months (p = 0.845).

CONCLUSION

Compared with JF, ALT free flap for PESCC patients after radiotherapy failure showed similar results in postoperative outcomes. ALT free flap may serve as a safe and feasible alternative for PESCC patients after radiotherapy failure.

Effects of perioperative radiation treatment on stricture and fistula formation in hypopharyngeal reconstruction: a meta-analysis

Hypopharyngeal reconstruction is a surgically challenging procedure, and postoperative management is important due to a high rate of complications following surgery. In particular, stricture and fistula formation is the most common long-term postoperative complication. Through systematic review and meta-analysis of 21 studies, a significant radiation effect of stricture and fistula formation was found in patients who underwent hypopharyngeal reconstruction. The perioperative radiation must be seen as a critical factor for stricture and fistula formation in hypopharyngeal reconstruction.

The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes

BACKGROUND

There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects.

METHODS

A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates.

RESULTS

Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013).

CONCLUSIONS

The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.

Noncontrast Magnetic Resonance Imaging of Perforators for Preoperative Evaluation of Anterolateral Thigh Flaps

The anterolateral thigh (ALT) flap is a commonly utilized perforator-based flap in reconstructive surgery. Although previous studies have used various angiographic techniques to preoperatively image ALT perforators, none have investigated the efficacy of noncontrast magnetic resonance imaging (MRI). Our study investigates the efficacy of our institutional fat suppression noncontrast MRI sequence to characterize the number, location, and course of dominant skin perforators in the ALT for preoperative planning.

Externally Monitored Versus Conventional Buried Flaps in Laryngopharyngeal Reconstruction

Objectives

To compare the surgical outcomes of externally monitored and conventional buried flaps with the goal of determining the usefulness of external monitoring of buried flaps.

Methods

In this case-control study with propensity score matching, 30 patients were evenly divided into externally monitored buried flap and conventional buried flap groups. The total operative time for free flap reconstruction, the flap survival rate, the length of hospital stay, the initial time of a reliable visual assessment, complications, the final diet achieved, and the duration until diet initiation were compared between the groups.

Results

The mean operative time for reconstruction was 115 minutes (interquartile range, 85–150 minutes) and 142 minutes (interquartile range, 95–180 minutes) in the externally monitored and conventional groups, respectively (P= 0.245). The median length of hospital stay was 24 days (interquartile range, 18–30 days) and 27 days (interquartile range, 20–41 days) in the externally monitored and conventional groups, respectively (P=0.298). The median duration until diet initiation was 15 days (interquartile range, 15–21 days) and 18 days (interquartile range, 15–34 days) in the externally monitored and conventional groups, respectively (P=0.466). The final diet, initial time of a reliable visual assessment, and complications were comparable between the groups, but the external skin paddle provided an excellent visual assessment immediately postoperatively in all cases.

Conclusion

The outcomes were comparable between the groups, indicating that externalization of the cutaneous component of a buried flap may be a straightforward and useful technique for monitoring a buried anterolateral thigh free flap in laryngopharyngeal reconstructions. The salvage and false-positive rates of compromised flaps should be compared in large subject groups in future studies to prove that the use of an external skin paddle improves flap monitoring.

Bacterial colonization of Montgomery salivary bypass tubes after hypopharyngeal reconstruction in head and neck cancer patients

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.

Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study

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.

Intraoperative Fluorescent Angiography Predicts Pharyngocutaneous Fistula After Salvage Laryngectomy

BACKGROUND

Technology to assess tissue perfusion is exciting with translational potential, although data supporting its clinical applications have been lagging. Patients who have undergone radiation are at particular risk of poor tissue perfusion and would benefit from this expanding technology. We designed a prospective clinical trial using intraoperative indocyanine green angiography to evaluate for wound-healing complications in patients undergoing salvage laryngectomy after radiation failure.

PATIENTS AND METHODS

This prospective trial included patients undergoing salvage laryngectomy at a National Cancer Institute-designated tertiary cancer center between 2016 and 2018. After tumor extirpation and prior to reconstruction, 10 mg indocyanine green dye was infused and the fluorescence (F_HYPO) and ingress rate of the pharyngeal mucosa recorded. The primary outcome measure was formation of a pharyngocutaneous fistula (PCF).

RESULTS

Patients who developed a PCF had significantly lower F_HYPO (87 vs 172, p < 0.001) and ingress rates (6.7 vs 15.8, p = 0.043) compared with those who did not develop a fistula. There were no fistulas in patients with F_HYPO > 150 (n = 21) or ingress > 15 (n = 15). There was a 50% fistula rate in patients with F_HYPO ≤ 103 (n = 10) and ingress rate ≤ 6 (n = 6).

CONCLUSIONS

Intraoperative indocyanine green angiography can assess hypoperfusion in patients and predict risk of PCFs after salvage laryngectomy, and can thus intraoperatively risk-stratify patients for postoperative wound-healing complications.

Chimeric vs composite flaps for mandible reconstruction

BACKGROUND

Composite mandibular reconstruction requires multiple tissue components inset in different planes. Intrinsic chimeric flap design provides this, and may be best suited for these reconstructions.

METHODS

A retrospective review of mandible reconstructions with composite, intrinsic chimeric, or 2 free flaps was performed. Patient and flap characteristics and complications were analyzed.

RESULTS

Seventy-five patients were reviewed. Defects reconstructed with intrinsic chimeric flaps had significantly more soft tissue needs than composite reconstructions. However, intrinsic chimeric bony defects were less complex. Despite significantly longer operative times for intrinsic chimeric flaps, there were no differences in complications or hospital stays. Intrinsic chimeric reconstruction resulted in significantly lower complication rates requiring an additional flap. This benefit was pronounced in through-and-through defects.

CONCLUSION

Intrinsic chimeric flaps are a better option than composite flaps for reconstruction of mandibular defects with large soft tissue needs with no increased complication risk despite longer operative time.

Hypothyroidism and Wound Healing After Salvage Laryngectomy

BACKGROUND

Patients undergoing salvage laryngectomy are predisposed to radiation-induced hypothyroidism and impaired wound healing secondary to the tissue effects of prior treatment. The impact of hypothyroidism on postoperative wound healing is not established.

METHODS

A single-institution retrospective case series was performed. The inclusion criteria specified preoperatively euthyroid adults who underwent salvage laryngectomy with concurrent neck dissection between 1997 and 2015 for persistent or recurrent laryngeal squamous cell carcinoma after radiation or chemoradiation therapy (n = 182). The principal explanatory variable was postoperative hypothyroidism, defined as thyroid-stimulating hormone (TSH) higher than 5.5 mIU/L. The primary end points of the study were pharyngocutaneous fistulas and wounds requiring reoperation. Multivariate analysis was performed.

RESULTS

The fistula rate was 47% among hypothyroid patients versus 23% among euthyroid patients. In the multivariate analysis, the patients who experienced hypothyroidism in the postoperative period had a 3.6-fold greater risk of fistula [95% confidence interval (CI) 1.8-7.1; p = 0.0002]. The hypothyroid patients had an 11.4-fold greater risk for a required reoperation (24.4 vs 5.4%) than the euthyroid patients (95% CI 2.6-49.9; p = 0.001). The risk for fistula (p = 0.003) and reoperation (p = 0.001) increased with increasing TSH. This corresponds to an approximate 12.5% incremental increase in the absolute risk for fistula and a 10% increase in the absolute risk for reoperation with each doubling of the TSH.

CONCLUSION

Postoperative hypothyroidism independently predicts postoperative wound-healing complications. The association of hypothyroidism with fistula formation may yield opportunities to modulate wound healing with thyroid supplementation or to provide a biomarker of wound progression.

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction

OBJECTIVES

Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain.

METHOD

We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods.

RESULTS

None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications.

CONCLUSIONS

The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction

Today's customary techniques for pharyngo-esophageal reconstruction are jejunum and radial forearm free flaps. In this type of reconstruction, the jejunum flap is considered as the reference, but when its harvesting is not possible, the radial forearm flap is used. Since perforator flaps have begun to be developed, the anterolateral thigh flap (ATF) has become increasingly prominent in pharyngo-esophageal reconstruction. The aim of our study was to describe the use of the anterolateral perforator flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks as regards oral feeding and esophageal speech.

A Simple Technical Modification for the Creation of an External Monitoring Skin Paddle for Tubed ALT Flap Reconstruction after Circumferential Hypopharyngeal Resection

Supplemental Digital Content is available in the text.

Optimizing Outcomes in Pharyngoesophageal Reconstruction and Neck Resurfacing: 10-Year Experience of 294 Cases

BACKGROUND

Pharyngoesophageal reconstruction is a complex endeavor that poses many challenges. This 10-year series examines factors impacting the need for neck skin resurfacing and evaluates the impact of reconstructive modalities on outcomes.

METHODS

A review identified 294 patients who underwent pharyngoesophageal reconstruction from 2002 to 2012. Patients were divided based on neck skin resurfacing requirements. Patients undergoing neck resurfacing were further subdivided into reconstructive technique, including a second skin paddle or muscle component from the same free flap pedicle, a local flap, or a second free flap. All groups were compared by comorbidities, complications, and functional outcomes.

RESULTS

Of 294 patients, 179 (60.9 percent) required neck skin resurfacing. In the resurfaced group, there were 90 circumferential defects (50.3 percent) and 89 partial defects (49.7 percent). In the resurfaced group, 110 (61.4 percent) underwent reconstruction with a second skin paddle from the same free flap pedicle, 21 (11.7 percent) underwent reconstruction with a muscle component from the same pedicle, and 25 (13.9 percent) received a pectoralis major flap. There were five external paddle flap losses in the resurfaced group (2.8 percent) and no internal flap losses. Overall complications were similar among groups. The resurfaced group had a lower pharyngocutaneous fistula rate (4.5 percent) compared with the primary closure group (11.3 percent) (p = 0.026). Prior neck surgery and radiation therapy were strong predictors of neck skin resurfacing (p < 0.001).

CONCLUSIONS

Neck resurfacing is often required in salvage pharyngoesophageal reconstruction. Providing additional vascularized tissue over the neoconduit is predictive of lower pharyngocutaneous fistula rates. An algorithmic approach to neck resurfacing is presented.

Mount Sinai Medical Center and Their Experience with Unfavorable Microsurgical Head and Neck Reconstruction

Radiation effects on tissues greatly complicate reconstruction of head and neck defects. We discuss the unfavorable surgical conditions set up by prior surgery and radiation in patients undergoing salvage ablation of recurrent cancer. With the focus on vessel selection, flap donor site characteristics, and management of potential complications, we hope to highlight some of the lessons learned from these complex cases. Special attention is given to the topic of laryngopharyngeal reconstruction.

Chimeric Anterolateral Thigh Flap for Total Thoracic Esophageal Reconstruction

Gastric pull-up is generally the first choice for a total thoracic esophageal reconstruction. Malfunction of this gastric conduit is uncommon, but devastating when it occurs: it causes marked comorbidity to the patient, preventing oral intake and worsening quality of life. Secondary salvage thoracic esophageal reconstruction surgery is usually performed with free or pedicled jejunum flaps or colon interposition. We present a case of a total thoracic esophageal reconstruction with an externally monitored chimeric anterolateral thigh flap, extending from the cervical esophagus to the retrosternal gastroplasty remnant. Intestinal reconstructive techniques were not an available option for this patient.

Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap

Objective

Chimeric anterolateral thigh free flaps are composed of multiple skin paddles or muscular components that allow for the reconstruction of complex 3-dimensional defects. We present our experience with the technique and applications for various head and neck defects.

Study Design

Retrospective chart review.

Setting

Academic tertiary care center.

Subjects and Methods

Subjects include 24 consecutive patients undergoing reconstruction with a chimeric anterolateral thigh free flap by a single surgeon. Our algorithm for pharyngeal reconstruction with this technique is described. Data include demographics, indications, comorbidities, operative findings, and surgical outcomes.

Results

The most frequent defects were pharyngocutaneous (n = 12, 50%) and skull base (n = 6, 25%). The flap consisted of a double skin paddle in 11 cases (45.3%) and a skin paddle with an independent component of vastus lateralis muscle in 13 cases (54.7%). Revision surgery was required in 4 cases and was associated with malnutrition ( P = .022). There were no total flap losses, but partial loss (distal skin paddle in all the cases) was observed in 3 patients and was related to severe congestive heart failure ( P = .021) and malnutrition ( P = .021). All except 1 patient who underwent pharyngeal reconstruction resumed oral diet and achieved alaryngeal speech.

Conclusion

Chimeric anterolateral thigh free flaps represent an excellent option for reconstruction of complex head and neck defects. Modifications to the technique are proposed in patients at high risk of surgical complications.

A new option with the pedicle thoracoacromial artery perforator flap for hypopharyngeal reconstructions

OBJECTIVES/HYPOTHESIS

The reconstruction of hypopharyngeal defects should focus on minimizing morbidity in a high-risk population while achieving adequate functional results with regard to the restoration of speech, swallowing, and airway control. We introduce the clinical application of the thoracoacromial artery perforator (TAAP) flap as a new reconstructive option for hypopharyngeal defects.

METHODS

This method was used to restore oncologic hypopharyngeal defects in nine patients: three who had previous irradiation and surgery, one who had previous surgery only, and another who had previous radiotherapy only.

RESULTS

All of the TAAP flaps of our series were transferred successfully and survived entirely. The donor sites were closed primarily in all cases. No fistulas, stenosis/strictures, dehiscence, or swelling occurred. Pectoralis major muscle function was completely preserved in all patients.

CONCLUSIONS

The use of TAAP flap to reconstruct hypopharyngeal defect is a simple and effective method that does not require microsurgical skills. The flap is thin and pliable, with a reliable blood supply.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1315-1320, 2016.

Choice of flap affects fistula rate after salvage laryngopharyngectomy

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.

Comprehensive analysis of functional outcomes and survival after microvascular reconstruction of glossectomy defects

BACKGROUND

Few studies on tongue reconstruction provide a comprehensive, multidisciplinary analysis examining defect size, flap selection, function, and long-term survival. This report presents the largest study in the literature evaluating free flap reconstruction after glossectomy.

METHODS

A retrospective review of patients undergoing free flap glossectomy reconstruction from 2000 to 2012 was performed.

RESULTS

In this review, 268 patients were identified. Resections involving the tongue only included 59 partial glossectomies, 86 hemiglossectomies, 28 subtotal glossectomies, and 24 total glossectomies. Glossectomies performed with mandibulectomies were analyzed independently for speech and swallowing function (32 partial glossectomies, 18 hemiglossectomies, 8 subtotal glossectomies, and 13 total glossectomies with mandibulectomy). A total of 299 free flaps were performed, with 30 patients receiving two free flaps. Multivariate analysis demonstrating smoking (p = 0.018), composite resections (p < 0.001), and larger resections (total and subtotal glossectomies; p < 0.001) were associated with significantly worse speech results. Advanced age (p = 0.002), radiation (p = 0.003), and larger or composite resections had significantly worse swallowing function (p < 0.001). Patients with a persistent tracheostomy had significantly worse speech and swallowing function (p < 0.001), whereas innervated flaps were associated with superior speech (p = 0.049) and better swallowing function (p = 0.004). The surgical complication rate was 23.5 %, with only one total flap loss. Tumor stage (p = 0.003), positive margins (p < 0.001), lymphovascular invasion (p = 0.023), and chemotherapy (p < 0.001) were associated with significantly worse overall survival. The median overall survival time was 50.5 months (range 39-79 months).

CONCLUSIONS

Although comorbidities and the extent of resection impair both speech and swallowing, reconstruction, particularly with innervated free flaps, still affords the majority of patients' reasonable function.

When the Gastrointestinal Conduit for Total Esophageal Reconstruction Is Not an Option: Review of the Role of Skin Flaps and Report of Salvage With a Single-Stage Tubed Anterolateral Thigh Flap

This review adds to the limited body of literature describing the use of skin flaps for reconstruction of the esophagus and includes a report of a successful 1-stage, intrathoracic reconstruction of the cervical and thoracic esophagus after failed gastrointestinal conduit. Already widely used for reconstruction of the pharynx and cervical esophagus, the versatile anterolateral thigh flap can be considered an option for more extensive defects of the cervical and thoracic esophagus in this challenging patient population when gastric, jejunal, or colon conduits are not available. The authors believe the anterolateral thigh flap should be considered in 1-stage anatomic reconstruction of the cervical and thoracic esophagus in the absence of feasible gastrointestinal conduits.