The prognostic value of abnormal findings on radiographic swallowing studies after total laryngectomy

Videofluoroscopic swallowing study to detect pharyngeal leak after total (pharyngo-) laryngectomy: Retrospective assessment of a single-institution protocol

BACKGROUND

We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL).

METHODS

This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL.

RESULTS

Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases.

CONCLUSION

This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF.

Water soluble swallow for leak detection after total laryngectomy post radiotherapy

AIM

Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake.

MATERIAL AND METHODS

Retrospective study including patients undergoing STL between 2008 and 2021 at Guy's Hospital. WSS was routinely performed within 15 days post operation.

RESULTS

Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively.

CONCLUSION

Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient's quality of life.

Improved Early Detection Models of Pharyngocutaneous Fistula after Total Laryngectomy

Early detection of pharyngocutaneous fistula (PCF) after total laryngectomy (TL) could prevent severe complications such as major vessel rupture. We aimed to develop prediction models for detecting PCF in the early postoperative period. We retrospectively analyzed patients (N = 263) who received TL between 2004 and 2021. We collected clinical data for fever (>38.0 °C) and blood tests (WBC, CRP, albumin, Hb, neutrophils, lymphocytes) on postoperative days (POD) 3 and 7, and fistulography on POD 7. Clinical data were compared between fistula and no fistula groups, and significant factors were selected using machine learning. Using these clinical factors, we developed improved prediction models for PCF detection. Fistula occurred in 86 (32.7%) patients. Fever was significantly (p < 0.001) more common in the fistula group, and ratios (POD 7 to 3) of WBC, CRP, neutrophils, and neutrophils-to-lymphocytes (NLR) were significantly higher (all p ≤ 0.001) in the fistula group than in the no fistula group. Leakage on fistulography was more common in the fistula group (38.2%) than in the no fistula group (3.0%). The area under curve (AUC) of fistulography alone was 0.68, but predictive models using a combination of fistulography, WBC at POD 7, and neutrophil ratio (POD 7/POD 3) showed better diagnostic performance (AUC of 0.83). Our predictive models may detect PCF early and accurately, which could reduce fatal complications following PCF.

Assessing the Clinical Utility of the Early Postoperative Pharyngogram in Hypopharyngeal Surgery for Dysphagia

OBJECTIVES/HYPOTHESIS

To evaluate the clinical utility of postoperative contrast x-ray pharyngograms (XRP) for detecting pharyngoesophageal leaks following hypopharyngeal dysphagia surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records were reviewed of patients undergoing endoscopic (E-) or open (O-) Zenker's diverticulectomy (-ZD) with cricopharyngeal myotomy (-CPM) and CPM alone from 2008 to 2020 at one academic institution. Exclusion criteria were patients who were fed enterally or underwent repair of epiphrenic diverticula or O-CPM during laryngectomy. XRP clinical indication, impact on clinical care, and factors associated with use patterns were examined using descriptive statistics and logistic regression (LR).

RESULTS

Of 152 subjects, 52% underwent O-ZD, 30% O-CPM, 15% E-ZD, and 3% E-CPM. An XRP was ordered for 65% of subjects, mostly routinely (94%). Among the four clinically apparent leaks observed in this cohort, early postoperative XRP confirmed one. It did not identify any clinically silent leaks. In univariate LR, undergoing XRP was associated with increasing day of diet advancement (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.5-10.5) and hospital stay duration (OR 3.2, 95% CI 2.1-5.2), as well as surgeon specialty of otolaryngology compared to general surgery (OR 12.8, 95% CI 4.8-40.8) and procedure sub-type (O-CPM: OR 0.03, 95% CI 0.002-0.16). In multivariate LR, the following variables were significantly associated with XRP use: hospital stay (OR 1.7; 95% CI 1.1-3.0), otolaryngology (OR 105; 95% CI 15.4-2193), O-CPM (OR 0.03; 95% CI 0.002-0.16), and E-CPM (OR 0.04, 95% CI 0.002-0.60).

CONCLUSIONS

Prospective, multi-institutional studies are needed to confirm the low clinical utility we observed of early, postoperative XRP following hypopharyngeal surgery for dysphagia.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Pharyngocutaneous fistulas after total laryngectomy or pharyngolaryngectomy: Place of video-fluoroscopic swallowing study

BACKGROUND

Specify place of video-fluoroscopic swallowing study (VFS) in the decision of oral refeeding after total pharyngolaryngectomy.

METHODS

At postoperative day 7, a blue dye testing was performed. If negative, a VFS was performed looking for a blind fistula. If this exam was negative, oral refeeding was started, but if a blind fistula was observed, cervical compression bandage was performed.

RESULTS

In 186 patients, a VFS was performed for 142 patients with negative blue dye testing. It was negative for 98 patients (69%) and positive for 44 patients (31%) (blind fistula). Patients had a probability of 7.1% to have a secondary pharyngocutaneous fistula (PCF) if the VFS was negative, and 15.9% if it was positive. No risk factor for the development of a secondary PCF or a blind fistula emerged from our analysis.

CONCLUSION

VFS should be performed before any oral refeeding in all patients operated with a total pharyngolaryngectomy.

Preservation of organ function in head and neck cancer

Preservation of function is a crucial aspect for the evaluation of therapies applied in the field of head and neck cancer. However, preservation of anatomic structures cannot automatically be equated with preservation of function. Functional outcome becomes increasingly important particularly for the evaluation of alternative treatment options with equivalent oncological outcomes.AS A RESULT, PRESENT STUDIES TAKE INTO ACCOUNT THREE TOPIC AREAS WITH VARYING EMPHASIS: (1) the effects of cancer therapy on essential physiological functions, (2) additional therapy-induced side-effects and complications, and (3) health-related quality of life. The present article summarizes vital aspects of clinical research from recent years. Functional outcomes after surgical and non-surgical treatment approaches are presented according to tumor localization and staging criteria. Additional methodological aspects relating to data gathering and documentation as well as challenges in implementing the results in clinical practice are also discussed.

Determining between chyle leak and anastomotic leak after esophageal reconstruction: the utility of methylene blue dye

OBJECTIVES/HYPOTHESIS

Two common complications of esophagectomy and immediate reconstruction comprise thoracic duct injury leading to chyle leak and anastomotic leakage. These can delay optimized nutrition, speech, and swallowing rehabilitation, and thus are important to identify and treat accordingly. When either chyle leak or anastomotic leak are clinically suspected, differentiation between the two can be very difficult clinically. As both complications may result in an increase in drain output once oral intake has occurred, an effective, quick, and accurate tool is required to determine whether this increase in drain output is related to an anastomotic leak or with a increase activity in chyle production.

STUDY DESIGN

Retrospective descriptive study.

METHODS

Description of the use of oral methylene blue dye as a safe, simple, and quick clinical bedside test.

RESULTS

When ingested orally, an anastomotic leak will lead to blue dye staining the neck drain output immediately (within seconds to minutes). A chyle leak may also result in blue staining of the drain output; however, this is not an immediate phenomenon, and rather, based on the bioavailability of methylene blue this would take a minimum of 1 hour, and more likely up to 4 hours, as the dye is absorbed into mesenteric lymphatics and travels via the thoracic duct.

CONCLUSIONS

With no documented contraindications or side effects from its oral use (in the absence of hypersensitivity reactions), methylene blue is an inexpensive and freely available test in the postoperative setting of esophageal reconstruction.

[Pharyngocutaneous fistula as a complication after total laryngectomy--clinical study and literature review]

Pharyngocutaneous fistula is an important therapeutic problem. It occurs in approximately 20% of cases as a complication after total laryngectomy, performed due to the larynx and/or hypopharynx cancer. The process of fistulas' conservative treatment is very long and sometimes reconstructive surgery of the pharynx and esophagus is necessary. Clinically, it is desirable to isolate a group of patients with risk factors of this complication. Numerous pathologies implicated in fistula formation are mentioned in the literature: wound infection, radiotherapy prior to surgery, hypoalbuminaemia, concomitant general diseases, postoperative anemia, location of the cancer in larynx and many others.

OBJECTIVE

This paper analyzes the incidence and etiology of cutaneous fistulas after total laryngectomies as well as overall characterization of risk factors on the basis of the material collected by the Department of Otolaryngology Medical University of Warsaw between the years 2006-2011. Furthermore, an analysis of the literature on cutaneous fistula after total laryngectomy of the last 10 years was performed.

MATERIAL AND METHODS

A retrospective analysis of medical records of patients with laryngeal and hypopharyngeal cancer, treated with total laryngectomy was performed. 12 patients developed cutaneous fistula in the early postoperative period.

RESULTS

The mean time of appearance of fistula after total laryngectomy was 19.3 days. In most cases, conservative management was used to obtain fistulas' closure - after an average of 32.5 days. For two patients operative closure was needed. Microbiological study confirmed the infection in the region of the fistula in 10 patients. There were identified different pathogens, both aerobic and anaerobic bacteria and fungi. 3 patients with a fistula were preoperatively irradiated. The most common location of the cancer in this group was supraglottic area and piriform recessus (8/12 patients).

CONCLUSIONS

The pathogenesis of cutaneous fistula as a complication after total laryngectomy seems to be complex. The most significant risk factors for fistula formation are: radiotherapy, supraglottic location of the tumor, extension of the surgery to the pharynx and malnutrition of the patient. Postoperative wound infection favors the formation of fistulas and extends their healing time. It seems reasonable to plan the surgery with the reconstruction of the pharynx for patients with several risk factors of fistulas' onset.