Periprosthetic Leakage in Tracheoesophageal Prosthesis: Proposal of a Standardized Therapeutic Algorithm

Benefit from regular versus leakage-related exchange of voice prostheses in patients post-laryngectomy considering complication rates and patient satisfaction feedback-a randomized case-controlled trial

Objective

The complications related to voice prosthesis usage substantially affect the physical and social functioning of patients after total laryngectomy, which influences their quality of life. Leakage dysfunction is the most common, causing uncertainty and requiring unscheduled hospital visits. Our study was designed to estimate the benefit of regular versus leakage-related replacement of the voice prosthesis. Study Design. Randomized case-controlled trials. Setting. Tertiary hospital.

Methods

The study included patients who underwent total laryngectomy with primary voice prosthesis insertion between 2020 and 2021 and were randomly assigned to one of two arms: regular exchange (REA) every 3 months or leakage-dependent exchange (LEA). The control treatment was continued for 12 months. The primary outcome measure was the comparison of complication rates in both arms, including periprosthetic leakage, granulation or atrophy of mucosa around the fistula, and dislocation of the prosthesis. The secondary outcome measures were the mean number of exchanges per year and patient satisfaction.

Results

Thirty-six patients continued the study according to the protocol, with 16 in REA and 20 in LEA. A total of 153 voice prostheses were replaced during the study period, including 98 in REA and 55 in LEA. Comparative analysis of REA and LEA revealed a significantly longer time between replacements in the LEA group (p = 0.023) and a significantly lower rate of complications in the REA group (p = 0.029). Periprosthetic leakage was the most common complication associated with the use of voice prostheses, occurring in 3.06% of patients in REA and 9.09% in LEA, but this difference was statistically insignificant (p = 0.137). The analysis of factors predisposing patients to leakage failure revealed that treatment schemes, concomitant diseases, dental conditions, and diet or alcohol consumption significantly affect the longevity of voice prostheses. The relative and absolute risks (RRR and ARR) of complications in the REA group were reduced by 69.39% and 13.88%, respectively. The number of replacements (NNTs) that should be performed in the REA scheme to prevent one complication over the LEA scheme is 721.

Conclusion

The replacement of regular voice prostheses improved the overall complication rate over the scheme based on leakage demand; however, it did not yield superior benefits in terms of patient satisfaction or economic aspects.

Clinical Trial Registration

https://clinicaltrials.gov/study/NCT04268459, identifier NCT04268459.

[Methods of Voice Restoration following Laryngectomy]

In Germany, approximately 950-1200 laryngectomies are performed annually due to extensive hypopharyngeal and laryngeal carcinomas. The removal of the larynx results in significant life changing functional losses, particularly in voice production and communication, resulting in psychological issues and social withdrawal. Rehabilitation requires a multidisciplinary team focusing on restoring communication skills. Methods include pseudowhispering, esophageal speech, external mechanical and electromechanical aids, and tracheoesophageal speech prostheses. Pseudowhispering uses air from the mouth and pharynx, while esophageal speech requires controlled release of esophageal air to produce sound. External aids include devices like the Electrolarynx. Tracheoesophageal speech prostheses, the current gold standard, offer superior phonation time and clarity but require frequent visits to the healthcare system to address complications due to the limited lifespan of the prosthesis. Despite high success rates with transoesophageal prostheses, some patients may face significant challenges. In conclusion, voice rehabilitation post-laryngectomy is crucial for social reintegration. Comprehensive patient education on the benefits and challenges of different methods is essential for making an informed decision tailored to their lifestyle.

A Multidisciplinary Approach to Secondary Tracheoesophageal Puncture for Voice Prosthesis Insertion Using Flexible Esophagoscopy

BACKGROUND

Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP.

METHODS

Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications.

RESULTS

We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks.

CONCLUSION

Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

A custom device for managing recurrent tracheoesophageal voice prosthesis dislodgement and aspiration due to treatment refractory, severely enlarged puncture: A video case report

We report the case of a laryngectomized patient with an enlarged tracheoesophageal puncture (TEP) that is refractory to standard treatments and culminating in life-threatening recurrent dislodgement and aspiration of custom fabricated dual extra-large flange voice prostheses (VP). The fabrication and use of a novel intraluminal prosthetic device to prevent dislodgement, lessen aspiration, and preserve TE voice is described. A custom device insetting a commercial VP into the posterior wall of a LaryTube (coined "inset-VP") was devised with the primary goal of eliminating chronic VP dislodgement and lessening aspiration while maintaining TE voice. Tools required to fabricate the device included a commercial laryngectomy tube, standard-flanged commercial indwelling voice prosthesis, felt-tip marker, 6 mm biopsy punch, and silk suture. After 7 months of using an inset-VP LaryTube device, the patient has experienced zero episodes of VP aspiration. Thin liquid aspiration control is equivalent or better than prior management with custom 24-30 mm dual collar prostheses. TEP voice is fluent and functional with device in place. Novel strategies are needed to manage the rare but devastating effects of a severely enlarged TEP. Solutions to manage symptoms need to be patient-specific, aligning with their anatomy, physiology, psychosocial needs, and goals. The inset-VP device described in this report may offer improved prosthetic retention in select patients with enlarged TE puncture and frequent VP dislodgements.

Prevention of periprosthetic leakage with double flange voice prosthesis: a systematic review and management protocol proposal

OBJECTIVE

To conduct a systematic review of the use and results of the Provox®VegaTMXtraSealTM in the prevention of periprosthetic leakage and to propose a management protocol for this voice prosthesis.

METHODS

Systematic search based on the PRISMA Statement during February 2020. Keywords were double flange, periprosthetic leakage, voice prosthesis, and laryngectomy.

RESULTS

Four articles with 315 voice prosthesis (94 XtraSeal and 221 controls) in 55 patients were found. The XtraSeal mean duration was 114.28 ± 73.2 (CI 95%, 98.29-130.26) days compared to 102.98 ± 17.74 (CI 95%, 100.62-105.35) days of the control group. Out of 266 replacements, endoprosthetic leakage was the most frequent cause in both groups (62.41%). Periprosthetic leaks were less frequent in the XtraSeal (9.62%) than in the control group (22.43%).

CONCLUSIONS

The XtraSeal could be effective in preventing periprosthetic leakage and lengthening the time between replacements. Studies with a robust methodology are necessary to confirm these results. Managing voice prosthesis is complex and requires a multidisciplinary and systematic approach by experienced professionals to reduce replacements and complications. Incorrect placement of the XtraSeal could cause a foreign body reaction and consequently inflammation, extrusion, or pressure lesions. The Tower of Hercules protocol: (1) Measurement of the tracheoesophageal fistula using the Provox® Measure, (2) Minimization of XtraSeal slack by avoiding the complete visualization of the prosthesis' blue ring, (3) Nasofibroscopic examination of the oesophageal wall confirming both flanges are in correct position; could prevent or minimize complications derived from the use of the XtraSeal.

The acceptance and voice quality of a new voice prosthesis 'Vega High performance' - a feasibility study

BACKGROUND

The Provox Vega High Performance (PVHP) is a newly developed voice prosthesis (VP) with an aim to achieve a longer and more predictable lifetime.

OBJECTIVES

This feasibility study aims to assess patient acceptance of the PVHP VP, evaluate adverse events, voice quality, and device lifetime.

METHODS

Laryngectomized patients previously using a Provox Vega or ActiValve Light were included. Acceptance and voice outcomes were evaluated at two-time points with a 2-week interval. Baseline measurements were taken with the standard VP, followed by placement of the PVHP for the 2-week assessment.

RESULTS

Fifteen participants completed the study, with thirteen being initial Vega-users. PVHP acceptance was 87% 2 weeks after placement. Median device lifetime for all VPs was 64 d (range 14-370). In the subgroup without periprosthetic leakage, the median device lifetime was 101 d (range 31-370). Acceptance dropped to 40% after device failure. Voice quality did not differ between PVHP and baseline VP. The most reported adverse event was PVHP valve stickiness (46%).

CONCLUSION AND SIGNIFICANCE

Acceptance of the PVHP is largely dependent on device lifetime, decreasing from 87% to 40% after leakage or replacement. Voice quality remains consistent across different VPs. Developing a long-lasting VP remains a challenge.

Fatal Tracheoesophageal Puncture Leakage Associated With Lenvatinib

Tracheoesophageal puncture (TEP) is a voice restorative option adopted by many head and neck cancer patients following laryngectomy. Though generally safe, TEP may develop leakage. Lenvatinib is a tyrosine kinase inhibitor (TKI) with anti-tumoral activity against head and neck malignancies.TKIs, including lenvatinib, have been associated with organ perforation or fistula formation. There remains a paucity of literature on the association between lenvatinib and TEP leakage. In this report, we described a patient with adenoid cystic carcinoma of the larynx who had a TEP. After approximately two weeks of treatment with lenvatinib, the patient developed a leakage of TEP. Despite several interventions, the patient died three months afterward due to a retropharyngeal abscess secondary to Fusobacterium nucleatum. To our knowledge, this is the first report of fatal lenvatinib-associated TEP leakage. Clinicians should be cognizant of a potentially rapid development of this complication when prescribing TKI for patients with TEP.

Cost-Effectiveness Study of Double-Flange Voice Prostheses in the Treatment of Periprosthetic Leakage in Laryngectomized Patients

BACKGROUND

Tracheoesophageal speech with a voice prosthesis is considered the rehabilitation treatment of choice in laryngectomized patients. The main reasons for prosthesis failure are endoprosthetic leakage and periprosthetic leakage. The Provox XtraSeal^® stent incorporates an additional double flange on the esophageal side to prevent periprosthetic leakage. The objective of this study is to compare the duration and costs of the Provox Vega^® and Provox XtraSeal^® prostheses used in these patients in a tertiary university hospital.

MATERIALS AND METHODS

A prospective crossover case study of laryngectomees with Provox Vega^® who underwent Provox XtraSeal^® placement due to recurrent periprosthetic leaks and decreased theoretical prosthesis life. The duration and possible factors affecting voice prostheses were studied using Kaplan-Meier curves and Cox regression. A cost-effectiveness analysis was carried out from the perspective of the Spanish National Health System with an incremental cost-effectiveness calculation.

RESULTS

A total of 38 patients were recruited, 35 men and 3 women, with a mean age of 66.26 ± 9.36 years old. Information was collected from 551 voice prostheses, 484 Provox Vega^® and 68 Provox XtraSeal^®. The mean duration of Provox Vega^® was 119.75 ± 148.8 days and that of Provox XtraSeal^® was 181.99 ± 166.07 days (p = 0.002). The most frequent reason for replacement was endoprosthetic leakage in both groups: 283 (60.86%) in the case of Provox Vega^® and 29 (48.33%) in that of XtraSeal^® (p < 0.000). To obtain no cost differences (ICE ~ 0) between Provox Vega and Provox XtraSeal, the latter should cost EUR 551.63.

CONCLUSIONS

The Provox XtraSeal^® is a cost-effective option in patients with increased prosthesis replacements due to periprosthetic leakage, reducing the number of replacements, increasing the duration of the prosthesis, and providing savings compared to Provox Vega^®.

Rehabilitation After Total Laryngectomy: An Integrated Protocol Remotely Delivered During COVID-19

The aim of this paper was to evaluate the results of an integrated treatment delivered remotely to laryngectomized patients with voice prosthesis. Eighteen laryngectomized patients were treated remotely in groups co-led by a speech therapist and a psychologist ("Online Group"). The results were compared with those of 17 patients ("In-Person Group") previously studied. The two groups obtained comparable results on all parameters of the INFVo perceptual rating scale, in the DEP, ANX, PHO and HOS areas of the Symptom Check List-90-Revised questionnaire, and in the areas investigated by the WHOQOL-B questionnaire. The "In-Person Group" obtained statistically better results on the Italian Self-Evaluation of Communication Experiences after Laryngeal Cancer questionnaire. Although the in-person treatment favored the acceptance of the new voice and the development of conversational skills, telerehabilitation guaranteed an adequate level of assistance in terms of voice acquisition, prevention of anxiety and depression, and recovery of a good QoL.

Does Prophylactic Replacement of Voice Prosthesis Make Sense? A Study to Predict Prosthesis Lifetime

OBJECTIVE

Voice prosthesis leakage significantly affects the quality of life of patients undergoing laryngectomy, causing insecurity and frequent unplanned hospital visits and costs. In this study, the concept of prophylactic voice prosthesis replacement was explored to prevent leakages.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary hospital.

METHODS

This study included all patients who underwent laryngectomy between 2000 and 2012 in the Netherlands Cancer Institute. Device lifetimes and voice prosthesis replacements of a retrospective cohort were used to calculate the number of needed voice prostheses per patient per year to prevent 70% of the leakages by prophylactic replacement. Various strategies for the timing of prophylactic replacement were considered: adaptive strategies based on the individual patient's history of replacement and fixed strategies based on the results of patients with similar voice prosthesis or treatment characteristics.

RESULTS

Patients used a median 3.4 voice prostheses per year (range, 0.1-48.1). We found high inter- and intrapatient variability in device lifetime. When prophylactic replacement is applied, this would become a median 9.4 voice prostheses per year, which means replacement every 38 days, implying >6 additional voice prostheses per patient per year. The individual adaptive model showed that preventing 70% of the leakages was impossible for most patients and only a median 25% can be prevented. Monte-Carlo simulations showed that prophylactic replacement is not feasible due to the high coefficient of variation (SD/mean) in device lifetime.

CONCLUSION

Based on our simulations, prophylactic replacement of voice prostheses is not feasible due to high inter- and intrapatient variation in device lifetime.

Long-term outcomes and cost-effectiveness of a magnet-based valve voice prosthesis for endoprosthesis leakage treatment

PURPOSE

Tracheoesophageal speech is considered the gold standard for rehabilitation following total laryngectomy. The main reason of voice prosthesis failure is the endoprosthesis leakage. Provox ActiValve^® incorporates a magnet-based valve system to achieve active closure of the valve to treat these leakages, with the drawback of being significantly more expensive. The aim of the study was to compare the Provox Vega^® and Provox ActiValve^® duration and costs in patients with replacements increase due to endoprosthetic leakage.

METHODS

Prospective case-crossover study in laryngectomized patients with Provox Vega^® and endoprosthesis leakage to whom a Provox ActiValve^® was placed. Survival and possible factors that affect voice prosthesis were studied using Kaplan-Meier curves and Cox Proportional Hazards Regression. Cost-effectiveness analysis from the perspective of the Spanish Public National Health System with incremental cost-effectiveness calculation was performed.

RESULTS

A total of 159 prostheses were evaluated. The most frequent reason for replacement was the endoprosthesis leakage (N = 129; 83.77%) in both models. The mean duration-time of Provox Vega^® was 44.77 ± 2.82 days (CI 95%, 39.18-50.35; median 36 days), and 317.34 ± 116.8 days (CI 95% 86.66-548; median 286 days) for the Provox ActiValve^® (p < 0.000). For every replacement not made thanks to the Provox ActiValve^® there was saving of 133.97€ CONCLUSIONS: The Provox ActiValve^® is a cost-effective solution in patients with increased prosthesis replacements due to endoprosthetic leakage, reducing the number of changes and cost compared to Provox Vega^®.

Regenerative Strategy for Persistent Periprosthetic Leakage around Tracheoesophageal Puncture: Is It an Effective Long-Term Solution?

Autologous tissue-assisted regenerative procedures have been considered effective to close different types of fistula, including the leakage around tracheoesophageal puncture. The aim of this study was to retrospectively review 10 years of lipotransfer for persistent periprosthetic leakage in laryngectomized patients with voice prosthesis. Clinical records of patients who experienced periprosthetic leakage from December 2009 to December 2019 were reviewed. Patients receiving fat grafting were included. The leakage around the prosthesis was assessed with a methylene blue test. Twenty patients experiencing tracheoesophageal fistula enlargement were treated with fat grafting. At the one-month follow-up, all patients were considered improved with no leakage observed. At six months, a single injection was sufficient to solve 75% of cases (n 15), whereas 25% (n 5) required a second procedure. The overall success rate was 80% (n 16). Results remained stable for a follow-up of 5.54 ± 3.97 years. Fat grafting performed around the voice prosthesis, thanks to its volumetric and regenerative properties, is a valid and lasting option to solve persistent periprosthetic leakage.