Effect of transcervical arterial ligation on the severity of postoperative hemorrhage after transoral robotic surgery

Complications including dysphagia following transoral non-robotic surgery for pharyngeal and laryngeal squamous cell carcinoma: A retrospective multicenter study

OBJECTIVE

Transoral surgery is a minimally invasive treatment but may cause severe dysphagia at a lower rate than chemoradiotherapy.

METHODS

We compared clinical information, surgical complications, and swallowing function in patients who underwent transoral nonrobotic surgery for laryngo-pharyngeal squamous cell carcinoma between 2015 and 2021 in a multicenter retrospective study.

RESULTS

Six hundred and forty patients were included. Postoperative bleeding was observed in 20 cases (3.1%), and the risk factor was advanced T category. Postoperative laryngeal edema was observed in 13 cases (2.0%), and the risk factors were prior radiotherapy, advanced T stage, and concurrent neck dissection in patients with resected HPC. Dysphagia requiring nutritional support was observed in 29 cases (4.5%) at 1 month postoperatively and in 19 cases (3.0%) at 1 year postoperatively, respectively. The risk factors for long-term dysphagia were prior radiotherapy and advanced T category. Short-term risk factors for dysphagia were prior radiotherapy, advanced T category, and concurrent neck dissection, while long-term risk factors for dysphagia were only prior radiotherapy and advanced T category.

CONCLUSION

Prior radiotherapy, advanced T stage, and concurrent neck dissection increased the incidence of postoperative laryngeal edema and short-term dysphagia, but concurrent neck dissection did not affect long-term dysphagia. Such features should be considered when considering the indication for transoral surgery and postoperative management.

The influence of perioperative enoxaparin on bleeding after TORS oropharyngectomy

Perioperative enoxaparin is often avoided in patients undergoing transoral robotic (TORS) oropharyngectomy. Our goal was to quantify the risk of postoperative hemorrhage (POH) in patients receiving enoxaparin after TORS oropharyngectomy. This was a retrospective database cohort study set up in 89 separate healthcare organizations. The TriNetX electronic database was queried for patients with OPSCC who underwent TORS oropharyngectomy. Propensity-score matching was used to create two cohorts, one receiving and one not receiving perioperative enoxaparin. Outcome measures were the POH rate within 1 day of surgery ("primary") and POH rate within 2-30 days of surgery ("secondary"). 1109 patients undergoing TORS for OPSCC were identified, 400 of which received perioperative enoxaparin. One-to-one propensity score matching resulted in 310 patients per cohort. After matching, the primary POH rates between patients receiving and not receiving enoxaparin were 3.23% for both cohorts (OR 1.000, 95% CI 0.410 to 2.438). The secondary POH rates between those receiving and not receiving enoxaparin were 5.47% vs. 3.54% (OR 1.577, 95% CI 0.726 to 3.424). The number needed to harm (NNH) with perioperative enoxaparin use for secondary POH after TORS was 53; no difference was found in primary POH rates. While not statistically significant, the use of perioperative enoxaparin after TORS is associated with increased odds of secondary POH with a NNH of 53; no difference was found in rates of primary POH. For patients undergoing TORS, enoxaparin use requires careful weighing of the risks and benefits.

Oncological and functional outcomes for transoral robotic surgery following previous radiation treatment for upper aerodigestive tract head and neck cancers. A French multicenter GETTEC group study

BACKGROUND

Transoral robotic surgery (TORS) opens new perspectives. We evaluated the outcomes for patients having undergone TORS after previous radiotherapy.

METHODS

A retrospective multicenter study (n = 138) in a previously irradiated area between 2009 and 2020. Survival was assessed with the Kaplan-Meier method. Prognostic factors were evaluated using a chi-squared test, Fisher's test, or Wilcoxon's test.

RESULTS

The median length of hospital stay was 12.5 days. Bleeding was the most frequent postoperative complication (15.2%, n = 22). Prophylactic vessel ligation did not significantly decrease bleeding. Complications were significantly lower for Tis, T1, and N0 tumors. 91.6% (n = 120) of the patients with a perioperative tracheotomy could be decannulated. Larynx was functional for 65.94% of the patients. The median length of follow-up was 26 months. The 5-year overall and relapse-free survival rates were respectively 59.9% and 43.4%.

CONCLUSION

Oncological and functional results confirmed the value of TORS as a treatment in previously irradiated area.

Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery

Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.

Analysis of Otolaryngologic Readmissions at a High-Volume Quaternary Referral Center

OBJECTIVES

To identify common reasons for readmission following otolaryngologic surgery at a high-volume center and identify possible risk factors for readmission.

METHODS

Retrospective chart review of readmissions identified by hospital-based electronic medical record reporting mechanism.

RESULTS

From January 2019 to September 2020, there were 87 readmissions following 808 index surgeries. The most common reason for readmission was for planned surgery (23%), followed by post-operative neck infection, bleeding, or pneumonia. Patients with unplanned readmissions had significantly longer index admission duration than patients who were not readmitted (median 7 days vs. median 5 days, resp.; p = 0.0056). Analysis of cases of unplanned readmission for neck infection and bleeding identified the oral cavity/pharynx as the most common site of initial surgery and that a majority of patients had a history of radiation therapy.

CONCLUSION

Neck infection, bleeding, and pneumonia were the most common reasons for unplanned readmission following otolaryngologic surgery, and a large portion of patients required additional procedures during readmission. Unplanned readmissions for bleeding were significantly more costly than readmissions for neck infections. Long-index hospitalizations, index surgery involving the oral cavity and pharynx, and a history of radiation therapy may be useful clinical features that could stratify the risk of readmission.

LEVEL OF EVIDENCE

4, retrospective chart review Laryngoscope, 133:2546-2552, 2023.

Complications following salvage transoral robotic surgery with and without reconstruction: A systematic review of the literature

BACKGROUND

Transoral robotic surgery (TORS) has been used in the salvage setting for head and neck cancers both with and without reconstruction. The complications of salvage TORS and the effect of reconstruction on complications has not been studied.

OBJECTIVE

To study the complications of salvage TORS and examine the effect of reconstruction on complication rates.

METHOD

An electronic search of the English- language literature using PubMed, Medline, and the Cochrane database was conducted and a systematic review performed in accordance with PRISMA guidelines (CRD42020181057).

RESULTS

A total of 23 studies including 533 patients have been published on salvage TORS.The average patient age was 61.2 years.Prior treatment was described for 420 patients.205 (48.8%) underwent prior definitive radiotherapy (RT).160 (38.1%) underwent definitive chemoradiotherapy (CRT).Only 55 (13.1%) had prior surgery.Overall, there were 158 complications with a pooled rate of 33.6% (95%CI: 25.4-42.3%).77 were major complications requiring surgical intervention with a pooled rate of 18.9% (95% CI: 14.8-23.3%).The number of patients undergoing reconstruction among salvage cases in the literature is 59 (9.19%), with 24 local flaps and 25 microvascular free flaps.Reconstruction was associated with lower overall hemorrhage rates but had no impact on major hemorrhage rates.

CONCLUSIONS

The pooled incidence rates of major complications, major POH and emergency tracheostomy following salvage TORS are 18.9%, 10.5%, and 4.4%.The rate of death following salvage TORS is 3.6%. Reconstruction was associated with lower overall hemorrhage rate after salvage TORS but had no impact on major postoperative hemorrhage rates.

Harnessing the Forgotten Triangles of the Neck for Lingual Artery Ligation in Glossectomies: A Technical Report

Various geometric structures, such as numerous triangles, are prevalent in the neck. Despite the fact that many of the neck's anatomical triangles have been well documented, others have been almost forgotten about. The repertoire of head and neck cancer surgeons should include an in-depth understanding of these forgotten triangles. This article seeks to contribute valuable information to the existing scientific literature by shedding light on these neglected triangles, which have significant surgical relevance. In this technical report, we provide a detailed description of a technique that employs these neglected triangles to ligate the lingual artery during glossectomies for tongue cancer.

A 3D map of the lingual artery-The perfect tool for transoral robotic surgeries on the base of tongue

BACKGROUND

Knowledge about the anatomy of the lingual artery (LA) is of immense importance when performing procedures on the base of tongue (BOT).

METHODS

A retrospective analysis was performed to establish morphometric data of the LA. The measurements were performed on 55 consecutive patients who underwent head and neck computed tomography angiographies (CTA).

RESULTS

A total of 96 LAs were analyzed. Additionally, a three-dimensional heat map (showing the oropharyngeal region from the lateral, anterior, and superior point of view) of the occurrence of the LA and its branches was created.

CONCLUSION

The length of the main trunk of the LA was measured to be 31.94 ± 11.44 mm. This reported distance is thought to be a surgical safe zone when performing transoral robotic surgery (TORS) on the BOT because it represents the area where the LA does not give off any major branches.

Updates in the management of unknown primary of the head and neck

Squamous cell carcinoma (SCC) from an unknown primary tumor (SCCUP) accounts for 2.0%–5.0% of all head and neck cancers. SCCUP presents as enlarged cervical lymph nodes without evidence of a primary tumor upon physical examination. Primary site detection is important to target treatment and avoid treatment-related morbidity. In this review, we discuss updates in SCCUP management. Diagnostic workup should focus on localization of the primary tumor in SCCUP. Initial workup centers on neck biopsy to confirm the presence of SCC. Given the increasing incidence of HPV-related SCC in the oropharynx, HPV testing is crucial. An HPV-positive status can localize the tumor to the oropharynx, a common site for occult tumors. Imaging includes neck CT and/or MRI, and PET/CT. After imaging, panendoscopy, palatine tonsillectomy or diagnostic transoral robotic surgery can facilitate high rates of primary tumor localization. Primary tumor localization influences treatments administered. SCCUP has traditionally been treated aggressively with large treatment fields to all potential disease sites, which can induce weight loss and swallowing dysfunction. As a result, primary localization can reduce radiation fields and provide possible de-escalation to primary surgical management. Advances in intensity-modulated radiation therapy and dose management also have the potential to improve functional outcomes in SCCUP patients. Given the improved prognosis associated with HPV-positive SCCs, HPV tumor status may also inform future treatment de-intensification to reduce treatment-related toxicity.

Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study

To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

Simple Summary

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Oncological and Functional Outcomes of Transoral Robotic Surgery and Endoscopic Laryngopharyngeal Surgery for Hypopharyngeal Cancer: A Systematic Review

Objectives

Hypopharyngeal carcinoma (HPC) is a head and neck carcinoma with poor prognosis. Traditional laryngopharyngectomy offered promising oncological outcomes at the cost of functional outcomes. The recent advent in transoral robotic surgery (TORS), an organ-preserving surgery, has opened up new perspectives in the treatment for HPC. Here, we evaluate minimally invasive organ preservation surgery [TORS and endoscopic laryngopharyngeal surgery (ELPS)] for HPC in terms of feasibility and oncological and functional outcomes.

Methods

This is a systematic review. Six databases [CUHK Full-Text Journals, Embase 1910 to 2021, Ovid Emcare, Ovid MEDLINE (R), CINAHL, PubMed] were searched for articles and primary studies for TORS and ELPS for HPC. Screening was completed using predefined inclusion or exclusion criteria.

Results

A total of 8 studies on TORS and 3 studies on ELPS were eventually chosen after full-text review. For studies on TORS, 61.3% of patients (84 out of 137) still survived at the last follow-up with a mean follow-up time of 23.20 months (range: 12.8–37.21 months). Severe intraoperative and postoperative complications have not been reported. No cases of TORS required a conversion to open surgery. Swallowing function was optimal postoperatively with only 6 patients eventually required a percutaneous endoscopic gastrostomy (PEG) for feeding. Disease-specific survival was taken as the parameter for the measurement of oncological outcomes. A total of 2 studies reported a disease-specific survival of 100% within their follow-up period of 1 and 1.5 years, respectively. Another 2 studies reported a 2-year DSS of 89 and 98%, respectively. A 5-year DSS of 100% in early stage and 74% in late stage were achieved in one study. Another study also reported a 5-year DSS of 91.7%. For studies of ELPS, a 5- and 3-year disease-specific survival of 100% were achieved in 2 studies. Patients who underwent ELPS had good postoperative swallowing function with no PEG placement. There were also no other fatal complications.

Conclusions

Both TORS and ELPS for HPC provide satisfactory long-term oncological and functional outcomes improving postoperative quality of life of patients.

Perioperative Mortality Risk in Patients Undergoing Transoral Robotic Surgery for T1-T2 Oropharyngeal Squamous Cell Carcinoma: A National Cancer Database Study

The National Cancer Database is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methods used or for the conclusions drawn from these data by the investigators.

The Nasoseptal Flap for Reconstruction of Lateral Oropharyngectomy Defects: A Clinical Series

OBJECTIVES/HYPOTHESIS

To study use of the nasoseptal flap (NSF) to reconstruct lateral transoral robotic surgery (TORS) oropharyngectomy defects.

STUDY DESIGN

Retrospective case series.

METHODS

A clinical series of six patients undergoing NSF reconstruction of lateral TORS oropharyngectomy defects was retrospectively studied. All patients underwent TORS for the treatment of intermediate-risk human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma of the lateral pharyngeal wall between January and June 2017. All patients underwent NSF reconstruction of lateral TORS defects with retrospective analysis of outcomes and complications.

RESULTS

Six patients underwent NSF reconstruction of lateral TORS defects. Operative times decreased from 180 minutes to 90 minutes over the study period. There were two cases of partial flap dehiscence and partial necrosis. There were no major donor site complications. All patients had temporary nasal obstruction and crusting. Two experienced temporary aural fullness. In all patients, the lateral wall was mucosalized in 1-3 weeks. Cephalometric analysis of preoperative imaging revealed that patients with high-arched palates (>3 cm) and defect lengths that are longer than NSF flap lengths are poor candidates for this technique.

CONCLUSIONS

This NSF is a vascularized, locoregional rotational flap that can reconstruct lateral TORS defects in salvages cases or those where the parapharyngeal carotid or mandibular bone are exposed. Postoperative morbidity is limited to temporary nasal dyspnea, aural fullness, and crusting. Preoperative imaging can determine which patient will have successful defect coverage.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:53-60, 2022.

Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects

Significant dysphagia, pain, and risk of bleeding occur after transoral robotic surgery (TORS) radical tonsillectomy. We present a novel surgical technique utilizing robotically assisted submandibular gland transposition (SMGT) to reconstruct the radical tonsillar defect. A 48-year-old male with p16+ tonsillar squamous cell carcinoma underwent deep TORS radical tonsillectomy, contralateral tonsillectomy, ipsilateral neck dissection, and TORS-assisted reconstruction of the radical defect with ipsilateral SMGT. Postoperatively, the patient experienced minimal pain and was discharged on postoperative day (POD) 3 tolerating a soft diet. There were no episodes of postoperative bleeding. This procedure was performed in five other cases as well. Transoral robotic SMGT can be used successfully to repair deep TORS radical tonsillectomy defects and may theoretically reduce dysphagia, pain, and the risk of hemorrhage.

A new landmark for lingual artery identification during transoral surgery: Anatomic-radiologic study

BACKGROUND

A landmark for the identification of the lingual artery (LA) through a transoral perspective can provide surgeons with an easy method to prevent and manage intraoperative bleeding during transoral approach to the base of tongue (BOT).

METHODS

Thirteen tongue and five head and neck specimens were dissected to identify and assess the reliability of the lingual point (LP) as a new landmark for the LA at BOT. The pathway of 42 LAs was radiologically evaluated; axial depth and vertical offset were measured for each LA.

RESULTS

Dissection study: a description of LP is provided; the LA was easily identified in all specimens (36/36 sides) using LP as a landmark. Radiologic study: the mean depth of the LA was 4.2 mm, the mean vertical offset was 1.3 mm.

CONCLUSIONS

LP is a simple and reliable landmark for identification of the LA, potentially helping surgeons to prevent and manage intraoperative bleeding.

Selective embolization of lingual artery in transoral robotic surgery for the management of recurrent base of tongue carcinomas

BACKGROUND

The incidence of oropharyngeal carcinoma has been on the rise in recent decades. About 30% of patients who undergo definitive chemoradiation as the initial treatment present with residual/recurrent disease. In such a situation, surgical salvage either in the form of traditional open surgery or transoral robotic surgery (TORS) remains a viable treatment option. However, the extensive vascular supply of the posterior tongue and tonsillar bed increases the risk of perioperative bleeding, which is a key concern. The article describes the technique of selective pre-operative embolization to reduce the risk of perioperative bleeding and enumerate its advantages in providing a bloodless field during surgery.

METHODS

Prospective study of 5 patients with recurrent or residual midline BOT tumours who underwent TORS after selective lingual artery embolization at our centre.

RESULTS AND CONCLUSIONS

None of the patients had any major perioperative bleeding or post procedural complications. All the patients after TORS had their tongue vascularity preserved with adequate recovery of tongue functions. Selective embolization of the feeder vessels provides a favorable bloodless surgical field without affecting the vascular integrity of the remnant tongue. This added advantage helps restoring the normal oral phase of swallowing.

Transoral Robotic Surgery and De-escalation of Cancer Treatment

This article outlines the ways that transoral robotic surgery and transoral laser microsurgery relate to treatment de-escalation in the treatment of head and neck cancer. Treatment de-escalation has particular importance in context of human papillomavirus-related oropharynx squamous cell carcinoma, which responds well to therapy but leaves many survivors with decades of treatment-related sequelae. We compare these less invasive transoral approaches with previously used open approaches to the oropharynx. We discuss the topic of treatment de-escalation in human papillomavirus-related disease and outline completed and ongoing clinical trials investigating the choice of primary treatment modality and de-escalation of adjuvant therapy.

Transcervical arterial ligation for prevention of postoperative hemorrhage in transoral oropharyngectomy: Systematic review and meta-analysis

BACKGROUND

Transcervical arterial ligation has been studied as a useful procedure to prevent bleeding events after transoral robotic surgery (TORS).

METHODS

A systematic review of English-language literature on arterial ligation in TORS from 2005 to 2019 was conducted using Cochrane, PubMed, Web of Science (WoS), and ScienceDirect databases. Studies evaluating ligation and rates of postoperative hemorrhage were included. Meta-analysis of included studies was performed to assess impact of ligation on postoperative hemorrhage.

RESULTS

Five studies with 2008 patients were included. History of radiation (odds ratio [OR] = 2.26, P = .02) and advanced tumor stage (OR = 1.93, P = .02) were found to predispose patients to postoperative hemorrhage. Arterial ligation was protective against severe hemorrhage in the mixed primary surgical modality cohort (OR = 0.33, P = .03) and in the TORS-only subgroup (OR = 0.21, P = .02), but did not significantly impact overall odds of postoperative hemorrhage.

CONCLUSION

Transcervical arterial ligation offers protection against major/severe postoperative hemorrhage in patients undergoing TORS.

LEVEL OF EVIDENCE

II.

Second postoperative hemorrhage five weeks after transoral robotic surgery

Transoral robotic surgery (TORS) is becoming widely used in Japan, and information on postoperative hemorrhage is needed. We treated a patient who developed a second massive postoperative hemorrhage on Day 35 post-TORS. The 69-year-old man was diagnosed with p16-positive, T1N1M0 stage I cancer of the anterior wall of the oropharynx. Curative treatment began with right neck dissection. The external carotid artery and its branches were not ligated. One month after right neck dissection, TORS was conducted. On Day 23 post-TORS, the patient was brought to the emergency room due to pharyngeal bleeding. Hemorrhage was stopped by reclosing the site with Z-shaped silk sutures. Severe hemorrhage recurred on Day 35 post-TORS. The patient went into hemorrhagic shock. Tracheostomy was immediately performed. The neck dissection wound was then opened and the external carotid artery clamped. Hemostasis was confirmed transorally, but the hemorrhage site was again sutured with Z-shaped silk sutures to stop the bleeding. The patient was discharged on Day 58 post-TORS. Even in hindsight, this hemorrhage would have been difficult to prevent with better local treatment. This means that using transcervical arterial ligation together with TORS is appropriate from the perspective of making every effort to prevent potentially fatal postoperative hemorrhage.

A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311

PURPOSE

Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA.

PATIENTS AND METHODS

E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections.

RESULTS

120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients.

CONCLUSIONS

We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.

Critical Care and Postoperative Management of the Head and Neck Patient

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.

Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review

OBJECTIVE

Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post-TORS hemorrhage.

STUDY DESIGN

Systematic Review and Metanlysis.

METHODS

A systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL).

RESULTS

A total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post-TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk [RR] = 1.46, 95% confidence interval [CI] = 1.00-2.12), large tumors (RR = 2.11, 95% CI = 1.48-2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54-3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post-TORS hemorrhage (RR = 0.40, 95% CI = 0.15-1.07).

CONCLUSION

The incidence of post-TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post-TORS hemorrhage. TAL does not reduce the overall incidence of post-TORS hemorrhage but may lead to fewer severe hemorrhages.

LEVEL OF EVIDENCE

III Laryngoscope, 131:95-105, 2021.

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GOAL

To evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.

METHOD

Retrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R=21) and without (NR=24) robotic assistance, in the period 2006-2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P< .005.

RESULTS

Three- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P=.34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P=.81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P=.05) without significant impact on 5-year actuarial local control (P=0.78).

CONCLUSION

Robotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.

Reconstruction of TORS oropharyngectomy defects with the nasoseptal flap via transpalatal tunnel

The nasoseptal flap (NSF) has been described as reconstructive option for soft palate defects following transoral robotic surgery (TORS). As described, this technique is does not provide adequate coverage of the lateral oropharyngeal wall, parapharyngeal space, exposed vessels, or exposed mandibular bone. The NSF for TORS reconstruction has been limited to soft palate reconstruction, given the limitations on length when passed via the nasopharynx. In this article, we describe (1) a novel technique for TORS reconstruction using direct transposition of the ipsilateral NSF into the oropharynx via a transpalatal tunnel at the hard-soft palate junction, and (2) its use in select patients.

Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline

PURPOSE

The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx.

METHODS

ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one.

RECOMMENDATIONS

For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Laser-assisted uvulopalatoplasty (LAUP) complications and side effects: a systematic review

Objective: Laser-assisted uvulopalatoplasty (LAUP) has been used as a treatment option for snoring and obstructive sleep apnea for almost three decades. It has been previously reported that some patient's sleep-disordered breathing worsened following surgery. The aim of this paper is to further elucidate the specific complications of LAUP. Data sources: A systematic search of the electronic databases MEDLINE/PubMed, Google Scholar, and Embase. Review methods: The PRISMA statement was followed. Databases were searched from inception through September 2, 2018. The following search was applied to MEDLINE/PubMed ((laser AND uvul*) OR (LAUP) OR (LAVP) OR (laser AND (apnea OR apnoea OR sleep))). Results: Forty-two studies with a mean follow-up of 16.1 months reported complications on 3,093 total patients who underwent LAUP. The percentages and associated complications of LAUP are as follows: bleeding (2.6%), candidiasis (0.3%), dryness (7.2%), dysgeusia (0.3%), dysosmia (0.2%), globus sensation (8.2%), surgical site infection (1.3%), velopharyngeal (VP) insufficiency (3.9%), and VP stenosis (1.6%). The mean duration of patient-reported pain in studies that reported pain was 11.65 days. Only globus and VP insufficiency had a significant incidence compared with either the general population or the post-oropharyngeal surgery population with relative risks of 1.48 and 2.25, respectively. Overall, there were approximately 26 complications per 100 patients who underwent LAUP. Conclusion: LAUP is associated with a statistically significant rate of VP insufficiency and globus sensation; however, studies lack details of surgical approaches, suggesting that in a population identified as good candidates, a tissue-sparing approach may result in fewer complications.

Oncological and functional outcomes of trans-oral robotic surgery for pyriform sinus carcinoma: A French GETTEC group study

BACKGROUND

Pyriform sinus carcinomas (SCC) present specific functional and oncological issues. The recent advent of trans-oral robotic surgery (TORS), as a conservative procedure, has opened up new perspectives.

OBJECTIVES

To present the oncological and functional outcomes of TORS for pyriform sinus SCC.

MATERIALS AND METHODS

We included, retrospectively, all TORS procedures for pyriform sinus SCC performed between 2009 and 2017 in eight French tertiary referral centers. We excluded lesions involving the pyriform sinus that had developed from the oropharynx, larynx, or other anatomic sub-sites of the hypopharynx.

RESULTS

We included 57 TORS procedures. Median hospital stay was 10 days. A preventive tracheotomy was performed in seven cases (12%), and all were successfully decannulated. Oral re-feeding was possible for 93%, after a median of 5 days. The main surgical complications were hemorrhages (three cases), all successfully handled, although 2 patients with heavy comorbidities died from blood loss in the days after. Adjuvant therapy was proposed in 31 cases (54%), including two cases of salvage surgery (total pharyngolaryngectomy). After a median follow-up of 23 months, overall and disease-free survival were, respectively, 84% and 74% at 24 months, and 66% and 50% at 48 months. At the end of follow-up, organ preservation rate was 96%. None of the surviving patients needed a tracheotomy and oral diet was possible for 96%.

CONCLUSION

The functional and oncological outcomes of TORS for pyriform sinus cancer are encouraging, and this procedure can be considered safe for selected early or moderately advanced cases as a conservative treatment.

Transoral robotic resection of benign tumors of the upper aerodigestive tract: Experience of the French group of GETTEC

BACKGROUND

The purpose of this study was to assess the current use of transoral robotic surgery (TORS) in benign tumors of the upper aerodigestive tract through a case series and a literature review.

METHODS

This multicentric retrospective study was conducted in 6 French centers between November 2009 and July 2017.

RESULTS

Twenty-one patients had a TORS resection of a tumor at varied locations with differing histopathologic characteristics. The mean postoperative hospital stay was 6.1 days. Eight patients had nasogastric tubes, which were removed after a mean of 5.6 days. Two patients had a prophylactic tracheostomy for an average of 5.5 days. A third tracheostomy was performed secondarily for postoperative bleeding. No recurrences were observed during the 2-year follow-up.

CONCLUSION

This technique caused few complications and resulted in short hospitalization, with satisfactory functional and recurrence outcomes. However, the risk of bleeding and edema must be considered, and the need for a tracheostomy must be approached wisely.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.