Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Infrahyoid muscle flap as augmentation of pharyngeal repair after total laryngectomy

INTRODUCTION

To assess the usage of contralateral infrahyoid muscles as onlay flap in prevention of pharyngo-cutaneous fistula (PCF) in total laryngectomy (TL) patients with high risk factors of PCF development.

METHODS

This study included 10 patients who suffered from advanced laryngeal carcinoma with presence of risk factors for development of PCF. We added an enforcement muscular layer during neo-pharynx wall repair, the infrahyoid muscle flap of the contralateral side of the tumour origin as an onlay muscular flap to cover the anastomotic site for healing augmentation. Patients were followed up for PCF development where the PCF incidence was calculated.

RESULTS

One patient died from congestive heart failure in the 21th post-operative day so, the actual PCF rate in TL patients with high risk factors of PCF development in our study was 11.11% (1 out of 9 cases).

CONCLUSIONS

Infrahyoid muscle flap may have a role in preventing PCF after TL in patients with high risk factors of PCF development in this case series study to be further assessed in other studies to justify its role.

LEVEL OF EVIDENCE: 4

Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube

BACKGROUND

There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture.

METHODS

Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without.

RESULTS

Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects.

CONCLUSION

The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

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.

Development of a nomogram for predicting pharyngocutaneous fistula based on skeletal muscle mass and systemic inflammation indices

BACKGROUND

Laryngeal and hypopharyngeal cancers often require surgical treatment, which can lead to the development of pharyngocutaneous fistula (PCF). Our research aimed to assess the predictive value of skeletal muscle mass (SMM) and systemic inflammation indices for PCF and construct a clinically effective nomogram.

METHODS

A nested case-control study of 244 patients matched from 1171 patients with laryngeal or hypopharyngeal cancer was conducted. SMM was measured at the third cervical level based on CT scans. A PCF nomogram was developed based on the univariate and multivariate analyses.

RESULTS

Glucose, white blood cell count, platelet-to-lymphocyte ratio, and skeletal muscle index were independent risk factors for PCF. The area under the curve for the PCF nomogram was 0.841 (95% CI 0.786-0.897). The calibration and decision curves indicated that the nomogram was well-calibrated with good clinical utility.

CONCLUSIONS

The nomogram we constructed may help clinicians predict PCF risk early in the postoperative period, pending external validation.

The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy

Objectives

Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial.

Methods

We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF.

Results

Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status.

Conclusion

PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Impact of stapler versus manual closure techniques on pharyngocutaneous fistula development post-total laryngectomy: A systematic review and meta-analysis

Pharyngocutaneous fistula (PCF) is a major complication after total laryngectomy, with significant morbidity and mortality. Whether mechanical stapler closure of the pharynx reduces fistula rates compared to hand-sewn techniques remains unclear. We conducted an updated systematic review and meta-analysis to clarify this question. Five databases were systematically searched from inception through November 2023 for studies comparing stapler versus suture closure for fistula outcomes after laryngectomy. Odds ratios (OR) were pooled using random-effects models and fixed-effects models. Subgroup and sensitivity analyses were performed. Risk of bias was appraised using NHLBI tools. Nine studies with 803 patients were included. Mechanical closure significantly reduced fistula incidence versus suture closure (OR = 0.57, 95% CI 0.34-0.95, p = 0.03). Subgroup analysis found that stapling's protective effect varied by patient age, country/region, linear stapler size and female percentage. Stapling reduced fistula odds by 80% in the Turkey subgroup (OR = 0.20, 95% CI 0.09-0.50) but showed no benefit in other regions. Patients <60 years showed an 84% fistula reduction with stapling (OR = 0.17, 95% CI 0.06-0.45), whereas older subgroups did not. Linear stapler size of 60 mm significantly reduced fistula occurrence while 75 mm did not. There was no evidence that low female percentage mitigated stapling benefits. Mechanical stapler closure after total laryngectomy meaningfully reduces the likelihood of postoperative PCF formation compared to hand-sewn closure, especially for patients younger than 60 years old. The absolute risk reduction supports its utility to prevent this complication.

Procalcitonin for Early Detection of Pharyngocutaneous Fistula after Total Laryngectomy: A Pilot Study

OBJECTIVES

The aim of this prospective study was to investigate the role of procalcitonin as an early diagnostic marker of pharyngocutaneous fistula (PCF) in a cohort of head and neck patients treated with total laryngectomy for squamous cell carcinoma.

METHODS

This prospective study was conducted on a sample of patients enrolled from January 2019 to March 2022. All patients were subjected to a "protocol" of blood chemistry investigations, scheduled as follows: complete blood count with formula, ESR dosage, CPR, and PCT. PCT was also dosed by salivary sampling and a pharyngo-cutaneous swab in patients who presented with PCF. The dosage scheme was systematically repeated: the day before the intervention (t0); the 5th day postoperative (t1); the 20th day postoperative (t2); and at time X, the day of the eventual appearance of the pharyngocutaneous fistula.

RESULTS

A total of 36 patients met the inclusion criteria. The patients enrolled in the study were subsequently divided into two groups: 27 patients underwent total laryngectomy (TL) for laryngeal cancer without postoperative complications, and 9 patients were undergoing TL with postoperative PCF. Using the Cochran's Q test, statistical significance was found for PCT among T0, T1, Tx, and T2 (p-value < 0.001) between the PCF and non-PCF groups. The Z test demonstrated that there is a difference in PCT levels at T1 and T2 and that this difference is statistically significant (p < 0.001).

CONCLUSIONS

PCT could be considered an early marker of complications in open laryngeal surgery. According to our results, it could be useful in the precocious detection of pharyngocutaneous fistulas and in the management of antibiotic therapy.

Delayed oral feeding reduces pharyngocutaneous fistula formation after open surgical treatment of primary hypopharyngeal cancer: A case-control study

OBJECTIVES

Pharyngocutaneous fistula (PCF) formation following open surgical treatment of hypopharyngeal cancer (HPC) is a common and troublesome complication. To date, the postoperative protocol of restarting oral intake is not clear, and vast discrepancies exist in the literature and among institutions. This study aimed to explore the impact of a postoperative protocol of restarting oral intake on PCF formation after open surgical treatment of primary HPC, and its impact on overall survival (OS) and swallowing function based on the functional outcome swallowing scale (FOSS).

MATERIALS AND METHODS

This was a prospective observational study of 42 patients who received open surgical treatment for primary HPC at Beijing Friendship Hospital between April 2019 and August 2021. This cohort included two groups: patients who restarted oral intake on the 10th postoperative day (Group 1), and those who started on the 20th (Group 2). The Chi-square test and Fisher's exact chi-squared test were used for comparing qualitative data among the groups.

RESULTS

Group 1 (n = 27) and Group 2 (n = 15) were comparable in clinical characteristics. PCF occurred in 7 (25.9%) patients in Group 1, while none occurred in Group 2 (P = 0.038). The 2-year OS of all 42 patients was 75.6%; 65.8% and 93.3% for Groups 1 and 2, respectively (P = 0.07). The swallowing function was satisfactory (FOSS Grades 0-III) for 19 (70.4%) patients in Group 1 and 15 (100%) patients in Group 2 (P = 0.035). Laryngeal preservation was achieved in 25 (59.5%) patients, while decannulation was successful in 22 (88.0%) patients.

CONCLUSIONS

Delayed oral feeding significantly reduces PCF after open surgical treatment of primary HPC, and improves the swallowing function outcome without jeopardizing the OS.

Early detection of pharyngocutaneous fistulae after total laryngectomy by cytokine in drainage: A pilot study (DEFILAC)

BACKGROUND

The determination of cytokines in the postoperative drainage (POD) fluid could be a method for early detection of the development of a pharyngocutaneous fistula (PCF).

MATERIALS AND METHODS

We conducted a prospective two-center study involving 28 patients. PODs were collected on Day 1 (D1) and Day 2 (D2) postoperatively for determination of a cytokine panel and cytobacteriological examination.

RESULTS

Eleven (39%) patients presented with PCF on average 13 ± 5.5 days after surgery. Patients with PCF had higher IL-10 (121 vs. 40.3, p = 0.04, effect size (ES) = 0.98 [0.16, 1.79]) and TNFα level (21.2 vs. 2.2, p = 0.02, ES = 0.83 [0.03, 1.63]) on D2. An IL-10 threshold of 72 pg/mL on D2 was diagnostic of the occurrence of PCF with a sensibility of 70%, specificity of 88%.

CONCLUSION

The determination of cytokines in POD fluid on D2 is a reliable tool for predicting the development of a PCF after total laryngectomy.

Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula

BACKGROUND

Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF.

METHODS

We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test.

RESULTS

There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test).

CONCLUSION

TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

Gastrostomy dependence following pharyngolaryngectomy: The effect of preoperative tube insertion

BACKGROUND

The aim of this study is to investigate the impact of preoperative gastrostomy in patients undergoing pharyngolaryngectomy (PL) on gastrostomy tube dependence at 6 months postoperatively.

METHODS

A retrospective review of patients undergoing PL for laryngeal squamous cell carcinoma between 2005 and 2019 was performed. Parameters were collected and analyzed within the multivariate models.

RESULTS

Ninety-three patients (82% male, mean age 63.4 [SD 9.4]) were included. Preoperative tube placement and pharyngocutaneous fistula (PCF) were associated with an increased likelihood of gastrostomy tube dependence at 6 months (odds ratio 6.43, CI 1.1-38.3, p = 0.041) after adjusting for multiple confounding factors. There was no difference in the incidence of delayed oral feeding, PCF, or hospital stay between the groups.

CONCLUSIONS

Preoperative tube and PCF are associated with an increased likelihood of tube dependence at 6 months. Patients for preoperative tube insertion should be carefully selected and early oral feeding reintroduction should be encouraged.

Effect of possible risk factors for pharyngocutaneous fistula after total laryngectomy of laryngeal carcinomas and surgical wound infection: A meta-analysis

A meta-analysis study to assess the effect of possible risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy of laryngeal carcinoma. A comprehensive literature examination till January 2023 was implemented and 1794 linked studies were appraised. The picked studies contained 3140 subjects with total laryngectomy of laryngeal carcinomas in the picked studies' baseline, 760 of them were PCF, and 2380 were no PCF. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of possible risk factors for PCF after total laryngectomy of laryngeal carcinomas and surgical wound infection after total laryngectomy of laryngeal carcinoma by the dichotomous and continuous styles and a fixed or random model. The PCF had a significantly higher surgical wound infection (OR, 6.34; 95% CI, 1.89-21.27, P = .003) compared with the no PCF in total laryngectomy of laryngeal carcinomas. The smoking (OR, 1.73; 95% CI, 1.15-2.61, P = .008), and preoperative radiation (OR, 1.90; 95% CI, 1.37-2.65, P < .001) had significantly higher PCF as a risk factor in total laryngectomy of laryngeal carcinomas. The preoperative radiation had a significantly lower spontaneous PCF closure (OR, 0.33; 95% CI, 0.14-0.79, P = .01) compared with the no preoperative radiation in total laryngectomy of laryngeal carcinomas. However, the neck dissection (OR, 1.34; 95% CI, 0.75-2.38, P = .32), and alcohol intake (OR, 1.95; 95% CI, 0.76-5.05, P = .17), had no significant effect on PCF in total laryngectomy of the PCF had a significantly higher surgical wound infection, and preoperative radiation had a significantly lower spontaneous PCF closure in total laryngectomy of laryngeal carcinomas. Smoking and preoperative radiation were shown to be risk factors for PCF, however, neck dissection and alcohol intake were not shown to be risk factors for PCF in total laryngectomy of laryngeal carcinomas. Although precautions should be taken when commerce with the consequences because some of the picked studies for this meta-analysis was with low sample sizes.

Pectoralis Major in Salvage Total Laryngectomy after Irradiation: Morbidity, Mortality, Functional, and Oncological Results in a Referral Center in Egypt

BACKGROUND

Nonsurgical organ preservation protocols have seen a large diffusion worldwide in the last decades. Their oncological and functional effectiveness in a real-world setting has been recently questioned because of the high morbidity of salvage procedures. The aim of this study is to review the outcomes of postirradiation salvage total laryngectomy (STL) and reconstruction with pectoralis major flap.

METHODS

This retrospective observational study included 37 cases of STL in the period from January 2015 to December 2021. Data for each patient were extracted from the hospital information system and reviewed.

RESULTS

The 3-year overall and disease-specific survival are, respectively, 28% and 51%. Only seven recurrences after salvage surgery were recorded and all of them died from the disease. The other 14 deaths derived from comorbidities, with diabetes being the most significant predictive parameter for overall survival. Also, lower postoperative albumin levels were associated with a higher risk of death.

CONCLUSIONS

Overall survival after STL and reconstruction with PMMF is low but most deaths are due to comorbidities and not to cancer progression or recurrence.

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.

Persistent Neopharynx Pseudomonas Infection After a Sealed Anastomotic Leak Post Total Laryngectomy

Total laryngectomy (TL) is the treatment of choice for advanced glottic cancer. Post-operative complications can be debilitating for patients, family members and healthcare workers. Complications following TL have been reported in many studies, with pharyngocutaneous fistula and wound infection being the most common. Identifying the risk factors that may give rise to these complications is vital to minimise post-operative morbidity. We present the case of a 62-year-old male who underwent salvage TL following radiation therapy for recurrent glottic carcinoma. The patient developed diffuse submental swelling upon the commencement of oral feeding. A flexible nasopharyngolaryngoscopy revealed a sloughy area at the neopharynx, with the finding of a sealed anastomotic leak on a repeat barium swallow study. We report persistent Pseudomonas aeruginosa infection following salvage TL, after a sealed anastomotic leak.

Stapler Pharyngeal Repair Versus Conventional Suturing After Laryngectomy in Jordanian Laryngeal Cancer Patients

Background

The use of staplers in surgical repair of the pharynx after laryngectomy has gained traction in recent years, with differing results.

Objective

In this study, we compare the use of stapler suturing (SS) after laryngectomy in comparison with the manual suturing (MS) technique in laryngeal cancer patients regarding pharyngocutaneous fistula (PCF) formation, operative time, blood loss, margin status, and length of hospital stay.

Methods

We conducted a retrospective cohort study of laryngeal cancer patients undergoing pharyngeal repair after total laryngectomy by either a stapler or manual suturing. Demographic data, stage of disease, postoperative complications, duration of hospital stay, and operative time were collected.

Results

A total of 59 laryngeal cancer patients were included, of which 22 underwent SS and 37 had MS. Our cohort was predominantly males (98%), and similar mean ages were observed across both suturing groups (60.5 vs 59.9, P = 0.83). Negative margins were more frequent with SS (100% vs 86.5%, P = 0.13) yet this difference was not statistically significant, whereas preoperative tracheostomy procedure was present more in MS patients (43.2% vs 0, P = 0.003). Lymph node involvement was higher in the manual suturing cohort, yet this difference was statistically insignificant (41.2% vs 25%, P = 0.49). The muscle flap procedure was significantly higher in the MS cohort (70.3% vs 20%, P = 0.001). In both groups, comparable PCF rates were noted (13.3% vs 10.8%) and there was no association between salvage laryngectomy and PCF occurrence in the entire cohort. For surgery details, there was no statistical difference between both groups in blood loss, hospitalization length, or oral feeding start. Only surgical time was significantly lower in the stapler cohort (277 vs 372.6 minutes, P = 0.000).

Conclusion

Both suturing techniques did not show any statistically significant difference in PCF rates. However, was markedly reduced with stapler use in comparison to manual suturing. Further randomized studies with larger sample size are needed to validate the role of stapler suturing for pharyngeal repair.

Botulinum Neurotoxin A in the Treatment of Pharyngocutaneous Fistula after Salvage Surgery in Head and Neck Cancer Patients: Our Preliminary Results

Objective: To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods: A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results: Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7-18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different (p < 0.05). Conclusions: BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Role of Exosomes in Pharyngucutaneous Fistula After Total Laryngectomy

Pharyngocutaneous fistula is the most common complication after total laryngectomy and is difficult to heal. Although conservative treatment and surgical repair are effective, they often take longer and additional trips to the operating room, which undoubtedly increases the financial burden on patients. Especially in combination with diseases such as diabetes and hypertension, which affect the efficacy of surgery. Adding growth factors into the repair material can promote fibroblast proliferation, angiogenesis, and accelerate wound healing. A substantial number of studies have shown that a type of nanoscale extracellular vesicle, called exosomes, facilitates organization repair by promoting blood vessel production, protein polysaccharides, and collagen deposition, thereby representing a new type of cellular therapy. At present, there is little research on the application of exosomes in pharyngocutaneous fistula regeneration after total laryngectomy. In this review, we summarize the biological characteristics of exosomes and their application in biomedical science, and highlight their application prospects in pharyngocutaneous fistula regeneration after total laryngectomy.

Thyroid Gland Flap for Prevention of Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES

Pharyngocutaneous fistula (PCF) is the one of the major complications after total laryngectomy (TL), which can result in saliva leakage, rupture of major vessels, and increased hospitalization. Several flaps have been tried to prevent PCF during TL, and they are usually associated with donor site morbidity and uncertain viability in case of previously irradiated patients. This study aimed to report a novel bilateral pedicled thyroid gland flap (TGF) technique for delicate and effective reinforcement of neopharynx suture line after TL.

METHODS

Bilateral pedicled TGF was performed for the reinforcement of neopharynx T-shape suture sites after TL in this case series.

RESULTS

A total of five cases of the TGF were performed during TL, with four of them being salvage setting following previous chemoradiation therapy (CRT). The well-adapted and viable TGF status was confirmed by post-operative computed tomography scan and normally preserved thyroid hormone levels in all patients. No post-operative infections, hemorrhage, hypothyroidism, hypoparathyroidism, or PCF were reported.

CONCLUSION

The TGF is an effective and reliable flap in TL patents and should be considered as a method in neopharynx reconstruction, even in salvage TL following prior CRT.

Inflammation-Based Score (Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio) Predicts Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES/HYPOTHESIS

Postoperative complications may depend on the systemic inflammatory response. We evaluated the predictive potential of the combination of platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for the incidence of pharyngocutaneous fistula (PCF) in patients who have undergone total laryngectomy.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients who underwent total laryngectomy between 2000 and 2020 were recruited from four hospitals. The correlations between the incidence of PCF and several risk factors, including the COP-NLR, were examined. Patients with both elevated platelet count and elevated neutrophil-to-lymphocyte ratio (NLR) were categorized as COP-NLR 2, and patients with either one or no abnormal values of both parameters were assigned as COP-NLR 1 and COP-NLR 0, respectively.

RESULTS

A total of 235 patients were identified. The overall incidence of PCF was 12.3%. The cut-off value for NLR before surgery was set at 3.95 (sensitivity = 58.6%, specificity = 69.4%, area under the curve [AUC] = 0.635), and the platelet count was set at 320 × 10⁹ /L (sensitivity = 27.6%, specificity = 87.9%, AUC = 0.571). Multivariate analysis revealed that COP-NLR was an independent risk factor for PCF (COP-NLR 1 vs. COP-NLR 0: odds ratio [OR], 4.17; 95% confidence interval [CI], 1.64 to 10.59; and COP-NLR 2 vs. COP-NLR 0: OR, 5.33; 95% CI, 1.38 to 20.56).

CONCLUSIONS

COP-NLR is a novel predictive factor for the development of PCF in patients undergoing total laryngectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Role of Pectoralis Major Myocutaneous Flap in Laryngectomy Surgery: Single Surgeon Experience

Objective

To analyze the effectiveness of the pectoralis major myocutaneous (PMMC) flap in preventing pharyngocutaneous fistula (PCF) formation for salvage total laryngectomy patients.

Study design

Retrospective chart review of all post-surgical laryngectomy patients for a single surgeon.

Methods

Inclusion criteria were adult patients 18 years and older who were diagnosed with laryngeal cancer and treated with a salvage total laryngectomy. Exclusion criteria were any laryngectomy patient treated without the PMMC flap or those with incomplete medical records.

Results

A total of 31 patient charts were identified, and 16 remained after exclusion criteria. The patient age range was 42-71 years (mean = 58.19; SD = 8.093). Greater than 85% of patients had T3 and T4 laryngeal cancers. Without PCF group were 13 patients and with PCF group were only three patients. The mean hospital days in without PCF group were 9.54 and in with PCF group were 16.33.

Conclusion

In this single surgeon’s experience, PCF was prevented by using the PMMC flap in salvage total laryngectomy patients.

Functional Shoulder Outcome and Quality of Life Following Modified Muscle-Sparing Pectoralis Major Flap Surgery

BACKGROUND

The pedicled pectoralis major muscle flap (PMMF) is a well established flap for fistula prophylaxis after salvage laryngectomy. To reduce donor site morbidity, we established a modified muscle-sparing harvesting technique. We herein investigate postoperative shoulder function and health-related quality of life (HRQOL).

METHODS

A chart review of patients receiving the modified muscle-sparing pectoralis major muscle flap between 2013-2020 was performed. Nineteen patients (male = 18, female = 1) were potentially eligible and six male patients were ultimately enrolled. Postoperative shoulder function was assessed on both sides (flap side versus non-flap side) using the Constant Murley Score and the Bak criteria. Health-related quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in cancer patients (EORTC QLQ-C30) and head and neck cancer patients (EORTC H&N35).

RESULTS

No Constant Murley Score subscale was statistically significant (p ≥ 0.180). Bak criteria was overall rated "Good". Solely upper extremity adduction force was significantly altered on the flap side (p = 0.039). Median EORTC QLQ-C30 score was 82.2 (IQR 11.1) on the functional scale and 10.3 (IQR 2.6) on the symptomatic scale. Median quality of life score was 75.0 (IQR 33.3) and median EORTC QLQ-H&N35 was 20.6 (IQR 9.8).

CONCLUSIONS

Postoperative shoulder function after modified muscle-sparing pectoralis major muscle flap surgery is comparable to function of the healthy side with a significant deficiency in adduction force not compromising daily life in this small study cohort.

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy

Objective

To demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas.

Study Design

Retrospective study.

Setting

Single academic tertiary care center.

Methods

In this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF.

Results

A total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap.

Conclusion

Preemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

"Fistula Zero" Project After Total Laryngectomy: The Candiolo Cancer Institute Experience

Objectives

Pharyngocutaneous fistula (PCF) is a troublesome complication after total laryngectomy. The “Fistula zero” project aims to reduce the number of PCF by following a detailed protocol based on three fundamental key points.

Materials and Methods

The Fistula zero project included 77 patients who underwent total laryngectomy in the period from January 2019 to December 2020. The protocol consisted of three main aspects: the systematic placement of a Har-El salivary bypass tube, the continuous horizontal watertight pharyngeal suture using a barbed suture, onlay insetting of a pedicled flap in pre-treated patients.

Results

One case of PCF (1.3%) and three small blind fistulas (3.9%) were observed in this series. The mean length of hospitalization was 18 days.

Conclusion

Pharyngocutaneous fistula (PCF) prolongs hospitalization and delays adjuvant treatments. Thanks to a strict adherence to the protocol, it was possible to reduce PCF rates, avoiding lengthy hospitalization and additional surgical procedures.

Do Salivary Bypass Tubes Reduce the Risk of Pharyngocutaneous Fistula after Laryngopharyngectomy-A Systematic Review and Meta-Analysis

Simple Summary

Salivary bypass tubes (SBT) have been introduced in order to reduce the risk of pharyngocutaneous fistula (PCF) after laryngectomy with pharynx reconstruction. Although the current literature is rather heterogenous, our meta-analysis demonstrates a favorable effect of SBT insertion on PCF formation in patients after laryngopharyngectomies.

Abstract

To evaluate the effect of salivary bypass tube (SBT) usage on the occurrence of pharyngocutaneous fistula (PCF) in patients after a laryngopharyngectomy, a total of 20 studies, published between 1988 and 2021, were identified including 2946 patients. We performed a meta-analysis assessing the risk of PCF occurrence in patients after SBT application compared to those without. PCF occurred in 26.8% of cases (669/2496) and SBT was applied in 33.0% of patients (820/2483). There was an overall trend towards lower PCF rates when using SBTs (22.2% vs. 35.3%; p = 0.057). We further selected five studies, comprising 580 patients who underwent laryngopharyngectomies, for meta-analysis showing that application of SBT reduced the risk of PCF formation (OR 0.46; 95% CI 0.18–1.18; p = 0.11). The meta-analysis demonstrates a beneficial effect of SBT insertion on PCF formation in patients after laryngopharyngectomy.

Influence of Preoperative Radiation Therapy on the Occurrence of Pharyngocutaneous Fistula After Total Laryngectomy

Introduction

Chemo-radiotherapy (CRT) has increasingly been employed for the treatment of laryngeal cancer at T3 or higher rather than total laryngectomy (TL), in order to preserve the larynx. However, TL is still frequently performed in patients with advanced laryngeal cancer, especially T4 disease. When CRT is performed for advanced cancer, there is a certain rate of residual disease or relapse, and TL is conducted as salvage surgery for those patients, but TL following CRT is associated with a high incidence of postoperative complications.

Objective

The purpose of this study was to investigate the influence of preoperative radiation therapy on the occurrence of postoperative complications of TL, particularly pharyngocutaneous fistula (PCF).

Methods

We retrospectively investigated 142 patients who underwent TL for laryngeal cancer whether postoperative complications were related to a history of radiation therapy or neck dissection. Detailed investigation of the 32 patients who underwent radiation therapy was also conducted.

Results

PCF was significantly higher after radiation therapy. Neck dissection was not related. As the time from radiation therapy to TL decreased, the incidence rate of postoperative PCF increased and the time to closure became significantly longer. Preoperative laboratory tests did not show a significant difference in Hb and Alb, but the lymphocyte count was significantly lower in patients with PCF.

Early versus late oral feeding following total (pharyngo)laryngectomy: Systematic review and meta-analysis

Timing of oral feeding following total laryngectomy is a contentious issue with highly varied practices. Multiple database search was performed to identify studies comparing outcomes of early (≤5 days) versus late (>5 days) oral feeding. Bias assessment was carried out using Cochrane bias tool. Random-effects meta-analysis was used. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The rate of pharyngocutaneous fistula (PCF) in randomized control trials (RCTs) in early versus late feeding was 15.2% versus 11.7% (RR 1.35, 95%CI [0.68-2.7], p = 0.40). The rate of PCF in the cohort studies was 14.1% versus 20.5% (RR 1.0, 95%CI [0.76-1.3], p = 0.98). The length of hospital stay was significantly shorter in the early feeding group (mean difference (days) -4.68 (-6.2 to -3.1, p < 0.0001). Early oral feeding appears to be safe and is associated with shorter hospital stay. However, the quality of evidence is low and the patient characteristics are not representative of current practices.

Intraoperative Dye Test in Total Laryngectomy: A Technique to Reduce the Incidence of Pharyngocutaneous Fistula

Background:

Pharyngocutaneous fistula (PCF) could complicate laryngectomy in advanced disease. The cause is multifactorial, and this may include poor technique in pharyngeal repair. Intraoperative assessment of the repaired mucosa integrity for adequate closure may reduce PCF, but this is not routinely done.

Objective:

The objective of this study is to describe a novel technique that has been successfully used to ascertain intraoperative pharyngeal repair integrity.

Methods:

Thirty-one patients who had total laryngectomy and pharyngeal reconstruction for locally advanced laryngeal squamous cell carcinoma were studied. Connell extramucosal suturing technique was used for the mucosal repair. Thereafter, a small feeding tube was introduced through the oral cavity to the site of the pharyngeal repair, and diluted methylene-blue dye was injected through it while digitally occluding the cervical esophagus. Whenever leakage of the dye was seen, the leakage site (s) was repaired. Thereafter, the dye test would be repeated to confirm the integrity of the repair.

Results:

Their mean age was 53.4 ± 10.9 years. Seven (22.6%) patients had Stage 3 disease and 24 (77.4%) had Stage 4 disease. All the patients had neck dissection, whereas 3 (9.7%) patients had salvage laryngectomy postradiotherapy. Dye test was performed intraoperatively for all the patients and leakages were seen in 4 (12.9%) patients which were successfully repaired. Oral feeding was commenced on the fifth postoperative day, and none of the patients had PCF.

Conclusion:

Performing a dye test intraoperatively helps detect the point of leakage and immediate repair will prevent PCF.

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.

Application of the Supraclavicular Artery Island Flap for Fistulas in Patients With Laryngopharyngeal Cancer With Prior Radiotherapy

OBJECTIVE

To evaluate the effect of the supraclavicular artery island flap (SAIF) in reconstructing pharyngocutaneous fistula in patients with laryngopharyngeal cancer with prior radiotherapy.

METHODS

Six patients with laryngopharyngeal cancer with pharyngocutaneous fistula due to previous radiotherapy and surgery during 2016 to 2019 were retrospectively analyzed. Initially, the fistula was treated conservatively. The SAIF was applied with double folding technique to reconstruct fistula in the patients who failed to heal after conservative treatment.

RESULTS

The fistulae closed in 4 patients after conservative treatment. After SAIF operation, fistula closure was achieved in the other 2 patients who received highest dose of radiation and had largest fistulae size. The flaps grew well and there were no donor-site complications in these 2 patients. All patients achieved oral feeding without any complications.

CONCLUSION

The SAIF is an effective and safe approach to reconstruct the pharyngocutaneous fistula after laryngopharyngeal surgery in patients with laryngopharyngeal cancer with previous radiotherapy, especially for those who have received high-dose radiation and have large fistula.

Is It Important Which Suturing Technique Used for Pharyngeal Mucosal Closure in Total Laryngectomy? Modified Continuous Connell Suture May Decrease Pharyngocutaneous Fistula

OBJECTIVE

The aim of this study is to research the correlation between pharyngeal mucosal suture techniques and pharyngocutaneous fistula (PCF) development after total laryngectomy. We also aimed to investigate other risk factor for fistula development.

METHODS

Medical charts of 85 patients who had total laryngectomy during August 2016 and February 2020 were reviewed. Sixteen patients were excluded due to exclusion criteria. Patients were grouped according to pharyngeal mucosal suture technique. Group 1 had modified continuous Connell suture and group 2 had interrupted submucosal suture for mucosal closure of pharynx. Demographic, medical, and surgical records reviewed for comparison.

RESULTS

Overall PCF rate was 28%;PCF rates were 16% (5/31) in group 1 and 39% (15/38) in group 2. This difference was significant (Pearson χ² P = .033). There was no difference between groups due to age, gender, smoking history, tumor stage preoperative albumin levels, preoperative hemoglobin levels, radiotherapy status, chronic obstructive pulmonary disorder and diabetes mellitus history of patients, previous tracheostomy, neck dissection. But correlation analysis revealed that PCF formation significantly related with suture technique (P = .032), preoperative albumin level <3.5 g/dL (P = .028), preoperative hemoglobin level <12.5 g/dL (P = .041), and previous radiotherapy status (P = .012) of the patients. We also showed that suture technique is an independent predictive factor for PCF formation when other factors were controlled by univariate analysis.

CONCLUSION

The suture technique used for pharyngeal mucosal closure, preoperative albumin level <3.5 g/dL, preoperative hemoglobin levels<12.5 g/dL, and previous radiotherapy to the head and neck are risk factors for PCF development. Modified continuous Connell suture is a good option for pharyngeal closure.

Effect of Low-Pressure Drainage Suction on Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVE

Pharyngocutaneous fistula (PCF) is one of the most severe multifactorial complications following laryngectomy. The current study aimed at determining the effect of a low-pressure vacuum drain on the incidence of PCF after total laryngectomy.

METHODS

The current randomized clinical trial was conducted on 35 patients undergoing total laryngectomy in Hazrat Rasoul Akram and Firoozgar hospitals in Tehran, Iran. The subjects were divided into the vacuum drain (n = 15) and control (without vacuum drain) (n = 20) groups. The incidence of PCF and the recovery time were recorded.

RESULTS

The rate of PCF formation from the stoma and wound edges was significantly lower in the low-pressure vacuum drain group than in the control group (6.7% vs 40%) (P < .05). There was no significant difference between the groups in time to recovery from PCF.

CONCLUSION

The low-pressure vacuum drain method is effective in reducing the incidence of PCF after total laryngectomy.

Versatility of the Supraclavicular Flap in Head and Neck Reconstruction

Objective: Head and neck oncologic resections often leave intricate defects whose reconstruction remains a challenge. The pedicled supraclavicular artery perforator flap is an emerging option, and its applicability in head and neck reconstruction is gaining popularity. Methods: A retrospective analysis of patients regarding medical history, surgical indication, surgical technique, postoperative complications, and outcomes was carried out on all patients admitted to undergo pedicled supraclavicular artery perforator flap reconstruction within our institution. Results: Nine pedicled supraclavicular artery perforator flap reconstructions were performed. Surgical indications were 3 pharyngocutaneous fistulas, 2 tracheoesophageal fistulas, 2 cutaneous defects, 1 immediate pharyngoesophageal reconstruction, and 1 cutaneous and intraoral defect. All flaps survived completely. Excluding one patient who required a second flap due to plate reexposure, the remaining functional and esthetic outcomes were good. Conclusions: The pedicled supraclavicular artery perforator flap is reliable, is quick to harvest, and entails minimal donor site morbidity. Also, it is thin, is pliable, and has a wide arc of rotation, making it extremely versatile. It is an option that should be added to the spectrum of solutions of any head and neck reconstructive surgeon.

Stapler Use in Salvage Total Laryngectomy: A Useful Tool?

OBJECTIVES/HYPOTHESIS

To analyze stapler benefits in salvage total laryngectomy in terms of surgical time, hospitalization length, oral feeding time, and occurrence of pharyngocutaneous fistula, and to evaluate risk factors for its onset.

STUDY DESIGN

Retrospective analysis.

METHODS

One hundred fourteen patients affected by endolaryngeal squamous cell carcinoma who underwent salvage total laryngectomy following primary treatment failure were reviewed. We divided patients into two groups based on type of pharyngeal suture performed: mechanical suture with stapler (group A) and manual suture (group B). These two groups were compared for surgical time, start of oral feeding, hospitalization length, surgical margins and pharyngocutaneous fistula incidence considering its relationship with diabetes mellitus, nutritional status, primary treatment, and neck dissection.

RESULTS

In group A and group B, oral feeding restarting time was 15 ± 9.33 versus 20.03 ± 13.81 days, hospitalization was 17.63 ± 10.08 versus 23.72 ± 14.29 days, and surgery lasted 268.39 ± 76.93 versus 294.26 ± 140.58 minutes, respectively (P < .05). Surgical margins resulted infiltrated in two patients (4.3%) in group A and 12 patients in group B (17.6%) (P = .03). Twenty-one patients (18.4%) presented with pharyngocutanoeus fistula. In group A and group B the incidence of fistula was 15.2% and 20.6%, respectively (P = .468). Fistula occurred in 7 of 18 diabetic patients (38.9%) and 14 of 96 (14.6%) nondiabetic patients (P = .015). Nineteen fistulas (90.5%) occurred in patients who had undergone previous radiation treatment (P = .013).

CONCLUSIONS

Using a stapler shortened operative time and hospitalization, while also providing a faster restart of oral feeding. Moreover, mechanical pharyngeal suture seems to decrease fistula rate even though its prevention role in salvage laryngectomy should be confirmed by further studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E473-E478, 2021.

Risk Factors for Pharyngocutaneous Fistula After Total Pharyngolaryngectomy

PURPOSE

To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in order to reduce their incidence and propose a perioperative rehabilitation protocol.

MATERIALS AND METHODS

This was a multicenter retrospective study based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical, surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients were divided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 and between 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population data and then applied on the validation population (temporal validation).

OBJECTIVE

To use a preoperative risk score in order to modify practices and reduce the incidence of pharyngocutaneous fistula.

RESULTS

Four hundred fifty-six patients were included, 328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, a history of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicle flap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminant with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI] = 0.59-0.73) and 0.70 (95% CI = 0.60-0.81) for the learning population and the validation population, respectively.

CONCLUSION

A preoperative risk score could be used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors.

3D Printed Fistula Plug: A Novel Bridge to Definitive Reconstruction

A case is presented showcasing the feasibility of three-dimensional (3D) printing patient-specific fistula plugs as a bridge therapy to definitive management of pharyngocutaneous fistulae. For this patient, a set of 3D printed fistula plugs was successfully used with low morbidity and positive results in the management of this postoperative issue. Utilizing 3D printed fistula plugs could represent a novel yet safe therapy for patients requiring long-term management of similar wounds. Further studies are warranted to evaluate implementation of this practice on a widespread scale. Laryngoscope, 131:111-114, 2021.

Post-operative complications due to salvage total laryngectomy for recurrent laryngeal cancer after radiotherapy - a multicentre retrospective study

Background: Few studies have demonstrated the utility of pharyngeal interposition graft (PIG) applying pectoralis major myocutaneous flap (PMMCF) by comparing pharyngocutaneous fistula (PCF) rates.Objective: The objective of this retrospective study was to clarify the utility of PIG applying PMMCF in reducing post-operative complications due to salvage total laryngectomy (STL).Material and methods: STL was performed in 59 patients with recurrent laryngeal cancer after radiotherapy, comprising 37 non-PMMCF patients and 22 PMMCF patients. The primary endpoint was PCF rate. Comparisons were made between two groups: a group with simple closure not using PMMCF (non-PMMCF group), and the other with PMMCF used in a PIG (PMMCF group).Results: PCF occurred in 15 of the 59 subjects (25.4%), including 13 of the 37 patients in the non-PMMCF group (35.1%) and 2 of the 22 patients in the PMMCF group (9.1%). PCF rate was significantly lower in the PMMCF group than in the non-PMMCF group (p = .033).Conclusions and significance: We demonstrated that PIG applying PMMCF significantly reduced the PCF rate due to STL. In the future, surgeons need to conduct research focused on additional innovations to reduce post-operative complications as much as possible.

The Comparative Analysis of Suture versus Linear Stapler Pharyngeal Closure in Total Laryngectomy: A Prospective Randomized Study

Objective

The aim of this study was to prospectively evaluate and compare the outcomes in patients undergoing pharyngeal closure with the linear stapler and suture techniques after total laryngectomy.

Methods

Forty-one patients who needed total laryngectomy for laryngeal cancer were enrolled in the study. Patients were randomized into two groups according to the pharyngeal closure technique: the linear stapler group (Group A) and the suture closure group (Group B). Rate of pharyngocutaneous fistula (PCF), nasogastric tube (NGT) removal time and pharyngeal closure time were analyzed and compared between the two groups.

Results

PCF developed in three patients in Group A (14.3%) and in seven patients in Group B (35%). Although the rate of PCF was lower in Group A, this did not represent a statistical difference (p:0.129). Median NGT removal time was 12 days (IQR=3) and 19.5 days (IQR=1) in Groups A and B, respectively. Median NGT removal time was not statistically different between the two groups (p:0.642). All patients were able to swallow liquids and solids without difficulty. Median pharyngeal closure time was 3 minutes (IQR=1) and 37.5 minutes (IQR=9) in Groups A and B, respectively. Median pharyngeal closure time was significantly lower in Group A (p:0.00).

Conclusion

The linear stapler technique in total laryngectomy is a reliable, safe, easy-to-apply and time-saving method. Closure with linear stapler significantly reduces pharyngeal closure time without adverse effect on NGT removal times and PCF rates.

Utility of negative-pressure wound therapy for orocutaneous and pharyngocutaneous fistula following head and neck surgery

BACKGROUND

Because of the difficulty of airtight sealing and risk of salivary contamination, negative-pressure wound therapy (NPWT) has rarely been applied for postoperative fistula following head and neck surgery; thus, its utility remains unclear.

METHODS

We applied NPWT in 34 patients who developed orocutaneous and pharyngocutaneous fistula after head and neck surgery. Here we retrospectively analyzed the utility of NPWT for managing those fistulas.

RESULTS

Thirty-two patients (94.1%) underwent NPWT as scheduled without adverse events. In 28 patients (82.4%), fistula closure was completed only by NPWT, and the mean period to fistula closure was 30.4 days. The mean period to closure did not differ significantly between fistulas with (21.7 days) and without (39.1 days) previous irradiation.

CONCLUSIONS

Airtight sealing can be maintained and postoperative fistula can be closed by NPWT with a high success rate, even after previous irradiation. NPWT is an effective and minimally invasive treatment for postoperative fistula.

Endoscopic Repair of Pharyngocutaneous Fistula Following Laryngectomy

Pharyngocutaneous fistula (PCF) is a typical complication after total laryngectomy. It is managed predominantly via conservative techniques, but in cases of a large orifice or a substantial loss of surrounding soft tissue, surgical management is mandatory. Our aim was to apply a new endoscopic surgical approach for closure of a pharyngocutaneous fistula.

We report a case of a 61-year-old patient, who had been subjected to total laryngectomy with partial resection of tongue base and postoperative radiotherapy for advanced laryngeal carcinoma. Pharyngocutaneous fistula developed two years after the initial treatment. Barium swallow radiographs revealed a fistula between the neopharynx and the skin at the C2-C4 level. An endoscopic surgical repair was performed. Fat tissue harvested from the abdomen was injected into the area surrounding the pharyngeal opening of the fistula. The opening was sclerosed and sutured. The patient resumed a normal diet after several days and the fistula did not recur throughout the follow-up period.

The management of pharyngocutaneous fistula is mainly conservative and only in therapy-refractory cases, surgery is considered. In well-selected cases, an endoscopic approach can be used. Autologous fat injection around the hypopharyngeal opening of the PCF may be one of the possible options.

Total Laryngectomy with Horizontal Mechanical Closure of the Pharyngoesophagectomy: Evaluation of the Effectiveness in Elderly Patients

Introduction  The main modalities of surgical treatment for laryngeal cancer include transoral laser microsurgery (TLM), open preservation surgery, and total laryngectomy (TL). In the elderly, for the presence of comorbidities, the surgical approach more appropriate in many cases remains TL. The use of a stapler for the closure of the esophagus has been introduced to reduce surgical time and postoperative complications such as pharyngocutaneous fistula (PCF).

Objective  In the present study, we have evaluated the effectiveness of the use of the horizontal mechanical pharyngoesophageal closure in patients who underwent TL.

Methods  This nonrandomized study was performed on consecutive patients with histopathologically proven squamous cell endolaryngeal carcinoma. The TL was performed using a linear stapler to mechanically suture the pharyngotomy using the semiclosed technique.

Results  A total of 33 patients underwent TL, and 13 of them underwent neck dissection. A total of 15 patients (45.4%) were ≤70 years old, and 18 were > 70 years old. Analyzing the results in relation to age, patients > 70 years old showed tumors at an earlier stage than those aged ≤70 years old. Furthermore, in this group there was a greater number of patients who had comorbidities ( p  = 0.014). In total, we had 2 (6%) cases of PCF in 6.6% in the group ≤70 years old, and in 5.5% of the group > 70 years old ( p  = 1.00).

Conclusions  The use of the stapler for the horizontal closure of the pharyngoesophagectomy in the patients subjected to TL is proven to be useful and safe even when used in elderly patients.

Outcomes following pharyngeal reconstruction in total laryngectomy - Institutional experience and review of literature

Background:

Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction.

Materials and Methods:

Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction.

Results:

Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003).

Conclusion:

Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps

BACKGROUND

Salvage surgery for laryngeal cancer recurring after radiotherapy is difficult and complications readily occur. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous (PMMC) flap, which has copious blood flow, for preventing post-irradiation pharyngocutaneous fistula.

AIMS/OBJECTIVES

The purpose of this study was to examine the incidence of post-operative complications of salvage total laryngectomy (STL) using the PMMC flap for post-radiotherapy recurrent laryngeal cancer at our institution.

MATERIAL AND METHODS

From among 162 patients with laryngeal cancer who had been treated at Tokyo Medical University Hospital between January 2014 and March 2018, we enrolled 11 patients who had undergone STL applying a PMMC flap. We examined patient backgrounds (age, gender, subtype, stage), initial therapy (radiotherapy/chemoradiotherapy), radiation dose, irradiation area, surgery type (with/without neck dissection) and postoperative complications.

RESULTS

No severe systemic complications were encountered. Pharyngocutaneous fistula occurred as a severe local complication in one patient (8.3%) and wound infection as a mild local complication in one patient (8.3%).

CONCLUSIONS

Rates of post-operative complications following STL tended to be lower at our institution than those reported for other institutions.

SIGNIFICANCE

PIG may be a useful surgical procedure in STL.

[Advances in prevention of pharyngocutaneous fistula after total laryngectomy]

Summary Total laryngectomy is a common method for the treatment of malignant tumors of the pharynx and larynx in China, but pharyngocutaneous fistula often happens after surgery, which burdens patients and affects postoperative recovery. At present, there are many measures to prevent pharyngocutaneous fistula, including strengthening nutrition pre-operative and post-operative, testing related indicators, controlling comorbidities, rational use of drugs, regular oral care, optimal selection of incision closure, and using of flaps and special materials during operation, etc. However, the choice of specific program needs to take care of the patient's condition, surgeon's skills and hospital conditions, and often requires multiple programs to be used together throughout the perioperative period. This article will provide a brief review of some strategies for preventing pharyngocutaneous fistula after total laryngectomy.

Neck Muscle Mass Index as a Predictor of Post-Laryngectomy Wound Complications

OBJECTIVE

We investigated the relationship between paravertebral muscle cross-sectional area (PVM CSA) at the third vertebra (C3) level using computerized tomography (CT) neck images and its relationship with complications after total laryngectomy.

DESIGN

Retrospective analysis of 60 advanced laryngeal cancer patients who underwent total laryngectomy was performed. The cross-sectional areas of paravertebral neck muscles using neck CT at C3 level images obtained preoperatively were analyzed.

RESULTS

A significant difference in PVM CSA between complication and no complication groups, F(1, 53 = 4.319, P = .043), was identified by ANCOVA. There were no significant differences in between-subject effects: T-stage ( F = 1.652, P = .204), body mass index ( F = 0.889, P = .35), albumin ( F = .359, P = .552), age ( F = 1.623 P = .208), and smoking ( F = 4.319, P = .41).

CONCLUSION

The PVM CSA measured at C3 level on pretreatment CT may help identify patients at higher risk of postoperative wound complications after total laryngectomy and who may particularly benefit from preoperative optimization of nutritional status.

Total laryngectomy: Surgical morbidity and outcomes - A case series

BACKGROUND

Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies.

AIM

The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center.

SETTING AND DESIGN

This was a retrospective review of a prospective database of TL patients operated during 2012-2013.

MATERIALS AND METHODS

Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien-Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan-Meier survival curves.

RESULTS

A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts.

CONCLUSION

TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.