Regional pedicled flaps in prevention and repair of pharyngocutaneous fistulas.

BACKGROUND: Pharyngocutaneous fistula (PCF) is a common complication after laryngopharyngeal surgery. It presents incredible difficulties to both doctors and patients and can lead to prolonged hospitalization. OBJECTIVE: To analyze the pros and cons of the pedicled skin flap in the prevention and repair of PCF and put forward the authors' views and experience about the selection and application of flaps for the treatment of PCF. METHODS: A literature review of pedicled flap application in PCF was carried out. RESULTS: Based on the analysis of the characteristics of the pedicled flap in PCF treatment, the advantages and disadvantages are compared. RESULTS: In the literature, the pectoralis major myocutaneous flap is the most widely used regional pedicled flap for PCF. Many other flaps can be used to prevent and treat PCF. Each kind of pedicled flap has advantages and limitations. This plays a role in the individualized selection and design of PCF to maximize the benefits of patients. CONCLUSIONS: Taking unity of function, aesthetics, and proficiency of operators into account, choosing the appropriate flap to repair PCF can reduce the occurrence rate of PCF and improve the patient's quality of life.

[The primary use of pectoralis myofascial flap in salvage laryngectomy]. / Die primäre Verwendung des myofaszialen M. pectoralis-major-Lappens bei der Salvage-Laryngektomie.

BACKGROUND: The salvage laryngectomy (SLE) is very often the only curative option in recurrent laryngeal or hypopharyngeal carcinomas. But the SLE is associated with an increased risk of complications such as the formation of salivary fistulas. To reduce the rate of fistulas a simultaneous elevation of the myofascial pectoralis major flap (PMML) is described. The aim of this study was to compare the SLE with and without the use of the PMML for prophylaxis of salivary fistulas. PATIENTS AND METHOD: 9 patients were included, suffering from a T4a larynx or hypopharynx carcinoma recurrence after RCT in the years 2012 and 2013 and subsequently treated by a SLE. An additional elevation of PMML was indicated due to the following criteria: end of RCT less than one year ago, tumor localization outside the glottis, infiltration of thyroid cartilage and prelaryngeal muscles. After PMML elevation the flap was sewed onto a primary closed pharynx. RESULTS: 6 out of 9 patients (2/3) received an additional covering of the pharynx by the PMML during SLE. In no case a postoperative salivary fistula was seen. In the remaining 3 patients (1/3) the pharynx was primarily closed without an additional covering by the PMML. In this group of patients one postoperative salivary fistula was seen. CONCLUSION: Due to the simultaneous application of the PMML in the context of SLE the rate of postoperative salivary fistula could be effectively reduced in our own patients. The PMML is suitable due to its safe elevation technique, the missing secondary thoracal cutaneous defect, and a good modelling possibility in the recipient area.

Reducing fistula rates following laryngotracheal separation.

OBJECTIVES: Laryngotracheal separation (LTS) is an uncommonly performed but highly effective procedure for intractable aspiration in patients with amyotrophic lateral sclerosis and other neurodegenerative conditions. Previously published series have noted rates of postoperative tracheocutaneous fistula formation as high as 1 in 3 patients. This report details the use of a muscle flap-reinforced imbrication technique to reduce the incidence of fistula formation after LTS surgery. METHODS: All patients who underwent LTS surgery at the reporting institutions between 2004 and 2010 were identified. The principal diagnosis, patient characteristics, the presence of a preexisting tracheotomy, and postoperative complications were recorded. We describe the technique for imbrication closure of the proximal stump with strap muscle reinforcement. RESULTS: Thirteen patients (10 male, 3 female; median age, 53 years; interquartile range, 45 to 66 years) underwent the LTS procedure; amyotrophic lateral sclerosis was the principal diagnosis in 8 of the 13 patients. Six patients had a preexisting tracheotomy. None developed tracheocutaneous fistula, hematoma, or wound infection. Two patients required stomaplasty at a later date. CONCLUSIONS: Strap muscle flap-reinforced imbrication closure of the proximal tracheal stump after LTS surgery allows for a low incidence of postoperative fistula formation.

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.

Semon Lecture: 'Laryngectomy Practice Based on Personal Research', Royal Society of Medicine, 5 November 2020, London, UK.

I wish to thank the Semon Committee for inviting me to deliver the 2020 Semon lecture. This is a very special honour, as is evidenced by the list of distinguished lecturers dating back to the inaugural lecture delivered at University College London in 1913. I am not the first South African to deliver the Semon lecture, having been preceded by my previous chairman Sean Sellars in 1993, and by Jack Gluckman in 2001, who was South African raised and educated and who subsequently became the chairman of otolaryngology in Cincinnati, USA.

[The application status of the linear stapler device in the total laryngectomy].

Summary It is very obvious that the linear stapler can shorten the operation time, reduce the incidence of pharyngeal fistula, and shorten the oral feeding time in total laryngectomy. However the stapler was used in the total laryngectomy not as widespread as in gastrointestinal surgery. In order to further understanding the function of the linear stapler device in the total laryngectomy, the stapler's composition, working principle, classification，method to use, operation method, and application of advantages and disadvantages will be reviewed.

Reconstruction after salvage laryngectomy.

Both early and advanced stage laryngeal cancers are treated with organ-preserving strategies including radiation alone or concurrent chemoradiotherapy. While organ-preserving modalities have proven effective in eradicating cancer while also preserving laryngeal function, there remains a proportion of cases where residual or recurrent cancer prevails, or conversely, where radiotherapy renders a larynx dysfunctional. In these circumstances, salvage total laryngectomy is often the surgical treatment. The effects of radiotherapy to the neck, amplified by chemotherapy, can create an inhospitable surgical environment, making the salvage laryngectomy an operation fraught with the potential for major complications such as the dreaded pharyngocutaneous fistula. The introduction of vascularized tissue from outside the irradiated field decreases the risk of major wound complications. Free tissue transfer, with a variety of donor sites available, is commonly employed to reconstruct either a patch or a circumferential segment of the pharynx. When there is enough pharyngeal mucosa for primary closure, a vascularized onlay graft or a pharyngeal interposition graft can be used to reinforce the closure. This has been demonstrated to both reduce the severity of pharyngocutaneous fistula and decrease the risk of developing a pharyngocutaneous fistula compared to primary closure alone. Beyond mitigating the risk for perioperative complications, flap selection may have implications on the long-term outcomes after salvage total laryngectomy and these must be considered preoperatively. The purpose of this review is to examine the various options for reconstruction after salvage total laryngectomy and to examine some of their advantages and disadvantages in the short and long-term.

Lessons learned using Snodgrass hypospadias repair.

BACKGROUND: This is a review of our experience with the Snodgrass technique for distal hypospadias repair and we point to lessons learned in improving results. METHODS: We reviewed all patients who underwent Snodgrass hypospadias repair for distal hypospadias over a four-year period by a single surgeon. Chart review followed by parental telephone interview was used to determine voiding function, cosmesis and complication rate. RESULTS: Thirty children and three adults were identified. Age at surgery ranged from seven months to 39 years. The urinary stream was straight in 94%, and 97% reported a good or satisfactory final cosmetic outcome. One patient (3.3%) developed a urethral fistula and 21% developed meatal stenosis which required general anaesthetic. CONCLUSION: The Snodgrass urethroplasty provides satisfactory cosmetic and functional results. High rates of meatal stenosis initially encountered have improved with modifications to technique which include modified meatoplasty and routine meatal dilatation by the parents.

Modification of the Radial Forearm Fasciocutaneous Flap in Partial Pharyngolaryngeal Reconstruction to Minimize Fistula Formation.

Reconstruction of pharyngolaryngoesophageal defects following salvage surgery in patients with a history of chemoradiation is a challenging problem with a high incidence of pharyngocutaneous fistula. The authors describe three cases of successful reconstruction of partial pharyngolaryngoesophageal defects using a modified radial forearm free flap with additional dermal reinforcement and review the literature for innovations in the use of radial forearm free flap for reconstruction of these difficult cases. Modification of the radial forearm free flap makes it a versatile, reliable flap that has become the "go-to" flap for partial pharyngolaryngoesophageal reconstruction.

Reduction of Pharyngocutaneous Fistulae in Laryngectomy Patients by a Comprehensive Performance Improvement Intervention.

OBJECTIVE: Pharyngocutaneous fistula is a common complication in laryngectomy patients, particularly in previously irradiated cases. We initiated a comprehensive performance improvement intervention in all head and neck surgery patients intended to reduce postoperative infection and fistulae rates. We report our review of outcomes within laryngectomy patients. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary referral center. SUBJECTS: Nineteen laryngectomy patients at risk of postoperative fistula formation. METHODS: We reviewed the medical records of all patients who had undergone laryngectomy procedures between January 2013 and April 2014. Clinicodemographic data were obtained, including history of diabetes, prior radiation therapy, type of reconstruction performed for closure of the pharyngeal defect, and the presence or absence of postoperative fistula. RESULTS: The study population comprised 19 laryngectomy patients. Prior to implementation of our performance improvement intervention, 8 of 11 (73%) patients undergoing laryngectomy developed postoperative fistulae. After intervention, 0 of 8 patients developed fistulae (P = .002). Prior radiation, diabetes mellitus, and overall stage were not associated with a reduction in fistula rate (P > .05). CONCLUSION: Comprehensive uniform application of a standard antibiotic prophylaxis, surgical technique, perioperative care, and treatment of comorbid conditions can significantly reduce and potentially eliminate fistulae in laryngectomy patients who are especially at risk.

Pedicled external spermatic fascia flap for urethroplasty in hypospadias and closure of urethrocutaneous fistula.

PURPOSE: To prevent the development of urethrocutaneous fistula after urethroplasty for hypospadias or recurrence after closure of a urethrocutaneous fistula, the authors developed a new simple technique wherein the readily available external spermatic fascia (ESF) surrounding the testis and cord is used as a pedicled blanket flap to cover the neourethra or the site of closure of a urethrocutaneous fistula. RESULTS: In three patients who had urethroplasty for hypospadias incorporating our ESF flap procedure, no urethrocutaneous fistula developed. It was also effective for closure of urethrocutaneous fistula in five patients, some of whom had had recurrent fistula formation.

Professional holistic care of the person with a stoma: online learning.

Stoma care nurse specialists are valued for their diverse expertise, but it is essential that all practitioners who regularly care for people with stomas have the opportunity to develop professionally and influence this important area of practice. The vision of a clinical and educational team from Suffolk and south Norfolk led to the development of innovative web-based learning material. The aim is to inspire nurses to engage actively with people who have a stoma. 'Professional care of the person with a stoma' is about caring for the whole person, physically and emotionally, from the period before surgery, to their continuing care in the community. An overview of four aspects of stoma care is presented here as a way of sharing with a wider audience the expert practice harnessed during the development of this web-based module.

[External intestinal fistulae following gynecological operations and their treatment]. / Naruzhnye kishechnye svishchi posle ginekologicheskikh operatsii i ikh lechenie.

The authors share their experiences with treatment of 38 patients with external intestinal fistulas after operations on internal genitals. The patients were divided into three groups: patients with pyo-inflammatory diseases, patients with benign tumors and patients with malignant neoplasms. It is noted that preoperative diagnosis of involvement of the intestine in the process is rather difficult, instrumental methods of examination in patients with pyo-inflammatory diseases are poorly informative. In patients with malignant diseases of the uterus and uterine appendages the sigmoid colon should be examined in order to exclude the penetration of the tumor. Adhesive processes resulting from previous operations are considered to be a predisposing factor. Relaparotomies must be performed with the obligatory participation of the surgeon. Operation on the intestine should be performed before the intervention on the internal genitals. The unloading colostomy must be made in suturing the defect of the colon. The use of the method described allowed to save the life of 36 patients (lethality was 5.3%).

Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review.

OBJECTIVES/HYPOTHESIS: Pharyngocutaneous fistulae (PCF) are known to occur in nearly one-third of patients after salvage total laryngectomy (STL). PCF has severe impact on duration of admission and costs and quality of life and can even cause severe complications such as bleeding, infection and death. Many patients need further surgical procedures. The implications for functional outcome and survival are less clear. Several studies have shown that using vascularized tissue from outside the radiation field reduces the risk of PCFs following STL. This review and meta-analysis aims to identify the evidence base to support this hypothesis. DATA SOURCES: English language literature from 2004 to 2013 REVIEW METHODS: We searched the English language literature for articles published on the subject from 2004 to 2013. RESULTS: Adequate data was available to identify pooled incidence rates from seven articles. The pooled relative risk derived from 591 patients was 0.63 (95% CI: 0.47 to 0.85), indicating that patients who have flap reconstruction/reinforcement reduced their risk of PCF by one-third. CONCLUSION: This pooled analysis suggests that there is a clear advantage in using vascularized tissue from outside the radiation field in the laryngectomy defect. While some studies show a clear reduction in PCF rates, others suggest that the fistulae that occur are smaller and rarely need repair.

Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis.

OBJECTIVES/HYPOTHESIS: Concurrent chemoradiotherapy is the gold-standard nonsurgical organ-preservation treatment for advanced laryngeal carcinoma. Total laryngectomy (TL) is increasingly reserved for surgical salvage. Salvage surgery is associated with more complications than primary surgery. A systematic review and meta-analysis was undertaken to establish the impact of organ preservation protocols on pharyngo-cutaneous fistula incidence following TL, and to synthesize evidence on the role of "onlay" prophylactic tissue flaps in reducing this complication in salvage TL. DATA SOURCES: The English language literature (January 1, 2000, to September 1, 2013) was searched, using PUBMED and EMBASE databases, for the terms "laryngectomy" and "fistula." Of 522 studies identified from database searches, 33 were included in the quantitative synthesis. REVIEW METHODS: Studies reporting fistula incidence following primary TL (PTL), salvage TL (STL), and STL with "onlay" flap-reinforced pharyngeal closure were included. Data were extracted by the first author (M.S.). Meta-analysis of fistula incidence was performed. RESULTS: PTL fistula incidence is 14.3% (95% CI 11.7-17.0), STL 27.6% (23.4-31.8), and STL with flap-reinforced closure 10.3% (4.6-15.9). Chemoradiotherapy is associated with a pooled fistula incidence of 34.1% (22.6-45.6), compared to 22.8% (18.3-27.4) for radiotherapy alone. Relative risk of fistula is 0.566 (0.374-0.856, P = 0.001) for STL with flap-reinforced closure compared to STL alone. The number needed to treat (NNT) to prevent one fistula is 6.05. CONCLUSION: Prophylactic flaps used in an "onlay" technique reduce fistula incidence in STL. Chemoradiotherapy increases fistula incidence more than radiotherapy alone. Prophylactic flaps should be offered in salvage cases after failed chemoradiation protocols.