Boerhaave's syndrome in a tracheoesophageal speaker: report of a case.

Boerhaave's syndrome is still associated with a high mortality rate and remains a therapeutic challenge. Pharyngo-laryngo-esophagectomy is performed as the standard treatment for advanced hypopharyngeal cancer and tracheoesophageal speech is an option for esophageal speech rehabilitation. We report what, to our knowledge, is the first case of Boerhaave's syndrome developing in a tracheoesophageal speaker.

Eating again: a physician's personal experience after laryngectomy.

This article presents the author's personal experiences in eating again after becoming a laryngectomee. He was diagnosed with hypopharyngeal carcinoma and underwent total laryngectomy with a free flap reconstruction. The personal story is told in the hope that nutritionists and other health care providers will realize the difficult challenges in obtaining adequate nutrition that a patient diagnosed with cancer who undergoes laryngectomy must face. These include the effects of radiation treatment and surgery, which create functional and anatomical changes that make swallowing difficult.

Synchronous reconstruction of esophageal defect and voice with J-flap after laryngopharyngectomy: Indications and outcomes.

BACKGROUND: The primary reconstruction goal for patients with laryngopharyngectomy is the restoration of esophagus, whereas voice reconstruction is less readily reconstructed. J-flap is a novel surgical technique designed to reconstruct voice and esophagus synchronously, permitting functional rehabilitation of aerodigestive tract after laryngopharyngectomy. OBJECTIVES: This study aims to present indications, surgical steps, and outcomes of an innovative technique for synchronous reconstruction of the esophagus and voice tube with a free thigh flap (J-flaps). METHOD: Single-center study from 2011 to 2017 recruiting patients with hypopharyngeal cancer needing laryngopharyngectomy and J-flaps reconstruction. Patient details were analyzed, and surgical outcomes were examined. RESULTS: 20 patients were recruited with an average age of 61. Tumor staging was IIB or above. The average follow-up period was 15 months. 65% of these patients resumed a full diet. The row phonation rate was 75%. The average maximum phonation time was 8.9 s, and the average number of counting in a breath was 14. CONCLUSIONS: Most patients achieved a conversational level of speech capacity with a humanoid voice. J-flap can be utilized safely, supporting the social re-integration of these patients with their new voice.

Surgical Treatment of Advanced Staged Hypopharyngeal Cancer.

It is not uncommon for patients with hypopharyngeal cancer to present at an advanced stage of disease. Surgical treatment provides a cure for the tumour with immediate relief from obstruction to the airway and the swallowing passage. Careful planning of surgery is important to ensure good outcome of treatment and prevent complications, some of which may be fatal. The shape of the hypopharynx resembles that of a funnel, with a wide circumference above in continuity with the oropharynx, and a small circumference below where it joins with the cervical oesophagus. As a result, while small tumours require the partial removal of the hypopharynx, large tumours, especially those involving the post-cricoid region, warrant a complete, circumferential pharyngectomy. For tumours that invade the cervical esophagus, transcervical approach is still feasible, and this is facilitated by the removal of the manubrium, allowing access to the tumour and resection with clear margins. In the presence of synchronous tumours lower down in the esophagus, pharyngo-laryngo-esophagectomy is indicated. Successful reconstruction of defects after tumour extirpation allows proper wound healing and early delivery of adjuvant radiotherapy. It is also important to ensure quick recovery of the long-term swallowing function. It ranges from the use of the soft tissue flap with skin island that is sutured as a patch to the remnants of the pharyngeal mucosa, to the use of a visceral flap, such as the free jejunal flap, to repair the circumferential pharyngectomy defects. The treatment protocol is personalized according to the extent of the tumour and the characteristics of the patients.

Long-term performance of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy.

OBJECTIVES: To assess the use of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy, to identify the clinicopathologic factors for favorable outcome, and to evaluate the factors that determine prosthesis lifetime. DESIGN: Retrospective review. SETTING: Tertiary care institution. PATIENTS: Sixty consecutive patients with total laryngectomy were included. All had indwelling tracheoesophageal speaking valves for voice restoration. INTERVENTION: Anterograde replacement of voice prosthesis in case of failure of functional speech production or leakage of saliva. MAIN OUTCOME MEASURES: Incidence of successful tracheoesophageal speech rehabilitation for daily communication, influence of different clinicopathologic factors on the outcome, and prosthesis lifetime and its relationship to different clinicopathologic factors. RESULTS: The success rate of speech rehabilitation was 78%. Age younger than 60 years was the only clinicopathologic factor associated with successful speech rehabilitation (P = .04, Fisher exact test). The median device lifetime was 8.2 months. Both age of 60 years or older and the use of subsequent prosthetic valves were identified as risk factors for valve failure on univariate analysis (n = 192; log-rank test; P = .02 and P = .03, respectively), with age of 60 years or older as the only risk factor that reduced the device lifetime in the Cox proportional hazards model (P = .03; relative hazard ratio, 1.5; 95% confidence interval, 1.1-2.4). CONCLUSIONS: Our success rate in using indwelling tracheoesophageal speaking valves was comparable to that reported in the Western literature. The median device lifetime of 8.2 months was satisfactory. Patient age was found to be a significant predictor of successful tracheoesophageal speech rehabilitation, with age of 60 years or more adversely affecting device lifetime.

Gastric pull-up reconstruction for pharyngo-laryngo-esophagectomy.

OBJECTIVE: To determine the results of gastric pull-up reconstruction following pharyngo-laryngo-esophagectomy. DESIGN: Retrospective review of 59 patients who underwent gastric pull-up reconstruction for carcinoma of the hypopharynx, larynx, and cervical esophagus during a 10-year period from 1983 to 1993. SETTING: Combined Head and Neck Service and Section of General Surgery, Department of Surgery, Yale University Medical School, New Haven, Conn. MAIN OUTCOME MEASURES: Morbidity, mortality, time to oral feeding, length of hospitalization, and long-term results. RESULTS: The mortality rate was 5%, perioperative morbidity rate, 27%, and the medical morbidity rate, 32%. Most patients took oral feedings within 6 days after surgery and were discharged within 16 days. There were two temporary fistulas and four strictures, none of which were permanent. There were no intrathoracic or mediastinal injuries or hemorrhage. The overall survival was 1 to 100 months (median survival, 12 months); the median survival was 34 months for patients alive to date and 8 months for patients who died. CONCLUSIONS: The gastric pull-up reconstruction is a safe, effective operation with a low mortality rate and excellent long-term functional results for patients with extensive carcinoma of the hypopharynx, larynx, and cervical esophagus.

Reconstruction of the laryngopharynx after hemicricoid/hemithyroid cartilage resection. Preliminary functional results.

OBJECTIVE: To evaluate the use of a sensate radial forearm free flap and free cartilage graft for reconstruction of the laryngopharyngeal defect that results from resection of pyriform sinus carcinoma that extends to the apex of the pyriform sinus and includes the hemithyroid and hemicricoid cartilages. DESIGN: Case series review of 6 patients treated during a 2 1/2-year period with an average follow-up of 23 months. Factors evaluated included oncologic outcome, as well as functional outcome with regard to the onset and quality of the airway, speech, and deglutition. SETTING: Mount Sinai School of Medicine, New York, NY, an academic, tertiary referral center. PATIENTS: Six men ranging in age from 51 to 73 years underwent a partial laryngopharyngectomy that included the hemicricoid and hemithyroid cartilages as well as the ipsilateral thyroid lobe and either unilateral or bilateral lymph node dissections for squamous cell cancer that involved the apex of the pyriform sinus. INTERVENTION: These extensive laryngopharyngeal defects were reconstructed with a sensate radial forearm flap that resurfaced the endolarynx, restored the depth of the pyriform sinus, and reconstructed the remainder of the hypopharynx. In the final 4 patients, a free costal cartilage graft was used to restore the infrastructure of the larynx. OUTCOME MEASURES: The status of the margins, the incidence and site of recurrent cancer, the quality of speech, and the times to decannulation and removal of the gastrostomy tube. RESULTS: Three recurrences developed, with 1 each at the primary site, in the neck, and systemically. All but 1 patient who had completed radiotherapy by the last follow-up had been decannulated, and all but 1 patient regained the ability to maintain nutrition by mouth. Complications were limited to pharyngocutaneous fistulae requiring surgical closure in 3 patients early in the series. CONCLUSIONS: Functional reconstruction of extensive laryngopharyngeal defects can be achieved with a sensate radial forearm flap and a cartilage graft, with favorable functional results and acceptable morbidity, thus expanding the limits of conservation laryngopharyngeal surgery.

Laryngopharyngectomy with reconstruction.

A wide range of reconstructive options allows the ablative surgeon to resect tumors completely with wide margins. Wide resection is especially important because of the rich lymphatic drainage and submucosal spread seen with carcinomas in the hypopharyngeal area. Postoperative stenosis can be a difficult, recurring problem if the neopharynx does not have enough tissue incorporated into the closure. Therefore, most laryngopharyngectomy procedures benefit from the addition of transposed tissue, either pedicled or using free tissue transfer microvascular techniques. Often the location of the tumor is a major factor in determining which reconstruction is best for the patient. Minimizing the donor-site morbidity must be carefully considered, also.

Preservation of laryngeal function after removal of carcinoma of the pyriform sinus.

Since March 1978, conservative laryngopharyngeal surgery has been used in the treatment of carcinoma of the pyriform sinus at this hospital. For pharyngeal reconstruction, cervical skin flap, deltopectoral flap, free microvascular bowel transfer, and pectoralis major myocutaneous flap and gastric pull-up transfer were used. The remaining part of the larynx was repaired with cervical skin flap, sternohyoid myofascia, epiglottis or remnant of epiglottis for complete rehabilitation (phonation, deglutition protection and respiration) or partial rehabilitation (phonation and deglutition protection) of laryngeal functions. 47 patients with carcinoma of the pyriform sinus were treated, and fairly good results were obtained. The 5-year survival rate was 41.7%, and the 3-year survival rate 50%. The laryngeal function restored completely in 31 patients and partially in 16. It is suggested that preservation of the unaffected part of the larynx is feasible both for eradication of tumor and preservation of laryngeal function.

[Rehabilitation and return-to-work after laryngectomy: the role of industrial otolaryngologists].

Rehabilitation and return-to-work are important problems for laryngectomized patients. Here, we report 2 cases of laryngectomized middle-aged men, and discuss the role of otolaryngologists from the viewpoint of an industrial physician. The first case is a 55-year-old post-office male clerk, who underwent radical and reconstructive surgery for hypopharyngeal carcinoma. He started light work following 3-month-rest at home after discharge, and fully returned to his previous work 3 years later. The second case is a 50-year-old mailman who also underwent radical and reconstructive surgery for hypopharyngeal carcinoma. He could not return to work because of the recurrence of tumor during rehabilitation. In such cases, comprehensive management including medical, mental and social supports is essential according to the occupational environment. Industrial otolaryngologists should play an important role in rehabilitation and return-to-work of laryngectomized patients.

[Quality of life evolution in patients after surgical treatment of laryngeal, hypopharyngeal or oropharyngeal carcinoma]. / Evolución de la calidad de vida en pacientes intervenidos de carcinomas de orofaringe, laringe o hipofaringe.

INTRODUCTION: The assessment of quality of life in patients with head and neck cancer is dependent on many variables. OBJECTIVE: The aim of this study was to evaluate the differences in quality of life among patients treated with conservative or radical surgery for laryngeal, oropharyngeal or hypopharyngeal cancer, evaluated before and at 3 and 6 months after definitive therapy. MATERIAL AND METHOD: Prospective study between November 2008 and June 2009 on 53 patients diagnosed and treated for head and neck carcinoma with surgery: partial (n=32) and radical (n=21). Quality of life was evaluated using the European Organization of Research and Treatment of Cancer (EORTC) general questionnaire EORTC QLQ-C30 and its specific head and neck EORTC QLQ-H&N35 before treatment, and at 3 and 6 months afterwards. RESULTS: No significant differences were found in overall health. Patients experienced the greatest changes in functional scale. There were no changes in swallowing problems or feeling of disease, while evident phonation problems were present in both groups. DISCUSSION AND CONCLUSIONS: The routine application of quality of life questionnaires in cancer patients improves information regarding how and to what extent patients feel that treatment and its sequelae modify it, making it possible to adapt rehabilitation and support programs to their real needs. This data helps in choosing between different options depending on the results, delivering improved care to patients.

Double vascular anastomosis in the neck for reliable free jejunal transfer.

To reduce the possibility of necrosis in free jejunal transfer after total pharyngolaryngo-oesophagectomy, we made a second set of arterial and venous anastomoses in addition to the usual cervical arterial and venous anastomoses. To obtain two different arterial flows (carotid and subclavian systems), the recipient arteries were the superior thyroid and the transverse cervical. For venous flow, the internal and external jugular veins were used. All flaps survived. This procedure, which is limited to the already dissected neck with no procedures in other areas, is less invasive than others. Its advantages are that when one vessel has thrombosed the other vessel functions as a safety valve, and the greater pliability of the vascular pedicles makes it easier to reach the recipient vessels. Because this method is theoretically safe and results in less possibility of losing a flap when the anastomosis is unreliable, the double-pedicled transfer can be an option for safer free jejunal transfer.

[Quality of life in treated head and neck cancer patients].

Sixty-Seven patients with head and neck cancer have been studied with respect to their quality of life after their treatment. The Grogono Woodgate index was used to evaluate their quality of life, the quality of life of patients treated for laryngeal cancer was excellent, even if they underwent total laryngectomy. On the contrary, however, patients who had hypopharyngeal cancer and had undergone a pharyngolaryngoesophagectomy had the lowest indices. As for patients with an oral cancer, their indices were high if the cancer was being controlled by radiotherapy.

[Visceral voice training for laryngectomy after hypopharyngectomy and visceral transplant].

OBJECTIVE: To establish a way to visceral voice after stomach or colon transplantation for patients with hypopharyngeal or cervical esophageal cancer. METHODS: Esophageal voice training was used and modified according to the compliance of the patients. Twenty laryngectomies with replacement of the hypopharynx and esophagus by stomach(13 cases), colon(6 cases) and jejunum (1 case) were trained for voice rehabilitation at the Department of Head and Neck Surgery. RESULTS: The patients with an artificial esophagus from vicera were easy to gain an influx of certain volume of gas into their artificial esophagus (stomach or colon) and to learn to speak. But on the whole the quality of voice was not so satisfactory. In this series nineteen out of 20 patients (95%) could express their idea by speech after a training course of three weeks. CONCLUSION: The literature has emphasized role of cricopharyngeus muscle in the training of esophageal voice. Owing to the fact that this series of patients who had had their cricopharyngeus removed, could easily get their voice rehabilitated, it seems this muscle played no major role in the voice rehabilitation.