The Value of the "Papillon" Anterolateral Thigh Flap for Total Pharyngolaryngectomy Reconstruction: A Retrospective Case Series.

PURPOSE: The tubed, buried anterolateral thigh (ALT) flap is a popular reconstruction method for total pharyngolaryngectomy defects. The "papillon"-designed ALT flap, described by Hayden et al, offers an alternative method of using the ALT flap in this situation. We report our early experience with the papillon ALT flap in a patient cohort. PATIENTS AND METHODS: On retrospective review, all patients who underwent reconstruction of circumferential total pharyngolaryngectomy defects with the papillon ALT flap from February 2012 to February 2015 were identified from our departmental database. Demographic and clinical data, operative details, and complications were analyzed from the records. RESULTS: Seven patients were included in this study. The mean length of hospital stay was 15 days (range, 10 to 32 days). Acute complications occurred in 5 of 7 patients, namely, partial flap loss managed by a pectoralis flap (1 of 7 [14%]); an early pharyngocutaneous fistula (4 of 7 [57%]) managed by simple repair, wound packing, or delayed repair; and a donor-site hematoma (1 of 7 [14%]). At follow-up (range, 2 to 24 months), there was 1 stricture formation, but no chronic fistula. All patients were able to swallow orally. CONCLUSIONS: Early results using the papillon ALT flap suggest that this technique is a viable alternative to the standard tubed ALT flap design. The advantages of this design include the following: 1) it offers simultaneous vascularized skin to resurface anterior neck skin deficiency without resorting to additional tissue elsewhere; 2) direct monitoring of the ALT flap is possible; and 3) any pharyngocutaneous fistula is exteriorized to the surface without compromising the internal neck structures and can be easily identified and repaired directly in the office.

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.

[Quality of life after oropharyngectomy]. / Qualité de vie après buccopharyngectomie transmandibulaire.

OBJECTIVE: The purpose of this study was to assess direct or non-direct links between functional abilities of the patient evaluated objectively and his quality of life after oropharyngectomy, a surgery capable of engendering bad functional outcomes. METHODS: Praxies and speech were examined in 16 patients at 3, 6, 9 or 12 months after surgery and 2 self-evaluation questionnaires were proposed: One about health related quality of life of cancer patients (EORTC QLQ-C30 and H&N35) and, the other about oral communication handicap (VHI). RESULTS AND CONCLUSION: A correlation between quality of life and objective functional abilities can not always be found. Self-evaluation questionnaires might be a complementary approach in order to guide management in patient care after oropharyngectomy.

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: preliminary report.

CONCLUSION: The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). OBJECTIVES: To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. MATERIAL AND METHODS: This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. RESULTS: All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.

Voice restoration by primary insertion of indwelling voice prosthesis following circumferential pharyngolaryngectomy with free jejunal graft.

BACKGROUND: Voice restoration after circumferential pharyngolaryngectomy (CPL) with free jejunal graft remains a difficult problem to solve. Few reports have analyzed the success rate and complications following primary insertion of indwelling voice prostheses during CPL with free jejunal graft. PATIENTS AND METHODS: Eight patients who underwent CPL with free jejunal graft had a Groningen voice prosthesis inserted as a tracheoesophageal (TE) shunt at the time of oncological surgery. A 10-point scale was used to assess each patient's speech intelligibility. Complications following the voice prosthesis insertion were also analyzed. RESULTS: Six of the eight patients (75%) achieved excellent speech intelligibility and the remaining two patients (25%) were judged as moderate. Six of the eight patients (75%) used the TE shunt as their major means of daily communication. Leakage through or around the prosthesis, which occurred in six (75%) patients, was the most frequent prosthesis-related complication. CONCLUSIONS: This safe and reliable technique can be effective in improving the quality of life in selected patients undergoing CPL.

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.

Anastomosis technique for high pharyngogastrostomy.

Pharyngogastric anastomosis, otherwise referred to as the "gastric pull-up" procedure, is the most reliable method of reconstruction after laryngopharyngectomy. We currently use a method of gastric to pharyngeal anastomosis that avoids excess tension, and thus decreases the incidence of fistulas and flap failures. With the stomach fully mobilized, the "pull-up" is brought high into the neck using a plastic bag to facilitate delivery via the posterior mediastinum. A curved, U-shaped incision is then made in the fundus of the tongue anteriorly, allowing the posterior nasopharynx to be reached without tension.

Reconstruction with free jejunal autograft after pharyngolaryngoesophagectomy.

Twenty-four patients with hypopharyngeal or cervical esophageal carcinoma were treated surgically. All had squamous cell carcinoma, and none had intrathoracic lymph node involvement by preoperative computed tomography. Endoscopy in 18 patients confirmed there was no intramural spread into the thoracic esophagus. The patients underwent pharyngolaryngoesophagectomy and bilateral modified radical neck dissection. Reconstruction of the cervical esophagus was performed with transplantation of a free jejunal autograft. Postoperative complications included anastomotic leak in 2 patients (8.3%), wound infection in 3 (12.5%), and intussusception in 4 (16.7%). Reconstruction of the cervical esophagus was successful in 23 (95.8%) of the 24 patients. The operative mortality rate was 4.2%, and the 5-year survival rate was 39.7%. We emphasize that pharyngolaryngoesophagectomy followed by transplantation of a free jejunal graft is suitable for cervical esophageal carcinoma or hypopharyngeal carcinoma when the disease is limited to the cervical region.

Reconstruction of the pharynx and upper esophagus after resection for cancer.

Construction of a new gullet after circumferential resection of the pharynx and upper portion of the esophagus for cancer is a major challenge to the head and neck surgeon. Techniques for reconstruction use cervical skin, adjacent pedicle flaps, and interposed visceral segments. Each technique has its place; none is ideal or free from complication or failure. Cure rates are poor, and unsolved problems remain. The quest for the perfect technique must continue, but the ultimate solution rests not with reconstruction techniques but with earlier diagnosis and elimination of the need for reconstruction.

Sensory recovery in noninnervated free flaps for head and neck reconstruction.

Recent studies have reported sensory recovery in innervated ("sensate") microvascular free flaps used for oromandibular reconstruction. To evaluate the efficacy of sensate free flaps used for head and neck reconstruction, the natural outcome of noninnervated flaps must be known. Data on the natural recovery of sensation in noninnervated head and neck free flaps are lacking in the literature. This study evaluates the degree of spontaneous sensory reinnervation in noninnervated microvascular free flaps used for reconstruction of a variety of head and neck defects. Eighteen flaps were evaluated--9 fibula osseocutaneous and 9 radial forearm. The fibula flaps were used to reconstruct composite defects of the mandible and oral cavity mucosa. The radial forearm flaps were used to reconstruct defects resulting from floor of mouth resection (3), total glossectomy (2), pharyngectomy (1), full-thickness cheek (1), and facial skin (2). Sensation to pinprick, light touch, and temperature discrimination were tested over the skin paddle at time intervals ranging from 6 to 24 months. The pattern of sensory reinnervation in these noninnervated flaps over time and by location is discussed.

Tracheoesophageal puncture for voice restoration after extended laryngopharyngectomy.

Tracheoesophageal puncture was performed in ten of our patients undergoing extended laryngopharyngectomy. Three fistulas were allowed to close, and two patients were dissatisfied with their results, which allowed for an overall 50% success rate in this subgroup. The resultant voice was objectively compared with similar groups of patients undergoing primary and secondary tracheoesophageal puncture after standard laryngectomy. There was no significant difference in maximum phonation time, average speaking intensity, and average fundamental frequency between these groups. However, the maximum intensity and average intensity were significantly lower for the flap group. Our results indicate that tracheoesophageal puncture should be attempted in patients undergoing the extended procedure, notwithstanding a lower expected success rate.

A comparative study of speech after total laryngectomy and total laryngopharyngectomy.

Quality of voice is an important factor in the consideration of treatment for advanced laryngeal cancer. This prospective study compared the speaking proficiency of patients who used the Blom-Singer valve after total laryngectomy and after total laryngopharyngectomy with jejunal graft reconstruction with that of a group of normal subjects. The total laryngectomy group demonstrated excellent communication ability both face-to-face and on the telephone. They exhibited superior scores for objective intelligibility, subjective intelligibility, acceptability, and intonation when compared with the total laryngopharyngectomy group. Both surgical groups produced similar amplitude and frequency parameters during normal conversation but had limited reserve when these functions were stressed. Despite these quantitative variations, patient acceptance was very high in both surgical groups. These results serve as a foundation for the evaluation and improvement of rehabilitation techniques.

Transcutaneous cervical miniesophagostomy.

Nasogastric tubes have been shown to cause damage to the pharyngolaryngeal complex, producing laryngeal inflammation, granulation, muscle damage, and even vocal cord immobility. The coexistence of nasogastric and tracheotomy tubes after conservation laryngeal surgery is especially harmful. The friction between these two semirigid structures may result in damage to the remaining part of the larynx. This may result in a significant delay in healing, oral feeding, and decannulation. Percutaneous endoscopic gastrostomy is a possible solution. This procedure requires time, special expertise, and cooperation between services. We present our experience with 17 transcutaneous cervical miniesophagostomies using a small-caliber feeding tube, which were performed during conservation laryngeal and/or pharyngeal surgery. The rate of minor complications was 11.7%, or 0.40 complications per 100 tube days, and no major complications were related to the procedure. Transcutaneous cervical miniesophagostomy is a simple and quick procedure that may be performed during the primary cancer surgery. It is done by the head and neck surgeon and does not require special expertise. It takes about 5 minutes to perform and, if done correctly with funneling under skin flaps, is associated with minimal or no postoperative morbidity.

Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience.

We describe the speech rehabilitation outcome of patients treated with total laryngectomy or total laryngopharyngectomy and insertion of Provox voice prostheses (Atos Medical AB, Hörby, Sweden) at the Helsinki University Central Hospital. We performed a retrospective chart review of 95 patients (88 men and 7 women; mean age, 63.5 years) who underwent insertion of a voice prosthesis in the period 1992 to 2002. Eighty-one percent (77/95) of the patients underwent a primary prosthesis insertion at the time of laryngectomy. A head and neck surgeon, a laryngologist, and a speech therapist rated the long-term tracheoesophageal speech of 78% (74/95) of the patients as good or average. The main causes for replacement of the device were obstruction, leakage or inadequate size of the prosthesis, and granulation or leakage around the fistula. According to our 10-year experience, use of the Provox prosthesis is an effective method of postlaryngectomy voice rehabilitation, and it continues to be our preferred method of voice restoration in the majority of cases.

Further experience with tracheojejunal shunt speech after pharyngolaryngoesophagectomy.

Over the past 10 years, 16 patients have undergone the tracheojejunal shunt operation for voice reconstruction after undergoing pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. For the purpose of voice reconstruction, a 2-cm inferiorly based tracheal flap is obtained from the membranous part of the trachea by removing 4 cartilaginous tracheal rings. After the establishment of digestive continuity with the jejunal graft, a side-to-side anastomosis is created by approximating the incised margin of the jejunal mucosa to that of the tracheal flap. The tracheal flap is tubed to construct the tracheojejunal shunt. In addition, the incised margin of the jejunal serosa is sutured to the lateral wall of the shunt to reinforce the approximation of the shunt to the jejunal graft. Thirteen of the 16 patients (81%) were initially capable of voice production. The length of time during which tracheojejunal speech has been used ranges from 18 to 122 months, with a mean of 55 months. During follow-up, 12 of the 13 patients (92%) have been able to swallow without aspiration.

Tracheoesophageal speech following laryngopharyngectomy and pharyngeal reconstruction.

Voice restoration following total laryngectomy and pharyngeal reconstruction is an achievable yet challenging reconstructive task. Because numerous methods exist for pharyngeal reconstruction in conjunction with total laryngectomy, a thorough knowledge of the tissues used for reconstruction is necessary. This knowledge allows for realistic expectations for patient success. Also, specific modifications in voice restoration may be necessary with individual reconstruction methods. This article reviews the methods for reconstruction and the available literature on voice restoration in reconstructed patients.

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.

Valve obturation of the nasopharynx.

Complete obturation of the nasopharynx can cause functional problems with breathing and swallowing due to obstruction of the nasal airway. A technique is described whereby a one way valve was incorporated in an obturator to allow normal nasal inspiration whilst maintaining an oropharyngeal seal during swallowing and speech.

[Reconstruction of the digestive tract using a free small intestine interpositional graft following total larynx-pharynx extirpation. Follow-up results]. / Reconstructie van de tractus digestivus met een vrij dunne-darminterponaat na totale larynx-farynxextirpatie, en follow-up-resultaten.

OBJECTIVE: To evaluate the results of pharyngo-oesophageal reconstruction after pharyngolaryngectomy using a free jejunal interposition graft. DESIGN: Retrospective study. SETTING: University Hospital Dijkzigt, Rotterdam. PATIENTS AND METHODS: Between 1982 and 1992, 59 selected patients (median age 63 years) undergoing laryngopharyngectomy for cancer had the continuity of the upper gastrointestinal tract restored by use of a free jejunal autograft. Twenty-three (36%) had had no previous treatment and received post-operative radiotherapy. Eight patients had laryngeal tumour recurrence after irradiation and in 28 (48%) patients pre-operative radiotherapy had been administered. RESULTS: Follow-up ranged from 1-127 months (mean 37 months). Graft necrosis secondary to vascular problems initially occurred in 5 patients. In four cases the jejunum was successfully replaced by another segment and in one patient a gastric transposition was performed. Fistulas occurred in eight patients of whom four required surgery. The mortality rate was 8.5%. After discharge 6 patients were reoperated on for dysphagia due to stricture formation. In four cases the distal or proximal anastomosis was revised and in the other two patients the graft was replaced, by another segment and by a colonic autograft, respectively. One year after operation 85% of the patients reported an adequate swallowing function and a normal oral intake. The overall 5-year survival rate of this selected group of patients was 42%, for those without primary lymph node involvement 66%. All patients with primary locoregional metastasis died within a period of 34 months after operation. CONCLUSION: Reconstruction of the upper alimentary tract after a laryngopharyngectomy with a free jejunal autograft appears to be a relatively safe procedure with an acceptable mortality and morbidity and, in patients without local lymph node involvement, good long-term results.

[Closure of esotracheal fistula after phonation implants. Technique and results of tracheal ascension]. / Fermeture des fistules oesotrachéales après pose d'implant phonatoire. Technique et résultat de l'ascension trachéale.

Enlarging tracheoesophageal fistula after tracheoesophageal prosthesis for voice rehabilitation remains a major challenge. The authors analyze the results of treatment of 15 severe enlarging tracheoesophageal fistulas among 28 cases (52%) of tracheoesophageal voice rehabilitation which occurred during a 4 years period of time. Among these 15 cases, a spontaneous closure occurred in 3 cases (20%), a two layers closure was performed in 4 cases (26%) and a closure using a tracheal ascension associated with the design of a new tracheostoma was performed on 8 cases (53%). The authors describe the surgical technique and discussed the advantages of surch technique.