Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group.

OBJECTIVE: Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction. MATERIAL AND METHOD: A multicenter retrospective study was conducted from January to September 2016 within the French GETTEC head and neck tumor study group. All patients in remission after circumferential pharyngolaryngectomy were included and filled out the Deglutition Handicap Index (DHI) questionnaire and underwent swallowing function fiberoptic endoscopy assessment. 46 patients (39 men, 7 women) were included. Reconstruction used a tubularized forearm free flap (FFF group) in 19 cases, pectoralis major myocutaneous flap (PMMF group) in 15 cases and free jejunum flap (FJF group) in 12 cases. RESULTS: Mean DHI was 24: 20 in the FFF group, 23 in the FJF group and 25 in the PMMF group, without significant differences. 27 patients had normal swallowing, 9 mixed diet, 8 liquid diet and 3 were fed by gastrostomy. On endoscopy, free flaps (FJF and FFF) were associated with significantly greater rates of normal swallowing of saliva and yogurt than in the PMMF group (P=0.04). CONCLUSION: Type of flap reconstruction after circumferential pharyngolaryngectomy had no significant impact on postoperative swallowing function assessed on the self-administered DHI questionnaire.

Clinical Assessment of Reconstruction Involving Gastric Pull-Up Combined with Free Jejunal Graft After Total Pharyngolaryngoesophagectomy.

BACKGROUND: Total pharyngolaryngoesophagectomy (PLE) is used as a curative treatment for synchronous laryngopharyngeal and thoracic esophageal cancer or for multiple cancers in the cervical and thoracic esophagus. Gastric pull-up is commonly used after PLE, but postoperative complications are common. The present study evaluated these procedures in patients with esophageal cancer. METHODS: Fourteen patients (7 with synchronous pharyngeal and thoracic esophageal cancer, 4 with synchronous cervical and thoracic esophageal cancer, and 3 with cervicothoracic esophageal cancer) underwent reconstructive surgery after PLE involving gastric pull-up combined with free jejunal graft between 2004 and 2015. RESULTS: Esophagectomy via right thoracotomy was performed in 9 patients, and transhiatal esophagectomy was used in 5. The posterior mediastinal route was used in 13 patients, excluding one patient with early gastric cancer. Interposition of a free jejunal graft included microvascular anastomosis using two arteries and two veins in all patients. Anastomotic leakage and graft necrosis did not occur in any of the 14 patients who underwent the above surgical procedures. Tracheal ischemia close to the tracheostomy orifice occurred in 4 patients (28.6%), but none of these patients developed pneumonia. No hospital deaths were recorded. CONCLUSIONS: The results indicate that gastric pull-up combined with free jejunal graft is a feasible reconstructive surgery after PLE. This procedure is a promising treatment strategy for synchronous pharyngeal and thoracic esophageal cancer or multiple cancers in the cervical and thoracic esophagus. Larger series are needed to show the distinct advantages of this procedure in comparison with conventional methods of reconstruction after PLE.

Assessment of the Predictive Value of the Modified Frailty Index for Clavien-Dindo Grade IV Critical Care Complications in Major Head and Neck Cancer Operations.

IMPORTANCE: Functional status and physiologic deficits independent of age are being recognized for surgical risk stratification. Frailty is expressed as a combination of decreased physiologic reserve and multisystem impairments distinct from normal aging processes. OBJECTIVE: To assess the predictive value of the Modified Frailty Index (mFI) for Clavien-Dindo grade IV (CDIV) (intensive care unit-level complications) and grade V (mortality) after major head and neck oncologic surgery. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of prospectively collected American College of Surgeons National Surgical Quality Improvement Program data. All major head and neck cancer operations data were obtained from the January 1, 2006, to December 31, 2013, American College of Surgeons National Surgical Quality Improvement Program databases. Fifteen variables composed a previously validated mFI, with higher mFIs identifying more frail patients. Clavien-Dindo grade IV and mortality were defined using a preexisting mapping scheme from the Canadian Study of Health and Aging. Multivariable logistic regression analyses were performed. MAIN OUTCOMES AND MEASURES: The primary outcome measures were Clavien-Dindo Grade IV critical care complications and Grade V complications (mortality). Second outcomes included morbidity, readmission, and reoperation. RESULTS: There were 1193 major head and neck operations in the American College of Surgeons National Surgical Quality Improvement Program databases, with 86 (7.2%) CDIV complications. The mean (SD) age of all patients was 63.4 (12.4) years, and 67.7% (807 of 1193) were male. Clavien-Dindo grade IV significantly increased from 4.6% (22 of 483) to 100% (1 of 1) from nonfrail to the frailest patients (R2 = 0.79, P < .001). Mortality increased with the mFI (but not significantly) from 0.8% (4 of 483) to 3.6% (2 of 55) (R2 = 0.46, P = .42). Overall morbidity was not significantly associated or correlated with the mFI. On cross tabulation, increases in the mFI led to more CDIV complications in patients undergoing glossectomy (P = .03), mandibulectomy (P = .02), or laryngectomy (P = .002). Patients undergoing pharyngectomy or esophagectomy did not have significant increases in CDIV complications by the mFI. The coefficients of determination for each category were R2 = 0.62 for glossectomy, R2 = 0.72 for mandibulectomy, R2 = 0.97 for laryngectomy, R2 = 0.94 for pharyngectomy, and R2 = 1.00 for esophagectomy. On multivariable analysis, the mFI was associated with CDIV complications (odds ratio, 1.65; 95% CI, 1.15-2.37) but not mortality (odds ratio, 0.78; 95% CI, 0.34-1.76). CONCLUSIONS AND RELEVANCE: The mFI is predictive of postoperative critical care support after surgery for head and neck cancer. Specifically, increases in mFIs were strongly associated with CDIV complications for glossectomy, mandibulectomy, and laryngectomy. Classifying patients by their functional status using the mFI may help predict outcomes after head and neck oncologic surgery.

Transoral robotic surgery for oropharyngeal and tongue cancer in the United States.

OBJECTIVES/HYPOTHESIS: To compare the clinical and cost outcomes of transoral robotic surgery (TORS) versus open procedures following the U.S. Food and Drug Administration approval in December 2009. STUDY DESIGN: Retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2011. METHODS: Elective partial pharyngectomies and partial glossectomies for neoplasm were identified by International Classification of Diseases, 9th Revision, Clinical Modification code. RESULTS: TORS represented 2.1% in 2010 and 2.2% in 2011 of all transoral ablative procedures. Patients undergoing open partial pharyngectomy for oropharyngeal neoplasms (n = 1426) had more severe illness compared to TORS (n = 641). However, after controlling for minor-to-moderate severity of illness, open partial pharyngectomy was associated with longer hospital stay (5.2 vs. 3.7 days, P < 0.001), higher charge ($98,228 vs. $67,317, P < 0.001), higher cost ($29,365 vs. $20,706, P < 0.001), higher rates of tracheostomy and gastrostomy tube placement, and more wound and bleeding complications. TORS was associated with a higher rate of dysphagia (19.5% vs. 8.0%, P < 0.001). The lower cost of TORS remained significant in the major-to-extreme severity of illness group but was associated with higher complication rates when compared to open cases of the same severity of illness. A similar analysis of TORS partial glossectomy for base of tongue tumors had similar cost and length of stay benefits, whereas TORS partial glossectomy for anterior tongue tumors revealed longer hospital stays and no benefit in charge or cost compared to open. CONCLUSIONS: Early data demonstrate a clinical and cost benefit in TORS partial pharyngectomy and partial glossectomy for the base of tongue but no benefit in partial glossectomy of the anterior tongue. It is likely that anatomic accessibility and extent of surgery factor into the effectiveness of TORS.

Quantitative assessment of the free jejunal graft perfusion.

BACKGROUND: Reconstruction with free jejunal graft (FJG) is often performed for patients with hypopharyngeal or cervical esophageal cancer. During reconstruction with an FJG after pharyngoesophagectomy, it is critical to intraoperatively detect venous anastomotic failure and subsequent venous malperfusion to avoid postoperative FJG necrosis. This study introduces a novel method for assessing blood perfusion in FJGs by using indocyanine green (ICG) fluorescence angiography. METHODS: We used ICG fluorescence angiography to quantitatively assess FJG blood perfusion in archived fluorescence video files from 26 patients who had undergone FJG transfer. A software program "ROIs", was used to create a time-fluorescence intensity curve. We retrospectively measured the maximum fluorescence intensity at the terminal ileum and the duration (T1/2max) between when the intensity began rising and when it reached half of the maximum. RESULTS: Among the 26 patients, 5 patients suffered venous anastomotic failure. In three of these cases, anastomosis was corrected intraoperatively; the other two patients underwent a second FJG transfer. Retrospective assessment showed that the mean T1/2max at the FJG serosae was significantly longer in these five patients than that in FJGs with good blood perfusion. Our analysis revealed that a T1/2max >9.6 s may be a good indicator of FJG venous malperfusion. CONCLUSIONS: Quantitative analysis of ICG fluorescence angiography proved useful for detecting venous anastomotic failure of FJG, and may help to reduce vascular problems in FJG reconstruction.

Determining the efficacy and cost-effectiveness of the ActiValve: results of a long-term prospective trial.

OBJECTIVES/HYPOTHESIS: To investigate 1) whether the Provox ActiValve results in increased device-life in individuals with below average device-life, 2) whether it is cost-effective, and 3) whether it has any impact on voice-related quality of life. STUDY DESIGN: Prospective study. METHODS: Individuals who experienced below-average tracheoesophageal prosthesis (TEP) life were studied. RESULTS: Individuals with persistent below-average TEP life were enrolled in the study and underwent periodic re-evaluation. The majority (73%) experienced significant improvement as a result of use of the device. Those who continued to wear the device were followed for an average of 30.45 months (range, 14.70-43.49 months) and wore a total of 31 devices over this time. They demonstrated an average increase in device-life of more than 500%, going from an average of 1.93 months with a traditional indwelling device to 10.30 months with the ActiValve. The majority of individuals found that voicing with the ActiValve was either the same or better than with their previous indwelling TEP. Voice-related quality of life was not significantly different from that of a group of controls. Overall satisfaction with the device was high, and the majority would have chosen the ActiValve in the future. Overall, there were estimated to be cost savings to third-party payers through use of the ActiValve in this population. CONCLUSIONS: The ActiValve is effective in increasing device-life in selected patients who have failed conservative measures. Our protocol for use of the device requires individuals to meet several usage criteria before initial placement and to return for periodic monitoring.

Impact of surgeon and hospital volume on short-term outcomes and cost of oropharyngeal cancer surgical care.

OBJECTIVE: To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for oropharyngeal cancer. METHODS: The Maryland Health Service Cost Review Commission database was queried for oropharyngeal cancer surgical case volumes from 1990 to 2009. Multivariable regression models were used to identify significant associations between surgeon and hospital case volume, as well as independent variables predictive of in-hospital death, postoperative wound complications, length of hospitalization, and hospital-related cost of care. RESULTS: Overall, 1,534 oropharyngeal cancer surgeries were performed during the study period. Complete financial data was available for 1,482 oropharyngeal cancer surgeries, performed by 233 surgeons at 36 hospitals. The only independently significant factors associated with the risk of in-hospital death were an APR-DRG mortality risk score of 4 (odds ratio [OR] = 14.0, P < .001) and total glossectomy (OR = 5.6, P = .020). Wound fistula or dehiscence was associated with an increased mortality risk score (OR = 5.9, P < .001), total glossectomy (OR = 6.9, P < .001), mandibulectomy (OR = 3.4, P < .001), and flap reconstruction (OR = 2.1, P = .038). Increased mortality risk score, total glossectomy, pharyngectomy, mandibulectomy, flap reconstruction, neck dissection, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization and hospital-related costs. CONCLUSIONS: After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for oropharyngeal cancer surgery.

Gastro-omental free flap in the reconstruction of the unfavourable hypopharyngeal defects: a functional assessment.

BACKGROUND: Reconstruction flaps following major head and neck cancer surgery should consider the state of tissue at the recipient site. This study presents the cumulative experience of the use of the gastro-omental free flap (GOFF) for pharyngeal reconstruction in cases with unfavourable recipient site conditions. METHODS: The GOFF reconstruction procedure and postoperative follow-up are described in details, and the functional results are analysed retrospectively. RESULTS: Fifteen patients underwent GOFF reconstruction. Previous treatments included radiotherapy, chemotherapy and surgery. Postoperatively, two patients (13%) developed partial flap necrosis, and four (27%) patients developed fistula and flap stenosis. On the functional level, eight (53%) patients developed oesophageal speech at different levels of audibility, and all patients developed oral alimentation ranging from a mixed diet with supplements to a regular oral diet. CONCLUSIONS: The GOFF is characterised by multiple survival advantages that favour its use in the presence of inhospitable recipient site conditions.

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.

Endoscopic stapling technique for the treatment of Zenker diverticulum vs standard open-neck technique: a direct comparison and charge analysis.

BACKGROUND: Presently, the 2 most widely used methods for the treatment of Zenker diverticulum are endoscopic stapling of the common party wall between the diverticulum sac and the esophagus and the standard open-neck technique involving diverticulectomy and cricopharyngeal myotomy. OBJECTIVE: To perform an analysis of the hospital charges to determine the economic efficiency of each technique based on our experience at the Mt Sinai Medical Center, New York, NY. METHODS: A retrospective analysis of 16 patients diagnosed as having Zenker diverticulum was conducted. Eight randomly chosen patients underwent endoscopic stapling with an EndoGIA 35-mm endoscopic stapler (Ethicon Inc, Somerville, NJ), and 8 randomly chosen patients underwent a standard open approach with diverticulectomy. Medical records were reviewed to determine operative time, length of hospital stay, time to oral intake, and postoperative complications. A charge analysis of the operative and postoperative fees was also performed. Statistical analysis between the 2 groups was conducted using analysis of variance and the paired t test. RESULTS: The mean +/- SD operative time for the endoscopic stapling technique was 25.5 +/- 15.78 minutes, which was significantly less (P<.001) than that for the open procedure, 87.6 +/- 35.10 minutes. The mean operative charges were roughly equivalent at US$ 5178 for the endoscopic procedure and US$ 5113 for the open procedure. The endoscopic procedure, while shorter in operative time, had the added expense of specialized equipment, specifically the EndoGIA endoscopic stapler. The mean +/- SD length of hospital stay for the endoscopic procedure was significantly shorter (P<.001) at 1.3 +/- 0.59 days vs 5.2 +/- 1.03 days for the open procedure. The inpatient hospital charges for the endoscopic group was also significantly less (P<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (P<.001) in the endoscopic group at 0.8 +/- 0.26 days vs 5.1 +/- 1.25 days for the open group. There were no major complications in either group, and all patients experienced resolution of preoperative symptoms. CONCLUSIONS: Compared with the standard open technique, the endoscopic stapling technique for the treatment of Zenker diverticulum results in a statistically significant shorter operative time, hospital stay, and time to resume oral feedings. While the charges of the operative procedures were roughly equivalent, the total hospital charges were significantly less for the patients treated endoscopically.

Montgomery salivary bypass tube in the reconstruction of the hypopharynx. Cost-benefit study.

This study analyzes the postoperative complications and the functional results in 61 patients who underwent total laryngectomy with partial or total (circumferential) pharyngectomy reconstructed with a pectoralis major myocutaneous flap, in relation to the use of the Montgomery Salivary Bypass Tube (MSBPT). There were no significant differences regarding frequency of postoperative cervical complications in relation to the use of the MSBPT. The median hospital stay for patients without the MSBPT (36 days) was significantly higher than that for patients with the MSBPT (25 days). Although the MSBPT did not modify the rate of complications at the cervical level, it did reduce their severity. A financial study showed the cost-effectiveness of using the MSBPT. Systematic use of the MSBPT is recommended after total laryngectomy with partial or total pharyngectomy reconstructed with a pectoralis major myocutaneous flap.

Suction drain management of salivary fistulas.

Salivary fistulas remain an unpleasant complication of upper aerodigestive tract surgery. To avoid a disastrous outcome such as carotid rupture, clinicians "medialize" (i.e., incise the skin flap in the anterior aspect of the neck and insert a Penrose drain) to divert fistula fluid from the carotid sheath and then perform laborious wound care. Meanwhile, patients endure the unpleasant odor, discomfort due to the wound dressing, occasional secondary surgical procedures, a lengthened hospital stay, and increased financial costs. In an effort to mitigate these problems, suction drains that had been placed at the time of the original surgical procedure were used as an alternative management technique. Out of a population of 118 reviewable patients who underwent standard or extended variations of supraglottic laryngectomy, partial laryngopharyngectomy, near-total laryngectomy, or total laryngectomy between 1988 and 1992, 16 patients appropriate for inclusion in this study developed postsurgical fistulas. Eight of these patients were treated with traditional medialization procedures, and the other 8 patients were treated with suction drainage. Comparison of the two groups revealed no significant difference with respect to complications or time to fistula closure. The advantages of simplified postsurgical care, less patient discomfort, reduced time demands on the clinician, and cost containment were noted for the group treated with suction drainage.

Scintigraphic assessment of swallow efficiency postlaryngectomy.

There have been reports of a high incidence of hypopharyngeal stenosis in total laryngectomy patients when the surgery requires a partial pharyngectomy for pyriform sinus involvement. In this study, three groups were compared: total laryngectomy patients without partial pharyngectomy, total laryngectomy patients with partial pharyngectomy, and normal controls. All patients had received radiation therapy following surgery. All were maintaining oral nutrition, and none complained of dysphagia. Patients were tested between 1 and 7 months postradiation therapy, with a mean of 3 months. Measures of swallowing efficiency were based on scintigraphic data for a liquid swallow. Patients with partial pharyngectomy had abnormally long oropharyngeal transit times and low efficiency scores. For a subgroup of patients with partial pharyngectomy, swallowing data were available postsurgery and postradiation therapy. Postsurgery this patient group did not differ significantly from normal patients in swallowing efficiency, and swallowing efficiency deteriorated in postradiation therapy. This scintigraphic methodology is shown to be a sensitive method of assessing swallowing function in this patient population.