Surgical management of pharyngocutaneous fistula after total laryngectomy.

PURPOSE: The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed. METHODS: A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed. RESULTS: Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage. CONCLUSIONS: Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.

Outcomes evaluation following bilateral breast reconstruction using latissimus dorsi myocutaneous flaps.

The demand for bilateral breast reconstruction has recently increased. Although numerous options exist, the latissimus dorsi myocutaneous flap remains a popular technique. The benefits of additional autologous coverage are evident; however, donor site morbidity does exist. The purpose of this report is to evaluate our experience with bilateral latissimus dorsi breast reconstructions, focusing on donor site morbidity and patient satisfaction. All patients who underwent bilateral latissimus dorsi breast reconstruction at Emory University Hospital, were evaluated and included in the series. Data points queried included patient demographics, risk factors, radiation therapy, timing of the procedure (immediate or delayed), type of procedure (latissimus dorsi only, latissimus dorsi with expander, latissimus dorsi with implant), and outcomes. Outcomes included >1 additional operation, any breast and any donor-site complications. A patient satisfaction survey was performed evaluating outcomes such as aesthetic results, general satisfaction, morbidities, and functional assessment. Comparisons were made using radiation therapy, timing of reconstruction, and type of reconstruction as variables. Eighty-three patients underwent bilateral latissimus dorsi breast reconstruction with an average follow-up of 2.3 years. The method of reconstruction included latissimus dorsi with expander (n = 54), latissimus dorsi only (n = 17), and latissimus dorsi with implant (n = 12). Breast complications occurred in 34% of the patients with radiation therapy being a significant risk factor. The average number of secondary operations was 2.3 with the expander group resulting in an increased need for additional procedures. Overall patient satisfaction was 3.93/5, with the average symmetry score being 3.82/5, shape 3.84/5, nipple position 3.92/5, and inframammary fold (IMF) position 4/5. The majority of patients (n = 28/37) reported no pain (0/5) at the time of the survey. Most patients (n = 33/37) reported no impairment in daily activities, however, some did report impairment in physical activity, decreased range of motion (ROM), and pain. The latissimus dorsi remains a reliable option for bilateral breast reconstruction. Although patient satisfaction with this approach remains high, functional impairment can occur and needs to be appropriately discussed.

Hotel-based ambulatory care for complex cancer patients: a review of the University College London Hospital experience.

Since 2005, University College London Hospital (UCLH) has operated a hotel-based Ambulatory Care Unit (ACU) for hematology and oncology patients requiring intensive chemotherapy regimens and hematopoietic stem cell transplants. Between January 2005 and 2011 there were 1443 patient episodes, totaling 9126 patient days, with increasing use over the 6-year period. These were predominantly for hematological malignancy (82%) and sarcoma (17%). Median length of stay was 5 days (range 1-42), varying according to treatment. Clinical review and treatment was provided in the ACU, with patients staying in a local hotel at the hospital's expense. Admission to the inpatient ward was arranged as required, and there was close liaison with the inpatient team to preempt emergency admissions. Of the 523 unscheduled admissions, 87% occurred during working hours. An ACU/hotel-based treatment model can be safely used for a wide variety of cancers and treatments, expanding hospital treatment capacity, and freeing up inpatient beds for those patients requiring them.

dazed gene is necessary for late cell type development and retinal cell maintenance in the zebrafish retina.

Several molecules, such as growth factors and neurotrophic factors, are required both for the differentiation of specific retinal cell types and the long-term cell survival of all retinal neurons. As diffusible factors, these molecules act non-cell-autonomously. Here, we describe the loss of function phenotype for dazed (dzd), a gene that acts cell-autonomously for retinal cell survival and affects the differentiation of rod photoreceptors and the Muller glia. By 3 days after fertilization, dazed mutant embryos have small eyes and slight heart edema. Acridine orange staining indicated a significant degree of retinal cell death occurring by 48 hr after fertilization, and histological analysis revealed that dying cells were found in the inner and outer nuclear layers and near the marginal zones. Although molecular and morphological differentiation of the inner retina and cone photoreceptors occurred, rod photoreceptors failed to differentiate beyond a small patch in the ventral retina and rod precursors failed to respond to exogenously added retinoic acid, which normally potentiated rod differentiation. Mosaic analysis indicated that the dazed gene acts cell-autonomously for rod production and cell survival, as dazed clones failed to produce rods outside the ventral patch and dazed cells were not maintained in wild-type hosts. Raising mutants under constant light resulted in severe retinal degeneration, whereas raising embryos under constant darkness did not provide any additional protection from cell death. Behavioral analysis showed that a subpopulation of adult fish that were heterozygous for the dazed mutation had elevated visual thresholds and were night blind, suggesting that dazed may also be required for long-term dim-light vision. Taken together, our studies suggest a role for the dazed gene in rod and Muller cell development and overall retinal cell survival and maintenance.