Surgical site infection in clean-contaminated head and neck cancer surgery: risk factors and prognosis.

Since new treatment strategies, such as chemoradiotherapy, have been introduced for head and neck cancer, a higher number of unknown factors may be involved in surgical site infection in clean-contaminated head and neck cancer surgery. The aim of the present study was to clarify the risk factors of surgical site infection in clean-contaminated surgery for head and neck cancer and the prognosis of patients with surgical site infection. Participants were 277 consecutive patients with head and neck cancer who underwent clean-contaminated surgery for primary lesions at the Aichi Cancer Center over a 60-month period. A total of 22 putative risk factors were recorded in each patient and statistically analyzed to elucidate surgical site infection related factors. Surgical site infection was observed in 92 (32.1 %) of 277 cases. Univariate analysis indicated that alcohol consumption, T classification, neck dissection, reconstructive procedure, and chemoradiotherapy were significantly associated with surgical site infection. Multiple logistic regression analysis identified two independent risk factors for surgical site infection: reconstructive surgery (p = 0.04; odds ratio (OR) 1.77) and chemoradiotherapy (p = 0.01; OR 1.93). In spite of surgical site infection, the five-year overall survival rate of patients with surgical site infection was not significantly different from those without surgical site infection. Although surgical site infection did not impact the overall survival of patients with surgical procedures, head and neck surgeons should pay attention to patients with previous chemoradiotherapy as well as to those with a high risk of surgical site infection requiring reconstructive surgery.

High pharyngoesophageal strictures after laryngopharyngectomy can also be treated by self-expandable plastic stents.

BACKGROUND: Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy can usually be treated by periodic dilation. Occasionally, however, conservative treatment is insufficient, and patients require long-term tube feeding. We describe 4 cases with stricture after laryngopharyngectomy who underwent insertion of self-expandable plastic stents (SEPSs) across the stricture for treatment of dysphagia. OBJECTIVE: The aim of this study was to evaluate the role of SEPSs in postlaryngopharyngectomy strictures. DESIGN: An interventional study of management of 4 patients of dysphagia after laryngopharyngectomy with SEPSs. SETTING: Medical gastroenterology unit in a tertiary care hospital. PATIENTS: Four patients with dysphagia after laryngopharyngectomy. INTERVENTIONS: SEPS placement and removal after 3 months. MAIN OUTCOME MEASUREMENTS: Improvement in dysphagia. METHODS: Four patients with dysphagia after laryngopharyngectomy underwent dilation of stricture followed by SEPS placement for 3 months. RESULTS: Three patients had grade IV, and 1 grade III dysphagia. Endoscopy showed stricture at 10 to 14 cm from the incisors. Stricture was dilated up to 15 mm on 3 occasions, 2 weeks apart. A silicone Polyflex stent was placed across the stricture and removed after 3 months. No dysphagia recurred after 2 months. No significant complications were noted. LIMITATIONS: Small sample size. CONCLUSIONS: SEPSs dilate postlaryngopharyngectomy strictures and prevent restenosis even after removal.

Patterns of cervical node positivity, regional failure rates, and fistula rates for HPV+ oropharyngeal squamous cell carcinoma treated with transoral robotic surgery (TORS).

OBJECTIVES: (1) Report the patterns of cervical node positivity for HPV + oropharyngeal squamous cell carcinoma (OPSCC) treated with transoral robotic surgery (TORS) and a unilateral level II-IV node dissection. (2) Investigate the regional failure rate following this operation. (3) Report the rate of pharyngocutaneous fistula (PCF) formation intraoperatively and postoperatively following TORS/neck dissection. METHODS: Retrospective case series of 88 patients with HPV+ OPSCC treated with TORS and simultaneous neck dissection levels II-IV at the University of Washington from 2010 to 2016. Primary endpoints were PCF, regional recurrence, disease-free survival (DFS), and overall survival (OS). RESULTS: The overall frequency of cervical node positivity was 93%, with 84% in level IIa, 7% in IIb, 23% in III, and 13% in IV. Two patients developed PCF intraoperatively, repaired with a local digastric flap, and no postoperative PCF occurred. Sixteen patients (18%) received surgery alone, 49 patients (56%) received adjuvant radiation, and 23 patients (26%) underwent adjuvant chemoradiation. DFS at 2 years was 95% and OS at 2 years was 100%. No concerning level Ib nodes were identified preoperatively or during surgery, and no regional failures occurred in this location. CONCLUSION: Our data suggests, in TORS for HPV+ OPSCC, neck dissection of levels II-IV accurately stages the neck pathologically and prevents regional recurrences, with adjuvant therapy when indicated, and survival outcomes are excellent. Single-staged operations did not result in any postoperative PCF. Avoiding dissection of level Ib with TORS oropharyngectomy limits morbidity to the marginal mandibular nerve and salivary function, and resulted in no postoperative fistulas with minimal reconstruction interventions.

Incidence, predisposing factors and outcome of pharyngocutaneous fistulas complicating head and neck cancer surgery.

A major complication of head and neck cancer surgery following radiation and extensive resection is pharyngocutaneous fistula. A retrospective analysis of 36 fistula patients out of 376 major head and neck procedures between January 1971 and July 1973 revealed certain guidelines for improved clinical management. Since a large discrepancy existed in the incidence of fistulas between the different surgical procedures, each operative group was examined separately. The incidence, predisposing factors, and methods of treatment for this complication following composite jaw-neck resections and various laryngeal procedures are analyzed and discussed.

Use of a nitinol stent to treat dysphagia post-laryngopharyngectomy.

Permanent dysphagia occurring after laryngectomy or laryngopharyngectomy is uncommon, and when it does occur, can usually be treated by periodic dilatation under general anaesthesia. Occasionally, however, conservative treatment is insufficient, and patients require long-term feeding via a gastrostomy or jejunostomy tube. We describe the case of a man with an anastamotic stricture post-pharyngectomy who underwent insertion of a nitinol stent across the stricture for treatment of dysphagia. The patient's swallowing was significantly improved in the short-term, however, ultimately, florid granulation tissue formation led to obstruction of the stent and a disappointing long-term result. This, to our knowledge, is the first documentation of the use of a stent to treat dysphagia in a patient post-laryngectomy or pharyngolaryngectomy.

[Value of preserving mandibular continuity in transmandibular bucco-pharyngectomy. Apropos of 11 cases]. / Intérêt de la conservation de la continuité mandibulaire dans les bucco-pharyngectomies transmandibulaires. A propos de 11 observations.

84 transmandibular bucco-pharyngectomies were carried out over 6 years between 1983 and 1988. Eleven, i.e. 13%, were performed with preservation of mandibular continuity. Histological examination of resected bone fragments did not demonstrate any bony invasion in 65 cases; in contrast, in 8 cases, extension of the tumour to involve bone was likely due to the topography of the tumour and the results of pre-operative X-ray examination.

[Conservative trans-mandibular lateral pharyngectomy. Functional results in a series of 38 patients]. / La pharyngectomie latérale transmandibulaire conservatrice. Résultats fonctionnels sur une série de 38 patients.

The authors present their experience with conservative transmandibular lateral pharyngectomy used for access to oropharyngeal tumours of the buccal cavity. This study was conducted to evaluate both early results and later aesthetic and functional sequelae after a simplified operation using mini-plaques. This surgical route was used for 38 patients since 1985, including 9 for salvage operations. Surgical indications were tumours of the posterior wall of the pharynx (28), the posterior part of the tongue (8), the retromolar tigone (1), the intramaxillary commissure (2) and the pelvi-lingual region (2). Access via the mandibulotomy was always evaluated peroperatively on the basis of the cleavability of the periosteum of the medial mandibular table. Immediate follow-up was uneventful in 74% cases. Post-operative complications included two general decompensations due to the original lesion, four minor local complications (spontaneous by regressive non-unions) and four local complications requiring a second intervention (flap necrosis, 2; orostomy, 2). Five of the complications were directly related to the mandibulotomy, giving an overall rate of 13%; the rates for first intention and salvage surgery were 9% and 18% respectively. Functional capacity was considered excellent in 75% of the cases and the aesthetic results were good in 94%. The satisfactory post-operative course, the low rate of major complications both after first intention and salvage surgery, and the excellent functional and aesthetic results suggest that transmandibular bucco-pharyngectomy should be preferred whenever the state of the cancerous lesion does not require exeresis of the ramus.

["Conservative" transmandibular buccopharyngectomy]. / La bucco-pharyngectomie trans-mandibulaire "conservatrice".

Tumors of the amygdaline region were up until now most often treated by transmandibular buccopharyngectomy (TMBP) with a systematic sacrifice of the mandibular angle. This exercise justified by wide carcinological imperatives, a larger surgical facility and simple immediate postoperative follow-up, in fact systematically shows a substantial esthetic and functional prejudice. This principle was reinforced by the occurrence of osteitis during the first attempts of osseous reconstruction using steel wires opposite the mandibular angle (Dargent, Charachon, 1963). In 1989, Gehanno and Beauvillain published a mandibular conservation technique by vertical paramedian osteotomy, right in front of the mental nerve, shifted from the future field of radiation, with osteosynthesis by titanium plates. This technique appeals to us because it is easy to use, reliable and carcinologically safe. We have currently adopted it with satisfaction for 8 of our patients over an 18-month period, without any case of osteitis and with both good esthetic and functional results.

[Use of polyglactin 910 mesh with collagen in the prevention of pharyngostomes]. / Utilisation du filet de polyglactine 910 avec collagène dans la prévention des pharyngostomes.

The use of the collagen-coated Polyglactine 910 mesh is proposed as a preventive treatment of pharyngostomes in extensive pharyngolaryngectomies for necrotized hypopharyngeal tumors. The good results obtained in this series of 12 cases may be explained by a distribution of stress in the pharyngeal sutures, associated to a decrease in the stress exerted on the tight mucosal suture, as well as a sliding-rotating effect of the pharyngeal muscular suture, which is thus displaced relative to the plane of the mucosal suture. This original technique seems to be fully effective during the first two postoperative weeks, and may greatly help in the prevention of the dangerous pharyngostomes during the postoperative period following extensive pharyngeal resections.

Method for removing hypopharyngeal salivary bypass tubes.

OBJECTIVE: To describe a novel method for the removal of the salivary bypass tube (SBT) that precludes the need for extraction under general anesthesia. STUDY DESIGN: Retrospective case series. METHODS/TECHNIQUE: Patients who had undergone laryngectomy/laryngopharyngectomy with subsequent development of pharyngocutaneous fistula and intraoperative placement of a salivary bypass tube were included in this series. The tubes were removed at the bedside or in clinic utilizing a Fogarty-type method over a Foley catheter. RESULTS: Three patients underwent removal of hypopharyngeal salivary bypass tubes 1 to 2 weeks after placement. Inflation of the Foley catheter within the lumen of the salivary bypass tube facilitated successful removal without the need for additional procedures. All three patients required only topical anesthetic and tolerated the procedure with minimal discomfort. CONCLUSIONS: Compared to current methods, this technique is cost-effective and time-efficient while not compromising patient safety or comfort.

Unwanted palatal hair: a consequence of complex oropharyngeal reconstruction.

Hair growth in the oral cavity following free-flap transfer from a hair-bearing area has been previously noted albeit outside the dermatology literature. Little is known about the incidence and treatment of this undesirable postoperative complication. We herein describe two cases of palatal hair occurring after complex oropharyngeal reconstruction treated with a novel combination of Nd:YAG laser together with mechanical epilation and electrolysis.

[Restoration of the mandible after trans-mandibular approach of invasive tumors of the oropharynx (43 cases)]. / La réparation de la mandibule après abord transmandibulaire des tumeurs étendues de l'oropharynx (43 cas).

Preservation of the mandible is often possible in surgery of invasive malignant tumors of the oropharynx. From 1983 to 1993, we operated 158 T3 of the oropharynx: 73% with mandibulectomy and 27% with osteotomy (43 cases). Now, the osteotomy of the mandible is performed in more than 90% of the patients. The osteosynthesis needs two titanium plates; the pharyngoplasty is made with a pectoralis major myocutaneous flap. Followup: 36 cases of 43 gave satisfactory results. The osteotomy complication rate was 5 (12%): 5 osteitis (2 after radiotherapy).

Dysphagia following head and neck cancer surgery.

Surgical resection of head and neck cancer results in predictable patterns of dysphagia and aspiration due to disruption of the anatomic structures of swallowing. Common procedures undertaken in the treatment of head and neck cancer include tracheostomy, glossectomy, mandibulectomy, surgery on the palate, total and partial laryngectomy, reconstruction of the pharynx and cervical esophagus, and surgery of the skull base. An overview is presented of normal swallowing physiology, as well as swallowing perturbations that are frequently encountered in postoperative head and neck cancer patients.

[Surgery of the oropharynx after radiotherapy]. / Chirurgie de l'oropharynx après radiothérapie.

Over 40 years after the first commando procedures performed by M Dargent, surgical techniques such as mandibulotomy and myocutaneous flaps yield important changes in oropharyngeal surgery after definitive radiotherapy. Wide resections and simultaneous neck dissection are possible with good functional results. From 1970 to 1990, 250 patients with a carcinoma of the oropharynx were operated on after radiotherapy, 163 because of failure or complication of irradiation, 87 for a metachronous carcinoma occurred in an previously irradiated field. The postoperative mortality rate was 6%. The risk of carotid blow-up did not increase with the extension of the resection. Survival rates at 1, 3 and 5 years are 55%, 22%, 16% in salvage surgery and 69%, 36% and 24% in patients with metachronous cancer. Postoperative complications and failures in the primary and/or the neck account for 60% of causes of death. These results suggest that prior surgery of deeply ulcerative carcinoma of the oropharynx followed by radiotherapy is a better strategy than definitive radiotherapy with salvage surgery in reserve.