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.

Sentinel lymph node biopsy in cutaneous melanoma: outcome after 5-years follow-up.

Sentinel lymph node procedure for cutaneous melanoma is largely used and sentinel lymph node status is an important prognostic factor. Few French centers have reported their experience and data. We analysed technique feasibility, recurrence-free and overall-survival rates at 36 and 60 months for the first 62 patients submitted to this technique. The positivity of sentinel lymph nodes was 17.7%. Recurrence-free survival at 36 and 60 months was of 85% and 78% respectively for patients with negative sentinel lymph nodes, whereas the rates were of 45% and 36% respectively for patients with positive sentinel lymph nodes (p = 0.0046). The overall survival rate was of 94% at 36 months and 85% at 60 months for negative patients as opposed to 82% at 36 months and 47% at 60 months for positive patients (p = 0.0019). In our experience, sentinel lymph node technique is a safe procedure with few complications and good pronostic value. This technique allows the identification of patients with a high risk of recurrence who could benefit from early adjuvant therapeutic management. However, these results show that the survival rate of patients with positive sentinel lymph nodes remains significantly lower, even when elective lymph node dissection is performed.

Use of tubed gastro-omental free flap for hypopharynx and cervical esophagus reconstruction after total laryngo-pharyngectomy.

In case of total laryngo-pharyngectomy (TLP), replacement of the pharyngoesophageal segment is more often done with jejunal flap; however, in some cases, this flap doesn't represent the best surgical technique of reconstruction. The tubed gastro-omental free flap (TGO) offers an alternative procedure in selective cases. The objective of the study was to assess the TGO as a method of pharyngoesophageal reconstruction. Our study was based on a literature review and a retrospective study of six consecutive cases of TGO reconstruction after TLP. Six patients aged from 52 to 70 years underwent TGO reconstruction after TLP. Five patients had previously received systemic chemotherapy and external irradiation at curative doses, and three had undergone previous surgery. No abdominal complication occurred. Partial necrosis of the gastric flap occurred in one case. Except for this case, the feeding tube could be removed after 15 days. One patient was successfully treated with pneumatic esophageal dilatation for stricture 2 months after surgery. Four patients died of loco-regional tumor evolution or distant metastatic disease. For both of the patients who survived (mean follow-up, 40 months), a normal diet and an esophageal voice were obtained. The TGO offers a safe method of reconstructing the pharyngoesophageal segment in a surgical field compromised of previous multimodal therapy.

Sphincter pharyngoplasty as a treatment of velopharyngeal incompetence in young people: a prospective evaluation of effects on sleep structure and sleep respiratory disturbances.

BACKGROUND: Sphincter pharyngoplasty (SP) appears to be the more "physiologic" surgical technique to treat velopharyngeal incompetence (VPI). This procedure creates a dynamic sphincter of variable diameter and keeps the flexibility of the soft palate. SP also induces velopharyngeal size reduction, mainly in the transverse diameter, which may cause upper airway (UA) occlusions during sleep. AIM: To prospectively evaluate the effects of SP by a modified Orticochea procedure on sleep structure and sleep respiratory disturbances. METHODS: Polysomnographic studies before and after surgery in 17 consecutive patients treated by a modified Orticochea procedure SP for VPI. RESULTS: For the whole group, SP did not induce significant impairment of apnea-hypopnea index or nocturnal oxygen saturation. Slow-wave sleep (SWS) was significantly reduced after surgery (25 +/- 9% of total sleep time [TST] vs 28 +/- 9% of TST before SP [p = 0.04]). Following surgery, there was a trend for an increase in the microarousal index) (p = 0.09) and more specifically in respiratory-related microarousals. CONCLUSION: SP, although creating a clinically obvious reduction of velopharyngeal diameter, generally did not lead to the occurrence of an obstructive sleep apnea syndrome. However, we found a significant reduction of SWS quantity and a trend toward an increase in the number of cortical microarousals. These findings suggest that the reduction of UA diameter associated with the surgical technique leads to increases in respiratory effort sufficient to induce sleep fragmentation and SWS reduction, even in the absence of apneas or hypopneas.

Computer-assisted orthognathic surgery: clinical evaluation of a mandibular condyle repositioning system.

PURPOSE: The purpose of this study was to evaluate a new method for positioning the mandibular condyle during orthognathic surgery based on 3-dimensional optical localization of infrared emitting diodes. PATIENTS AND METHODS: Eleven patients ("empirical group") underwent condylar repositioning using the empirical repositioning method (standard technique) and were considered controls. In 10 patients ("active group"), the computer-assisted system was used to replace the condyle-bearing fragment in its sagittal preoperative position. In these patients, the condylar torque was not controlled. In the third group of 10 patients ("graft group"), the computer-assisted system was used to replace the condyle in all 3 directions. Very often it was necessary in this group to fill the osteotomy gap with a bone graft. The clinical evaluation was based on 4 major criteria: the quality of the postoperative occlusion, the stability of skeletal position on successive cephalometric radiographs, the occurrence of temporomandibular dysfunction (TMD), and the preservation of mandibular motion. Clinical assessment was made at 1, 3, 6, and 12 months follow-up. RESULTS: Forty-five percent of the "empirical group" did not have the expected postoperative occlusion, 5 patients showed evidence of clinical relapse at 1 year, 45% had worsened TMD status, and only 63.37% of mandibular motion had been recovered at 6 months. All the patients in the "active group" had the expected occlusion and only 1 patient exhibited a mild relapse and TMD symptoms; however the average mandibular motion recovery was only 62.65% at 6 months. All the patients in the "graft group" had a good occlusion and no relapse or TMD. Their percentage of mandibular motion recovery was 77.58%. CONCLUSION: The quality of sagittal repositioning is the main factor contributing to a good occlusion and bone stability. Functional results (in particular, recovery of mandibular motion) are more related to limiting condylar torque.