Hemostatic Options for Transoral Robotic Surgery of the Pharynx and Base of Tongue.

Surgery with transoral robotic surgery (TORS) offers significant advantages compared with traditional open surgical approaches and potentially minimizes the long-term side effects of organ preservation therapy with chemoradiation. Angled telescopes and wristed instruments allow visualization and access to areas of the pharynx that are difficult to reach with line-of-sight instrumentation. Although the application of TORS in head and neck surgery has expanded considerably, there are still only limited data available on the postoperative complications and their management. As further data become available, it is likely that further risk factors and treatment strategies will become available.

Negative pressure wound therapy in head and neck surgery.

IMPORTANCE Negative pressure wound therapy has been shown to accelerate healing. There is a paucity of literature reporting its use as a tool to promote wound healing in head and neck reconstruction. OBJECTIVE To review 1 institution's experience with negative pressure dressings to further describe the indications, safety, and efficacy of this technique in the head and neck. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series at a tertiary care academic hospital. One hundred fifteen patients had negative pressure dressings applied between April 2005 and December 2011. Data were gathered, including indications, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, bone exposure, great vessel exposure, in the field of previous microvascular free tissue transfer, or in the case of peristomal application in laryngectomy). EXPOSURE Negative pressure wound therapy utilized after head and neck reconstruction. MAIN OUTCOMES AND MEASURES Indications for therapy, length and number of dressing applications, identification of wound healing risk factors, classification of wound complexity, wound healing results, and adverse events related to the use of the device. RESULTS Negative pressure wound therapy was used primarily for wounds of the neck (94 of 115 patients [81.7%]) in addition to other head and neck locations (14 of 115 patients [12.2%]), and free tissue transfer donor sites (7 of 115 patients [6.1%]). The mean (SD) wound size was 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2), with an application length of 3.7 (1.4) days. Potential risk factors for compromised wound healing were present in 82 of 115 patients (71.3%). Ninety-one of 115 patients (79.1%) had complex wounds. Negative pressure dressings were used in wounds with salivary contamination (n = 64), bone exposure (n = 40), great vessel exposure (n = 25), previous free tissue transfer (n = 55), and peristomal application after laryngectomy (n = 32). Adverse events occurred in 4 of 115 patients (3.5%). CONCLUSIONS AND RELEVANCE Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal. LEVEL OF EVIDENCE 4.

Intraluminal negative pressure wound therapy for optimizing pharyngeal reconstruction.

IMPORTANCE: Pharyngocutaneous fistula formation after pharyngeal reconstruction is one of the most common and challenging problems to manage. Despite many advances in management, the published success rates indicate a role for any adjuvant therapy that could potentially decrease this complication. OBJECTIVE: To describe the use of intraluminal negative pressure dressings (NPDs) in pharyngeal reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series at a tertiary care academic hospital. Twelve laryngectomy patients underwent pharyngeal reconstruction augmented by placement of an intrapharyngeal NPD in combination with the introduction of vascularized tissue from August 2011 to May 2012. All patients had potential risk factors for compromised wound healing defined as previous radiation therapy, hypothyroidism, diabetes mellitus, compromised nutrition, or established pharyngocutaneous fistula. INTERVENTIONS: An NPD was placed in an intraluminal position spanning the length of the pharyngeal defect as part of the reconstructive procedure. The negative pressure sponge was attached to a standard nasogastric tube to which negative pressure was applied. External closure of the pharynx was then achieved with regional or free tissue transfer. MAIN OUTCOMES AND MEASURES: Pharyngeal closure rates, timing until return to oral diet, identification of wound healing risk factors, and adverse events related to use of the device. RESULTS: Eleven of 12 patients (92%) achieved pharyngeal closure with reconstruction using negative pressure wound therapy. All patients had at least 1 potential risk factor for compromised wound healing, with 11 of 12 (92%) having 2 or more. Seven patients had an established pharyngocutaneous fistula, and 5 patients underwent primary reconstruction after laryngopharyngectomy. In 6 of these 7 patients undergoing fistula repair, pharyngeal closure was achieved, and they resumed an oral diet at 1 week postoperatively. The other had successful leak repair initially, but 1 week later developed a separate area of wound breakdown and a second fistula. All 5 patients in whom an intraluminal NPD was placed at the time of initial vacularized tissue reconstruction were able to resume an oral diet by 3 weeks postoperatively, with 3 of them eating by mouth at 1 week postoperatively. No serious adverse events could be attributed to the use of intraluminal NPDs. CONCLUSIONS AND RELEVANCE: Intraluminal negative pressure wound therapy is feasible and safe. Future research should be conducted to determine its potential in optimizing pharyngeal reconstruction in high-risk patients.

Learning curve for transoral robotic surgery: a 4-year analysis.

IMPORTANCE: As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve. OBJECTIVE: To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes. DESIGN: Prospective case study. SETTING: A single tertiary care academic institution. PARTICIPANTS: A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months). INTERVENTION: Transoral robotic surgery. MAIN OUTCOMES AND MEASURES: Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications. RESULTS: Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required. CONCLUSIONS AND RELEVANCE: This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.

Hemorrhage after transoral robotic-assisted surgery.

OBJECTIVE: An increasing number of head and neck surgeons have begun using transoral robotic-assisted surgery. Our objective was to examine the postoperative bleeding complications we have encountered to determine risk factors and to discuss the topic of hemorrhage control. STUDY DESIGN: Case series with chart review. METHODS: Medical records were reviewed in 147 consecutive patients undergoing transoral robotic-assisted surgery for any indication at one tertiary academic medical center between March 2007 and September 2011. RESULTS: Eleven of 147 (7.5%) patients undergoing transoral robotic-assisted surgery experienced some degree of postoperative hemorrhage, with 9 patients requiring reoperation for examination and/or control of bleeding. Bleeding occurred at a mean of 11.1 ± 9.2 days after initial operation. Eight of 11 (72%) patients who bled were on antithrombotic medication (anticoagulants or antiplatelet agents) for other medical comorbidities. The postoperative hemorrhage rate in patients taking antithrombotic medication (8/48 patients = 17%) was significantly higher than in those not taking antithrombotics (3/99 patients = 3%), P = .0057. While the bleeding rate in salvage surgery (3/29 = 10.3%) was slightly higher than in primary surgery (8/118 = 6.8%), this difference did not reach statistical significance. CONCLUSION: Potential for postoperative bleeding in association with antithrombotic medications in patients undergoing transoral robotic-assisted surgery should be recognized. Various effective techniques for management of these patients without robotic assistance were demonstrated.

Assessment and incidence of salivary leak following laryngectomy.

OBJECTIVES/HYPOTHESIS: To determine the incidence and risk factors of pharyngocutaneous fistula formation in patients undergoing either primary or salvage laryngectomies and evaluate the role of barium esophagram in these patients. STUDY DESIGN: Retrospective cohort study. METHODS: Medical records of 259 patients who underwent total laryngectomy between 2003 and 2009 at our institution were reviewed. Risk factors for fistula formation were analyzed, including primary treatment modality, comorbidities, and operative details, which included use of a free flap for closure, concurrent neck dissections, margin status, and preoperative tracheostomy. The length of time until leak, postoperative swallow study results, and fistula management strategies were also assessed. RESULTS: Fifty-five patients developed a pharyngocutaneous fistula (overall incidence, 21%) in a median time of 12 days (range, 4-105 days). Twenty of these patients underwent laryngectomy as their initial treatment modality, and 35 had failed previous radiotherapy. Fistula formation was significantly higher in salvage surgery patients (P = .03), particularly those with hypothyroidism (P < .0002). A barium swallow performed at approximately 1 week after laryngectomy demonstrated a sensitivity of 26% with a specificity of 94%. Sixty-two percent of the fistulas healed with conservative measures only. CONCLUSIONS: Our data confirmed that previous radiotherapy and hypothyroidism, particularly in salvage laryngectomy patients, are important significant predictors of postoperative pharyngocutaneous fistula. The use of a postoperative barium swallow in these patients may be useful but was not found to be highly sensitive in predicting who will develop a clinically evident leak and should be used with caution.

Incidence and outcomes of stricture formation postlaryngectomy.

OBJECTIVE: Postlaryngectomy stricture formation and dysphagia negatively affect quality of life and result in nutritional compromise. Understanding risk factors and successful treatment strategies may improve treatment outcomes. STUDY DESIGN: Historical cohort study. SETTING: Tertiary care medical center. SUBJECTS AND METHODS: Patients at a tertiary care center who underwent a total laryngectomy between 2003 and 2009 (N = 263) were evaluated in a retrospective manner. Patient demographics, comorbidities, tobacco and alcohol usage, dietary outcomes, feeding tube dependence, and treatment modalities were assessed. Management strategies and outcomes were evaluated. RESULTS: Strictures developed in 19% (n = 49) of patients, and the majority (82%) occurred in the first year. Incidences of stricture formation were similar for primary (19%) and salvage laryngectomy (19%) patients. Patients undergoing salvage laryngectomy were 2 times more likely to be reconstructed with a free flap, whereas those undergoing a primary laryngectomy were 3 times more likely to be closed primarily. Tubed flap reconstruction significantly increased the incidence of stricture formation compared to primary closure (P = .02) in salvage laryngectomy cases. In primary laryngectomy patients, stricture formation did not correlate with flap reconstruction (P = .34) or adjuvant radiation therapy (P = .79). Patients who required a single dilation had better dietary outcomes compared to patients who required serial dilations (P = .14). There was no difference in overall disease-free survival in primary vs salvage laryngectomy patients (P = .95). CONCLUSION: Rates of stricture formation were the same in patients undergoing salvage compared to primary total laryngectomy.

Transoral robotic-assisted surgery for head and neck squamous cell carcinoma: one- and 2-year survival analysis.

OBJECTIVE: to report 2-year survival outcomes for head and neck squamous cell carcinoma using transoral robotic-assisted resection. DESIGN: prospective case study. SETTING: two tertiary care centers. PATIENTS: eighty-nine patients from 2 tertiary care centers (University of Alabama at Birmingham and the Mayo Clinic in Rochester, Minnesota) with head and neck squamous cell carcinoma of all stages and subsites, who underwent transoral robotic-assisted resection between March 2007 and December 2008, with a median follow-up time of 26 months. MAIN OUTCOME MEASURES: disease-free survival, cancer recurrence, and gastrostomy tube dependence RESULTS: seventy-one patients had T1 (n = 29) or T2 (n = 42) tumors while 18 patients had T3 (n = 8) or T4 (n = 10) tumors. There were 24 patients with overall stage I or II disease and 65 with stage III or IV disease. At the time of the last follow-up visit (median, 26 months), there had been a total of 11 patients with recurrent cancer: 3 with local; 7, regional (2 of whom also had distant metastases); and 1, distant. Seven patients were treated for recurrent disease. Eighty-two patients had no evidence of disease, 1 patient died of the disease, 2 died of other disease, and 4 were alive with disease at the last follow-up visit. Results of Kaplan-Meier survival analysis showed that the 2-year recurrence-free survival rate for the cohort was 86.5%. None of the patients were gastrostomy tube dependent at the last follow-up visit. CONCLUSION: the 2-year functional and oncologic results justify the continued treatment of select patients with head and neck squamous cell carcinoma with robotic-assisted surgical resection.

Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy in high-risk patients.

OBJECTIVES/HYPOTHESIS: To describe the outcomes of bedside percutaneous dilatational tracheostomy (PDT) extended to the care of high-risk patients in the intensive care unit (ICU) by the use of suspension laryngoscopy (SL) to secure the airway. STUDY DESIGN: Retrospective chart review. METHODS: The records of 117 consecutive patients who underwent suspension laryngoscopy-assisted percutaneous dilatational tracheostomy (SL-PDT) between April 2006 and May 2009 at our institution were reviewed. Data gathered included patient demographics, anatomical conditions, ventilator settings, intraoperative findings, presence of coagulopathy or anti-coagulation, and outcomes. RESULTS: One hundred seventeen patients underwent SL-PDT. Eighty (68%) were considered high risk by virtue of one or more of the following: morbid obesity, coagulopathy, prior neck surgery or head and neck trauma, laryngotracheal stenosis or tracheomalacia, a high-riding innominate artery, or high ventilator demands. Thirty-five patients (30%) had two or more of these risk factors. A total of 11 (13.7 %) complications occurred in the high-risk group. Two major and nine minor complications occurred during the study. There were no adverse sequelae. CONCLUSIONS: SL-PDT is a safe and effective means of bedside airway management in critically ill patients. This new technique offers several advantages over traditional percutaneous dilatational tracheostomy (T-PDT) and can be safely employed by otolaryngologists, especially in high-risk patients. This is most useful when T-PDT is considered untenable or when transport to the operating room for a standard open tracheostomy is considered too cumbersome or potentially dangerous.

Outcomes following temporal bone resection.

OBJECTIVES/HYPOTHESIS: To evaluate survival outcomes in patients undergoing temporal bone resection. STUDY DESIGN: Retrospective review. METHODS: From 2002 to 2009 a total of 65 patients underwent temporal bone resection for epithelial (n = 47) and salivary (n = 18) skull base malignancies. Tumor characteristics, defect reconstruction, and postoperative course were assessed. Outcomes measured included disease-free survival and cancer recurrence. RESULTS: The majority of patients presented with recurrent (65%), advanced stage (94%), cutaneous (72%), and squamous cell carcinoma (57%). Thirty-nine patients had perineural invasion (60%) and required facial nerve resection; 16 (25%) had intracranial extension. Local (n = 6), regional (n = 2), or free flap (n = 46) reconstruction was required in 80% of patients. Free flap donor sites included the anterolateral thigh (31%), radial forearm free flap (19%), rectus (35%), and latissimus (4%). The average hospital stay was 4.9 days (range, 1-28 days). The overall complication rate was 15% and included stroke (n = 4), cerebrospinal fluid leak (n = 2), hematoma formation (n = 1), infection (n = 1), flap loss (n = 1), and postoperative myocardial infarction (n = 1). A total of 22 patients (34%) developed cancer recurrence during the follow-up period (median, 10 months), 17 (77%) of whom presented with recurrent disease at the time of temporal bone resection. Two-year disease-free survival was 68%, and 5-year disease-free survival was 50%. CONCLUSIONS: Aggressive surgical resection and reconstruction is recommended for primary and recurrent skull base malignancies with acceptable morbidity and improved disease-free survival.