RESUMO
OBJECTIVES: The aim of the current study was to evaluate the functional outcomes of stapler pharyngeal closure after total laryngectomy by the incidence of PCT and assessment of swallowing after surgery. In addition, the study aimed to evaluate the oncological outcomes in terms of patients' survival rates. METHODS: This randomized clinical trial was conducted on 58 patients with advanced laryngeal carcinoma who underwent total laryngectomy. Patients were randomly assigned to two groups according to the method of pharyngeal repair after laryngectomy: manual closure group (n = 28), and stapler group (n = 30). Functional and oncological outcomes were assessed and compared. RESULTS: The incidence of pharyngocutaneous fistula was significantly less in the stapler group. Additionally, operative time was significantly shorter and swallowing function was better in the stapler group compared to the manual group. There was no statistically significant difference between groups regarding survival rates. CONCLUSION: The stapler is a reliable method for pharyngeal closure after total laryngectomy if the limits of its indications regarding the primary tumor are considered. Stapler closure decreases the incidence of PCF and decreases the surgical time. Good swallowing outcomes are achieved without compromising the oncological outcomes.
Assuntos
Neoplasias Laríngeas , Laringectomia , Humanos , Laringectomia/métodos , Masculino , Feminino , Pessoa de Meia-Idade , Neoplasias Laríngeas/cirurgia , Idoso , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Faringe/cirurgia , Duração da Cirurgia , Resultado do Tratamento , Grampeadores Cirúrgicos , Adulto , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/epidemiologia , Grampeamento Cirúrgico/métodos , Deglutição/fisiologiaRESUMO
PURPOSE: Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. PATIENTS AND METHODS: Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects. RESULTS: The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. CONCLUSIONS: Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.
Assuntos
Fístula Cutânea , Hipotireoidismo , Laringectomia , Complicações Pós-Operatórias , Terapia de Salvação , Tiroxina , Humanos , Masculino , Laringectomia/efeitos adversos , Feminino , Pessoa de Meia-Idade , Terapia de Salvação/métodos , Idoso , Tiroxina/administração & dosagem , Tiroxina/efeitos adversos , Tiroxina/uso terapêutico , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Hipotireoidismo/etiologia , Hipotireoidismo/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Fístula/etiologia , Fístula/prevenção & controle , Administração Intravenosa , Adulto , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/tratamento farmacológico , Estudos ProspectivosRESUMO
INTRODUCTION: To assess the usage of contralateral infrahyoid muscles as onlay flap in prevention of pharyngo-cutaneous fistula (PCF) in total laryngectomy (TL) patients with high risk factors of PCF development. METHODS: This study included 10 patients who suffered from advanced laryngeal carcinoma with presence of risk factors for development of PCF. We added an enforcement muscular layer during neo-pharynx wall repair, the infrahyoid muscle flap of the contralateral side of the tumour origin as an onlay muscular flap to cover the anastomotic site for healing augmentation. Patients were followed up for PCF development where the PCF incidence was calculated. RESULTS: One patient died from congestive heart failure in the 21th post-operative day so, the actual PCF rate in TL patients with high risk factors of PCF development in our study was 11.11% (1 out of 9 cases). CONCLUSIONS: Infrahyoid muscle flap may have a role in preventing PCF after TL in patients with high risk factors of PCF development in this case series study to be further assessed in other studies to justify its role.
Assuntos
Neoplasias Laríngeas , Laringectomia , Doenças Faríngeas , Retalhos Cirúrgicos , Humanos , Laringectomia/métodos , Masculino , Pessoa de Meia-Idade , Neoplasias Laríngeas/cirurgia , Idoso , Feminino , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Procedimentos de Cirurgia Plástica/métodos , Faringe/cirurgiaRESUMO
PURPOSE: Pharyngocutaneous fistula (PCF) is a possible complication following total laryngectomy (TL), with a mean incidence of 17%. We intended to investigate the effect of pharyngeal closure type during TL on the prevention of PCF. METHODS: We retrospectively reviewed patients that underwent TL with a horizontal pharyngeal closure over a 10-year period. The frequency of PCF clinically, dysphagia, total oral diet, postoperative dilatation of the neopharynx and voice problems were tabulated. RESULTS: Seventy-seven subjects underwent TL due to laryngeal tumor without pharyngeal extension. Of them, 45 underwent a salvage TL. PCF occurred in 1/77 subjects. The rest of the subjects (76/77) did not develop a PCF, neither in the early nor in the late postoperative phase. All subjects (15/77) that underwent implantation of a voice prosthesis were satisfied with their voice. No subject complained about dysphagia. Every subject achieved total oral diet. CONCLUSION: The horizontal pharyngeal closure is a safe pharyngeal closure technique during TL, reduces PCF rates (< 2%), results in excellent voice rehabilitation and swallowing function, and can also be used during salvage TL instead of a major pectoral flap. This type of closure should be used only in selected patients with laryngeal disease without pharyngeal extension.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Laringectomia , Doenças Faríngeas , Complicações Pós-Operatórias , Humanos , Laringectomia/efeitos adversos , Laringectomia/métodos , Fístula Cutânea/prevenção & controle , Fístula Cutânea/etiologia , Masculino , Estudos Retrospectivos , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/etiologia , Feminino , Pessoa de Meia-Idade , Idoso , Neoplasias Laríngeas/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Faringe/cirurgia , Idoso de 80 Anos ou mais , Fístula/prevenção & controle , Fístula/etiologiaRESUMO
OBJECTIVE: Salvage laryngectomy is more predisposed to complications than primary operations, with pharyngocutaneous fistula (PCF) being among the most challenging to manage. Vascularized flaps are increasingly employed during salvage laryngectomy, with a previous review finding a PCF incidence of 31.2% and 22.2% after primary and flap-assisted closure respectively. We aim to better define the role of vascularized flaps after salvage laryngectomy by performing an updated review comparing the rate of PCF in those undergoing primary or vascularized flap-assisted closure. DATA SOURCES: Pubmed/Medline, CINAHL, and CENTRAL. REVIEW METHODS: An updated literature review was conducted of English language literature from 2003 to 2023. A random effects and network meta-analysis of odds ratios (OR) and pooled proportions were conducted. RESULTS: Literature search found 31 studies, including seven from the previous review. Overall random effects pooled PCF rate was 25% (95% CI 0.21; 0.30, I2 = 72%, p = <0.01), whereas incidence in primary closure was 37% (95% CI 0.32; 0.43, I2 = 60%, p = <0.01) and 19% (95% CI 0.12; 0.20, I2 = 47%, p = <0.01) after flap closure. Pooled OR was 0.39 (95% CI 0.28; 0.55, I2 = 36%, p = 0.04) in favor of vascularized tissues. The number needed to treat was 6.5. The rate of PCF was lower after free and pedicled flaps, and on-lay and patch closure compared to primary closure techniques. Network meta-analysis found all combinations of closure techniques and vascularized tissue were superior to primary closure. CONCLUSION: The updated analysis has demonstrated a widening in the rates of PCF between primary and vascularized flap-assisted closure. Surgeons should strongly consider the use of free or pedicled flaps in any salvage laryngectomy procedure. Laryngoscope, 134:2991-3002, 2024.
Assuntos
Fístula Cutânea , Laringectomia , Metanálise em Rede , Complicações Pós-Operatórias , Terapia de Salvação , Retalhos Cirúrgicos , Humanos , Laringectomia/efeitos adversos , Laringectomia/métodos , Terapia de Salvação/métodos , Retalhos Cirúrgicos/transplante , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/cirurgia , Fístula Cutânea/epidemiologia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/cirurgia , Neoplasias Laríngeas/cirurgia , Incidência , Fístula/etiologia , Fístula/prevenção & controle , Fístula/cirurgia , Fístula/epidemiologiaRESUMO
BACKGROUND: Total laryngectomy (TL) is a surgical procedure commonly performed on patients with advanced laryngeal or hypopharyngeal carcinoma. One of the most common postoperative complications following TL is the development of a pharyngocutaneous fistula (PCF), characterized by a communication between the neopharynx and the skin. PCF can lead to extended hospital stays, delayed oral feeding, and compromised quality of life. The use of a myofascial pectoralis major flap (PMMF) as an onlay technique during pharyngeal closure has shown potential in reducing PCF rates in high risk patients for development of PCF such as patients undergoing TL after chemoradiation and low skeletal muscle mass (SMM). Its impact on various functional outcomes, such as shoulder and neck function, swallowing function, and voice quality, remains less explored. This study aims to investigate the effectiveness of PMMF in reducing PCF rates in patients with low SMM and its potential consequences on patient well-being. METHODS: This multicenter study adopts a randomized clinical trial (RCT) design and is funded by the Dutch Cancer Society. Eligible patients for TL, aged ≥ 18 years, mentally competent, and proficient in Dutch, will be enrolled. One hundred and twenty eight patients with low SMM will be centrally randomized to receive TL with or without PMMF, while those without low SMM will undergo standard TL. Primary outcome measurement involves assessing PCF rates within 30 days post-TL. Secondary objectives include evaluating quality of life, shoulder and neck function, swallowing function, and voice quality using standardized questionnaires and functional tests. Data will be collected through electronic patient records. DISCUSSION: This study's significance lies in its exploration of the potential benefits of using PMMF as an onlay technique during pharyngeal closure to reduce PCF rates in TL patients with low SMM. By assessing various functional outcomes, the study aims to provide a comprehensive understanding of the impact of PMMF deployment. The anticipated results will contribute valuable insights into optimizing surgical techniques to enhance patient outcomes and inform future treatment strategies for TL patients. TRIAL REGISTRATION: NL8605, registered on 11-05-2020; International Clinical Trials Registry Platform (ICTRP).
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Humanos , Laringectomia/efeitos adversos , Músculos Peitorais , Neoplasias Laríngeas/patologia , Estudos Retrospectivos , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/cirurgia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
BACKGROUND: Pharyngocutaneous fistula is one of the most common complications following total laryngectomy. It increases hospital stay and the financial burden on patients, and prolongs nasogastric feeding. This paper presents novel techniques for prevention of pharyngocutaneous fistula. METHOD: A retrospective study was conducted at a tertiary referral centre to assess the effectiveness of continuous extramucosal pharyngeal suturing and the hydrogen peroxide leak test in prevention of pharyngocutaneous fistula in 59 patients who had undergone total laryngectomy with or without partial pharyngectomy for locally advanced cancers of the larynx and hypopharynx. RESULTS: The incidence of pharyngocutaneous fistula in our study was 6.8 per cent, which is considerably lower than the incidence reported in various previous studies. CONCLUSION: The continuous extramucosal suturing technique provides watertight closure of the neopharynx and can be recommended as a reliable method for neopharyngeal closure post total laryngectomy to reduce the occurrence of pharyngocutaneous fistula.
Assuntos
Carcinoma de Células Escamosas , Fístula Cutânea , Neoplasias Hipofaríngeas , Neoplasias Laríngeas , Laringe , Doenças Faríngeas , Humanos , Neoplasias Hipofaríngeas/cirurgia , Estudos Retrospectivos , Neoplasias Laríngeas/cirurgia , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/complicações , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/epidemiologia , Laringectomia/efeitos adversos , Laringectomia/métodos , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controleRESUMO
PURPOSE: Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection. METHODS: A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded. RESULTS: One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula. CONCLUSION: Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection.
Assuntos
Fístula Cutânea , Neoplasias de Cabeça e Pescoço , Neoplasias Orofaríngeas , Doenças Faríngeas , Procedimentos Cirúrgicos Robóticos , Humanos , Esvaziamento Cervical/efeitos adversos , Esvaziamento Cervical/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Austrália/epidemiologia , Neoplasias Orofaríngeas/cirurgia , Neoplasias Orofaríngeas/patologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/cirurgia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Neoplasias de Cabeça e Pescoço/cirurgiaRESUMO
INTRODUCTION: The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario. METHODS: A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included. RESULTS: A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce. CONCLUSION: We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Procedimentos de Cirurgia Plástica , Humanos , Fístula Cutânea/prevenção & controle , Fístula Cutânea/complicações , Neoplasias Laríngeas/cirurgia , Laringectomia/efeitos adversos , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/cirurgia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Pharyngocutaneous fistula (PCF), a major complication of total laryngectomy, is caused by pharyngeal repair failure. OBJECTIVE: Assess the usefulness of endoscopic observation of the pharyngeal suture's healing process for the early detection of PCF development. METHODS: Pharyngeal mucosal sutures were endoscopically observed postoperatively in patients who underwent total laryngectomy with primary closure. RESULTS: Postoperatively, a white coat adhered to the pharyngeal mucosal suture of all patients. In most cases, the white coat gradually receded, which was considered to be a normal healing process. Thickening of the white coat and/or dehiscence of surgical wound were interpreted as 'poor healing conditions'. Three cases were judged to have developed poor healing conditions of the pharyngeal mucosal suture and one patient developed PCF. The other two patients did not develop PCF, possibly due to early detection of 'poor healing condition' and conservative approach, such as discontinuation of oral intake. CONCLUSIONS: Postoperative poor healing conditions of the pharyngeal mucosal suture may be precursors to PCF development. Endoscopic observation enables early detection of these conditions and may enable the prevention of PCF.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Humanos , Laringectomia/efeitos adversos , Estudos Retrospectivos , Neoplasias Laríngeas/cirurgia , Neoplasias Laríngeas/complicações , Faringe/cirurgia , Fístula Cutânea/prevenção & controle , Doenças Faríngeas/prevenção & controle , Suturas/efeitos adversos , Complicações Pós-Operatórias/etiologiaRESUMO
The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Fístula Cutânea/epidemiologia , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Humanos , Neoplasias Laríngeas/complicações , Neoplasias Laríngeas/cirurgia , Laringectomia/efeitos adversos , Pessoa de Meia-Idade , Doenças Faríngeas/epidemiologia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos RetrospectivosRESUMO
PURPOSE: To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL). METHODS: An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines. RESULTS: A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62-66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20-0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first). CONCLUSIONS: A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Humanos , Pessoa de Meia-Idade , Laringectomia/efeitos adversos , Laringectomia/métodos , Metanálise em Rede , Teorema de Bayes , Neoplasias Laríngeas/cirurgia , Estudos Retrospectivos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgia , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/cirurgia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/cirurgia , Terapia de Salvação/métodosRESUMO
INTRODUCTION: The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL). METHODS: A consecutive series of 133 patients who underwent total laryngectomy between 1997 and 2019 was reviewed. The incidence of PCF was compared between patients who did not receive SBT (nSBT group; n = 55) and those preventively receiving SBT (SBT group; n = 78) in both primary and salvage TL. Risk factors for PCF were evaluated in a univariate and multivariate analyses. RESULTS: The overall PCF rate was 30%. Preoperative characteristics were similar between the nSBT and SBT groups, except for older age (p = 0.016), lower preoperative hemoglobin (p = 0.043), and lesser neoadjuvant chemotherapy (p = 0.015) in the SBT group. The rate of PCF the nSBT group, was 41.5%, compared to 21.8% in the SBT group (p = 0.020). In multivariate analysis, only the use of SBT was associated with lower risk of PCF (OR = 0.41 (95% CI 0.19-0.89), p = 0.026). This effect was verified only in the subgroup of patient operated for salvage TL (OR = 0.225; 95% CI 0.09-0.7; p = 0.008). CONCLUSION: The use of SBT in our series in salvage TL, appears to be associated with a decreased risk of PCF.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Idoso , Fístula Cutânea/epidemiologia , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Humanos , Neoplasias Laríngeas/cirurgia , Laringectomia , Doenças Faríngeas/epidemiologia , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos RetrospectivosRESUMO
INTRODUCTION: One of the most common complications in the immediate and late postoperative period following total laryngectomy or pharyngolaryngectomy is pharyngocutaneous fistulae (PCF) formation and pharyngoesophageal stenosis (PES), causing significant mortality and morbidity. Since 1978, Montgomery salivary bypass tube (MSBT) has been used to reduce the incidence of PCF and PES. The aim of this retrospective study was to analyze the outcomes of using MSBT both as a tool to prevent PCF and PES and to treat these complications in the postoperative period. METHODS: Between January 2013 and December 2019, we inserted 109 MSBT in 87 patients with laryngeal/hypopharyngeal cancer treated in the Unit of Otolaryngology of our University Hospital. RESULTS: Sixty (86.9%) patients healed from complications with primary and secondary placement of MSBT. Seven patients presented a persistence of PCF and 2 presented a recurrence of PES. Secondary placement of MSBT allowed treating successfully 15 (83%) of 18 patients. Only 3 of them presented a PCF at the end of the follow-up period. CONCLUSION: According to our experience, the MSBT is an affordable, easy to apply and well-tolerated tool. Although it is generally used for PCF treatment, it can also be used intraoperatively for PCF and PES prevention.
Assuntos
Fístula Cutânea , Neoplasias de Cabeça e Pescoço , Neoplasias Laríngeas , Otolaringologia , Doenças Faríngeas , Constrição Patológica/complicações , Constrição Patológica/cirurgia , Fístula Cutânea/etiologia , Fístula Cutânea/prevenção & controle , Fístula Cutânea/cirurgia , Neoplasias de Cabeça e Pescoço/complicações , Humanos , Neoplasias Laríngeas/complicações , Laringectomia/efeitos adversos , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgia , Estudos RetrospectivosAssuntos
Materiais Biocompatíveis/uso terapêutico , Fístula Cutânea/prevenção & controle , Laringectomia/efeitos adversos , Laringectomia/métodos , Doenças Faríngeas/prevenção & controle , Ácido Poliglicólico/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Fístula do Sistema Respiratório/prevenção & controle , Idoso , Fístula Cutânea/etiologia , Feminino , Humanos , Neoplasias Laríngeas/cirurgia , Masculino , Pessoa de Meia-Idade , Doenças Faríngeas/etiologia , Complicações Pós-Operatórias/etiologia , Fístula do Sistema Respiratório/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
I wish to thank the Semon Committee for inviting me to deliver the 2020 Semon lecture. This is a very special honour, as is evidenced by the list of distinguished lecturers dating back to the inaugural lecture delivered at University College London in 1913. I am not the first South African to deliver the Semon lecture, having been preceded by my previous chairman Sean Sellars in 1993, and by Jack Gluckman in 2001, who was South African raised and educated and who subsequently became the chairman of otolaryngology in Cincinnati, USA.
Assuntos
Neoplasias Laríngeas/cirurgia , Laringectomia/métodos , Complicações Pós-Operatórias/prevenção & controle , Traqueostomia/métodos , Pesquisa Biomédica , Fístula Cutânea/prevenção & controle , Nutrição Enteral/métodos , Recursos em Saúde , Humanos , Laringe Artificial , Recidiva Local de Neoplasia/epidemiologia , Tratamentos com Preservação do Órgão , Otolaringologia , Doenças Faríngeas/prevenção & controle , Cuidados Pós-Operatórios/métodos , Inibidores da Bomba de Prótons/uso terapêutico , Qualidade de Vida , Radioterapia , Classe Social , África do Sul , Voz Esofágica , Estomas Cirúrgicos , TireoidectomiaRESUMO
BACKGROUND: Pharyngocutaneous fistula (PCF) is a common complication after laryngopharyngeal surgery. It presents incredible difficulties to both doctors and patients and can lead to prolonged hospitalization. OBJECTIVE: To analyze the pros and cons of the pedicled skin flap in the prevention and repair of PCF and put forward the authors' views and experience about the selection and application of flaps for the treatment of PCF. METHODS: A literature review of pedicled flap application in PCF was carried out. RESULTS: Based on the analysis of the characteristics of the pedicled flap in PCF treatment, the advantages and disadvantages are compared. RESULTS: In the literature, the pectoralis major myocutaneous flap is the most widely used regional pedicled flap for PCF. Many other flaps can be used to prevent and treat PCF. Each kind of pedicled flap has advantages and limitations. This plays a role in the individualized selection and design of PCF to maximize the benefits of patients. CONCLUSIONS: Taking unity of function, aesthetics, and proficiency of operators into account, choosing the appropriate flap to repair PCF can reduce the occurrence rate of PCF and improve the patient's quality of life.
Assuntos
Fístula Cutânea/cirurgia , Doenças Faríngeas/cirurgia , Complicações Pós-Operatórias/cirurgia , Fístula do Sistema Respiratório/cirurgia , Retalhos Cirúrgicos , Fístula Cutânea/prevenção & controle , Humanos , Procedimentos Cirúrgicos Otorrinolaringológicos/efeitos adversos , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Doenças Faríngeas/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Qualidade de Vida , Fístula do Sistema Respiratório/prevenção & controle , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the risk factors of pharyngocutaneous fistula after total pharyngolaryngectomy (TPL) in order to reduce their incidence and propose a perioperative rehabilitation protocol. MATERIALS AND METHODS: This was a multicenter retrospective study based on 456 patients operated for squamous cell carcinoma by total laryngectomy or TPL. Sociodemographic, medical, surgical, carcinologic, and biological risk factors were studied. Reactive C protein was evaluated on post-op day 5. Patients were divided into a learning population and a validation population with patients who underwent surgery between 2006 and 2013 and between 2014 and 2016, respectively. A risk score of occurrence of salivary fistula was developed from the learning population data and then applied on the validation population (temporal validation). OBJECTIVE: To use a preoperative risk score in order to modify practices and reduce the incidence of pharyngocutaneous fistula. RESULTS: Four hundred fifty-six patients were included, 328 in the learning population and 128 in the validation population. The combination of active smoking over 20 pack-years, a history of cervical radiotherapy, mucosal closure in separate stitches instead of running sutures, and the placement of a pedicle flap instead of a free flap led to a maximum risk of post-op pharyngocutaneous fistula after TPL. The risk score was discriminant with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI] = 0.59-0.73) and 0.70 (95% CI = 0.60-0.81) for the learning population and the validation population, respectively. CONCLUSION: A preoperative risk score could be used to reduce the rate of pharyngocutaneous fistula after TPL by removing 1 or more of the 4 identified risk factors.
Assuntos
Fístula Cutânea/etiologia , Fístula/etiologia , Laringectomia/efeitos adversos , Doenças Faríngeas/etiologia , Faringectomia/efeitos adversos , Carcinoma de Células Escamosas/cirurgia , Fístula Cutânea/prevenção & controle , Feminino , Fístula/prevenção & controle , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Laringectomia/reabilitação , Masculino , Pessoa de Meia-Idade , Doenças Faríngeas/prevenção & controle , Faringectomia/reabilitação , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Fumar/efeitos adversosRESUMO
OBJECTIVE: To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. METHODS: Retrospective review. RESULTS: Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). CONCLUSION: Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E875-E881, 2021.