Risk Factors for Pharyngocutaneous Fistula After Total Pharyngolaryngectomy.

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.

The Value of the "Papillon" Anterolateral Thigh Flap for Total Pharyngolaryngectomy Reconstruction: A Retrospective Case Series.

PURPOSE: The tubed, buried anterolateral thigh (ALT) flap is a popular reconstruction method for total pharyngolaryngectomy defects. The "papillon"-designed ALT flap, described by Hayden et al, offers an alternative method of using the ALT flap in this situation. We report our early experience with the papillon ALT flap in a patient cohort. PATIENTS AND METHODS: On retrospective review, all patients who underwent reconstruction of circumferential total pharyngolaryngectomy defects with the papillon ALT flap from February 2012 to February 2015 were identified from our departmental database. Demographic and clinical data, operative details, and complications were analyzed from the records. RESULTS: Seven patients were included in this study. The mean length of hospital stay was 15 days (range, 10 to 32 days). Acute complications occurred in 5 of 7 patients, namely, partial flap loss managed by a pectoralis flap (1 of 7 [14%]); an early pharyngocutaneous fistula (4 of 7 [57%]) managed by simple repair, wound packing, or delayed repair; and a donor-site hematoma (1 of 7 [14%]). At follow-up (range, 2 to 24 months), there was 1 stricture formation, but no chronic fistula. All patients were able to swallow orally. CONCLUSIONS: Early results using the papillon ALT flap suggest that this technique is a viable alternative to the standard tubed ALT flap design. The advantages of this design include the following: 1) it offers simultaneous vascularized skin to resurface anterior neck skin deficiency without resorting to additional tissue elsewhere; 2) direct monitoring of the ALT flap is possible; and 3) any pharyngocutaneous fistula is exteriorized to the surface without compromising the internal neck structures and can be easily identified and repaired directly in the office.

Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) free flap.

We retrospectively reviewed 15 cases of pharyngolaryngectomy for advanced laryngeal carcinoma reconstructed with the anterolateral thigh (ALT) free flap. Thirteen patients had primary surgery and adjuvant treatment (radiotherapy or chemoradiotherapy), and two had salvage surgery. Thirteen had stage III or IV disease, and eight had cervical nodal extracapsular spread. In this series all the flaps survived, and at median follow-up of 14.5 months (range 3.7-31.2), 12 of the 15 patients were alive. One patient developed a chronic pharyngocutaneous fistula, and five required repeat balloon dilatations for late pharyngeal strictures. Six patients enjoyed restoration of full oral intake, seven were able to take a soft diet, and two were dependent on feeding by percutaneous endoscopic gastrostomy. Four patients developed adequate tracheo-oesophageal speech, and one successfully developed oesophageal speech. In this series many of the surgical problems associated with pharyngolaryngectomy reconstruction were addressed successfully by the ALT, but late dysphagia remained troublesome in an appreciable minority. While adjuvant radiotherapy could have contributed to this, future innovations will focus on the reduction of late strictures.

Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy.

BACKGROUND: Enlarged tracheoesophageal puncture (TEP) is a challenging complication of surgical prosthetic voice restoration. Prevention of this complication requires identification of high-risk individuals, and surgical and prosthetic correlates of TEP enlargement. METHODS: Multivariable logistic regression methods were used to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP in a 5-year retrospective cohort. RESULTS: Enlarged TEP only occurred in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced (N2 or N3) nodal disease (odds ratio [OR](adjusted) , 4.3; 95% confidence interval [CI], 1.0-19.1), postoperative stricture (OR(adjusted) , 3.2; 95% CI, 1.2-8.6), and diagnosis of locoregional recurrence or distant metastasis after laryngectomy (OR(adjusted) , 6.2; 95% CI, 2.3-16.4) increased risk of enlarged TEP. Extended resection and preoperative nutritional status were also significantly associated with enlarged TEP. Prosthetic parameters did not significantly correlate with enlargement. CONCLUSION: Development of enlarged TEP is a multifactorial process related to both baseline and postoperative factors.

Functional results of pharyngo-laryngectomy and total laryngectomy: a comparison.

OBJECTIVE: To compare the key functional results (regarding swallowing and voice rehabilitation) in patients treated by pharyngo-laryngectomy with flap reconstruction, versus standard, wide-field, total laryngectomy. METHOD: We studied 97 patients who had undergone total laryngectomy and pharyngo-laryngectomy with flap reconstruction. The main outcome measures were swallowing (i.e. solid food, soft diet, fluid or enteral feeding) and fluent voice development. RESULTS: There were 79 men and 18 women, with follow up of one to 19 years. Voice (p = 0.037) and swallowing (p = 0.041) results were significantly worse after circumferential pharyngo-laryngectomy than after non-circumferential pharyngo-laryngectomy. There was no significant difference in voice (p = 0.23) or swallowing (p = 0.655) results, comparing total laryngectomy and non-circumferential pharyngo-laryngectomy. The presence of a post-operative fistula significantly influenced voice (p = 0.001) and swallowing (p = 0.009) outcomes. CONCLUSION: The additional measures involved in pharyngo-laryngectomy do not confer any functional disadvantage, compared with total laryngectomy, but only if the procedure is non-circumferential. Functional results of circumferential pharyngo-laryngectomy are worse than those of both non-circumferential pharyngo-laryngectomy and total laryngectomy. If oncologically possible and safe, it is better to keep a pharyngo-laryngectomy non-circumferential.

Pharyngolaryngectomy with free jejunal autograft reconstruction and tracheoesophageal voice restoration: Indications for replacements, microbial colonization, and indwelling times of the Provox 2 voice prostheses.

BACKGROUND: The purpose of this prospective study was to investigate shunt-related and device-related complications and microbial colonization of voice prostheses in patients after pharyngolaryngectomy with jejunal autograft reconstruction in comparison to patients after standard laryngectomy. METHODS: Nine patients after pharyngolaryngectomy with jejunal autograft reconstruction (group 1) and 14 patients after standard laryngectomy (group 2) equipped with the Provox(®) 2 voice prostheses were followed up over 2 years. Anamnestic data, documentation of shunt-related or device-related complications, the Provox(®) 2 indwelling time, and standard microbiological procedures of voice prostheses were used for analyses. RESULTS: A total of 157 prostheses were replaced. No significant difference in mean prosthesis indwelling time (p = .45) was observed between group 1 (116 ± 114 days) and group 2 (129 ± 99 days). Patients with jejunal autograft reconstruction needed prosthesis replacements more frequently within the first 60 days after prosthesis insertion in comparison to patients after standard laryngectomy (p = .007). The main indication for replacement in both groups was the device leakage (group 1: 93.1%, group 2: 92.1%). Prostheses of group 1 were more often colonized with Staphylococcus aureus (p = .027) and Enterobacteriaceae (p = .015). CONCLUSION: This study demonstrated that, in comparison with patients after standard laryngectomy, patients after jejunal autograft reconstruction have similar shunt-related and device-related complications and prosthesis indwelling times. Therefore, tracheoesophageal voice rehabilitation could be strongly recommended in these patients.

Effect of primary, cross-over, zigzag neopharyngoplasty on acoustic characteristics of alaryngeal, tracheoesophageal voice.

OBJECTIVE: To evaluate the effect of primary, cross-over, zigzag neopharyngeal construction on tracheoesophageal voice, compared with pharyngoesophageal myotomy, following total laryngectomy with partial pharyngectomy. STUDY DESIGN: Prospective clinical trial. SETTING: Otolaryngology department, Tanta University Hospital (tertiary referral centre), Egypt. PATIENTS AND METHODS: Over five years, 30 patients underwent total laryngectomy with partial pharyngectomy to manage stage III or IV laryngeal cancer, followed by primary tracheoesophageal puncture for voice restoration. For neopharyngeal construction, 15 patients underwent pharyngoesophageal myotomy (group one) and 15 cross-over, zigzag neopharyngoplasty (group two). Acoustic parameters of tracheoesophageal voice were compared. RESULTS: Most acoustic parameters were almost equivalent for the two groups, although significant differences were seen for loud intensity, dynamic range, shimmer, loud fundamental frequency, loud jitter, fluency and speaking rate. One post-operative pharyngocutaneous fistula (6.6 per cent) occurred in each group, and resolved with conservative measures. CONCLUSION: The cross-over neopharyngoplasty modification of hypopharyngeal closure may help avoid pharyngoesophageal spasm and assist maintenance of effective voice amplitude, fundamental frequencies, temporal measures and perceptual values.

Determining the efficacy and cost-effectiveness of the ActiValve: results of a long-term prospective trial.

OBJECTIVES/HYPOTHESIS: To investigate 1) whether the Provox ActiValve results in increased device-life in individuals with below average device-life, 2) whether it is cost-effective, and 3) whether it has any impact on voice-related quality of life. STUDY DESIGN: Prospective study. METHODS: Individuals who experienced below-average tracheoesophageal prosthesis (TEP) life were studied. RESULTS: Individuals with persistent below-average TEP life were enrolled in the study and underwent periodic re-evaluation. The majority (73%) experienced significant improvement as a result of use of the device. Those who continued to wear the device were followed for an average of 30.45 months (range, 14.70-43.49 months) and wore a total of 31 devices over this time. They demonstrated an average increase in device-life of more than 500%, going from an average of 1.93 months with a traditional indwelling device to 10.30 months with the ActiValve. The majority of individuals found that voicing with the ActiValve was either the same or better than with their previous indwelling TEP. Voice-related quality of life was not significantly different from that of a group of controls. Overall satisfaction with the device was high, and the majority would have chosen the ActiValve in the future. Overall, there were estimated to be cost savings to third-party payers through use of the ActiValve in this population. CONCLUSIONS: The ActiValve is effective in increasing device-life in selected patients who have failed conservative measures. Our protocol for use of the device requires individuals to meet several usage criteria before initial placement and to return for periodic monitoring.

Use of an 'elephant trunk' shunt for voice restoration: a decade of experience in voice restoration using a free jejunal graft in patients who have undergone laryngopharyngoesophagectomy.

Although the structural integrity of the hypopharynx can be readily restored in individuals who have undergone laryngopharyngoesophagectomy by transferring a segment of the jejunum by a microsurgical technique, rehabilitation is often hindered by voice loss. The outcomes achievable with conventional approaches of artificial voice box reconstruction have been, generally speaking, unsatisfactory. A new reconstructive technique was devised to create a connection between the tracheal stump and the neo-hypopharynx to shunt airflow for phonation. The technique consisted of modifying one of two jejunal segments nourished by a single vascular pedicle to make a side mucosal tube resembling an elephant's trunk. With the larger end of one segment connected to the tracheal stump, the side arm having a smaller calibre was connected to the neo-oesophagus which was reconstructed with the second jejunal segment. Upon recovery from the surgery, the patient was trained for phonation by shunting the airflow into the neo-pharyngoesophagus. A total of 39 individuals underwent the elephant trunk shunt procedure for voice restoration at our hospital during the past 10 years. Although phonation was restored in 28 patients who had survived the original disease, the speech was assessed in 11. The mean duration of follow up was 5.6 years. The quality of speech was considered to be adequate in all. The rehabilitation of individuals who had undergone laryngopharyngoesophageal resection was enhanced and the quality of life was improved by voice restoration. That objective is attainable by incorporating a jejunal segment that shunts airflow to the jejunal pouch, thereby enabling phonation.

Reconstruction of circumferential pharyngolaryngectomy using a 'horseshoe-shaped' pectoralis major myocutaneous flap.

Eighteen patients underwent a circumferential pharyngolaryngectomy reconstruction post pharyngolaryngectomy. All tumours showed pharyngo-oesophageal junction invasion or circular involvement of the hypopharynx, requiring total, circumferential pharyngolaryngectomy. A pectoralis major myocutaneous flap was directly sutured to the pre-vertebral fascia. A Montgomery salivary bypass tube was introduced into the oesophagus, and a nasogastric tube was placed within it. No post-operative complications occurred for 14 patients and only minor ones for the other four. Average post-operative stay was 12 days. For 15 patients, feeding returned to normal throughout the follow-up period. No fistulae were noted and neopharyngeal stenosis occurred in three patients (16 per cent). Thirteen had complete resection with normal margins. Thirteen were still alive after one to three years of follow up. The local recurrence rate was 16 per cent. The use of a pectoralis major myocutaneous flap with Spriano's technique provides a simple, reliable method for circumferential hypopharyngeal resection. It has been applied to a wide range of patients, especially elderly ones and those with poor general status, as well as to cases in which widespread involvement was detected during surgery.

[Quality of life after oropharyngectomy]. / Qualité de vie après buccopharyngectomie transmandibulaire.

OBJECTIVE: The purpose of this study was to assess direct or non-direct links between functional abilities of the patient evaluated objectively and his quality of life after oropharyngectomy, a surgery capable of engendering bad functional outcomes. METHODS: Praxies and speech were examined in 16 patients at 3, 6, 9 or 12 months after surgery and 2 self-evaluation questionnaires were proposed: One about health related quality of life of cancer patients (EORTC QLQ-C30 and H&N35) and, the other about oral communication handicap (VHI). RESULTS AND CONCLUSION: A correlation between quality of life and objective functional abilities can not always be found. Self-evaluation questionnaires might be a complementary approach in order to guide management in patient care after oropharyngectomy.

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: preliminary report.

CONCLUSION: The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). OBJECTIVES: To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. MATERIAL AND METHODS: This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. RESULTS: All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n=2), distant metastasis (n=1) and suicide (n=1). One patient was alive with disease despite neck recurrence.

Voice restoration by primary insertion of indwelling voice prosthesis following circumferential pharyngolaryngectomy with free jejunal graft.

BACKGROUND: Voice restoration after circumferential pharyngolaryngectomy (CPL) with free jejunal graft remains a difficult problem to solve. Few reports have analyzed the success rate and complications following primary insertion of indwelling voice prostheses during CPL with free jejunal graft. PATIENTS AND METHODS: Eight patients who underwent CPL with free jejunal graft had a Groningen voice prosthesis inserted as a tracheoesophageal (TE) shunt at the time of oncological surgery. A 10-point scale was used to assess each patient's speech intelligibility. Complications following the voice prosthesis insertion were also analyzed. RESULTS: Six of the eight patients (75%) achieved excellent speech intelligibility and the remaining two patients (25%) were judged as moderate. Six of the eight patients (75%) used the TE shunt as their major means of daily communication. Leakage through or around the prosthesis, which occurred in six (75%) patients, was the most frequent prosthesis-related complication. CONCLUSIONS: This safe and reliable technique can be effective in improving the quality of life in selected patients undergoing CPL.

Tracheoesophageal speech following laryngopharyngectomy and pharyngeal reconstruction.

Voice restoration following total laryngectomy and pharyngeal reconstruction is an achievable yet challenging reconstructive task. Because numerous methods exist for pharyngeal reconstruction in conjunction with total laryngectomy, a thorough knowledge of the tissues used for reconstruction is necessary. This knowledge allows for realistic expectations for patient success. Also, specific modifications in voice restoration may be necessary with individual reconstruction methods. This article reviews the methods for reconstruction and the available literature on voice restoration in reconstructed patients.

Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience.

We describe the speech rehabilitation outcome of patients treated with total laryngectomy or total laryngopharyngectomy and insertion of Provox voice prostheses (Atos Medical AB, Hörby, Sweden) at the Helsinki University Central Hospital. We performed a retrospective chart review of 95 patients (88 men and 7 women; mean age, 63.5 years) who underwent insertion of a voice prosthesis in the period 1992 to 2002. Eighty-one percent (77/95) of the patients underwent a primary prosthesis insertion at the time of laryngectomy. A head and neck surgeon, a laryngologist, and a speech therapist rated the long-term tracheoesophageal speech of 78% (74/95) of the patients as good or average. The main causes for replacement of the device were obstruction, leakage or inadequate size of the prosthesis, and granulation or leakage around the fistula. According to our 10-year experience, use of the Provox prosthesis is an effective method of postlaryngectomy voice rehabilitation, and it continues to be our preferred method of voice restoration in the majority of cases.

[Selection of methods of rehabilitation for hypopharyngeal defects after hypopharyngeal carcinoma removal].

OBJECTIVE: To explore how to repair hypopharyngeal defects after hypopharyngeal carcinoma removal. METHOD: We analysed the methods of stage I rehabilitation for hypopharyngeal defects and deglutitory function in 31 cases carried out hypopharyngeal carcinoma operation in our department from June, 1996 to June, 2001. RESULT: 1 case was performed "zero rehabilitation". In 15 of 17 cases (88.2%) carried out with direct suture rehabilitation, deglutitory function is good. In 6 of 13 cases (46.2%) carried out with tissue graft rehabilitation, deglutitory function is good. In 9 of 14 cases carried out with preserved laryngeal operation synchronously, deglutitory function is good(all direct suture rehabilitation). There were 5 cases with worse deglutitory function(each case occured inhalational error, 2 of them were direct suture rehabilitation and 3 of them were, issue graft rehabilitation). CONCLUSION: Patients obtain a better deglutitory function after direct suture rehabilitation. For total hypopharyngeal defects, stomach/intestines pull-up is superior to myocutaneous flap transposition. For synchronous preserved laryngeal operation, we should pay more attentions in case selection and inhalational error prevention. "Zero rehabilitation" is helpful to enhance the indication of surgical treatment for hypopharyngeal carcinoma.

Laryngopharyngectomy with reconstruction.

A wide range of reconstructive options allows the ablative surgeon to resect tumors completely with wide margins. Wide resection is especially important because of the rich lymphatic drainage and submucosal spread seen with carcinomas in the hypopharyngeal area. Postoperative stenosis can be a difficult, recurring problem if the neopharynx does not have enough tissue incorporated into the closure. Therefore, most laryngopharyngectomy procedures benefit from the addition of transposed tissue, either pedicled or using free tissue transfer microvascular techniques. Often the location of the tumor is a major factor in determining which reconstruction is best for the patient. Minimizing the donor-site morbidity must be carefully considered, also.

Voice restoration after circumferential pharyngolaryngectomy with free jejunum repair.

Speech restoration after circumferential pharyngolaryngectomy with free jejunal repair for advanced tumors of the hypopharyngo-esophageal tract remains a difficult problem to solve. We report here the results of secondary voice restoration in six patients who received a Provox 2 type prosthesis and intensive speech therapy after circumferential pharyngolaryngectomy with free jejunum repair. No patient had operative or post-operative complications due to insertion of the prosthesis. No patient had to have the prosthesis removed during the follow-up (8 to 14 months). Analysis of some acoustic parameters of voice (fundamental frequency, waveform perturbations) and qualitative characteristics of speech (intelligibility, pleasantness and acceptability) demonstrated that all the patients were able to produce satisfactory speech after tracheojejunum puncture and speech therapy and were satisfied with their own ability to communicate. Our results are reassuring and we therefore advise that in patients undergoing free jejunum flap reconstruction of the hypopharyngo-esophageal tract voice restoration should be attempted by placing a voice prosthesis through a secondary tracheo-esophageal puncture and providing intensive speech training.

Further experience with tracheojejunal shunt speech after pharyngolaryngoesophagectomy.

Over the past 10 years, 16 patients have undergone the tracheojejunal shunt operation for voice reconstruction after undergoing pharyngolaryngoesophagectomy with free jejunum reconstruction for advanced hypopharyngeal cancer. For the purpose of voice reconstruction, a 2-cm inferiorly based tracheal flap is obtained from the membranous part of the trachea by removing 4 cartilaginous tracheal rings. After the establishment of digestive continuity with the jejunal graft, a side-to-side anastomosis is created by approximating the incised margin of the jejunal mucosa to that of the tracheal flap. The tracheal flap is tubed to construct the tracheojejunal shunt. In addition, the incised margin of the jejunal serosa is sutured to the lateral wall of the shunt to reinforce the approximation of the shunt to the jejunal graft. Thirteen of the 16 patients (81%) were initially capable of voice production. The length of time during which tracheojejunal speech has been used ranges from 18 to 122 months, with a mean of 55 months. During follow-up, 12 of the 13 patients (92%) have been able to swallow without aspiration.

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction.

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.