Postoperative complications of salvage total laryngectomy

Intra-operative lymphatic mapping and sentinel node biopsy in laryngeal carcinoma using radiotracer injection

OBJECTIVE

The purpose of this study was to determine the value of sentinel lymph node biopsy (SLNB) in the laryngeal SCC, using intra-operative peri-tumoral injection of Tc-99m-phytate.

METHODS

Patients with biopsy-proven squamous cell carcinoma of the larynx were included. On the day of surgery, after anesthesia induction, suspension laryngoscopy was performed to inject 74 MBq/0.4 ml Tc-99m-phytate in four aliquots into the sub-mucosal peri-tumoral location. After a 10-min wait, a portable gamma probe was used to locate sentinel nodes. Subsequently, all patients underwent laryngectomy and neck dissection. Both sentinel nodes and non-sentinel nodes were examined using hematoxylin and eosin (H&E) staining.

RESULTS

Twenty-six patients with a diagnosis of laryngeal carcinoma were included in the study. The SLN detection rate was 65.4%, with a 100% detection rate in the supraglottic region and a 52.6% detection rate for glottis/transglottic patients. Permanent pathology results showed lymph node involvement in four patients, but only one patient had a negative result in the SLNB, resulting in an overall false negative rate of 25%. The sensitivity of the SLN technique was 75% overall, 100% in the supraglottic region, and 67% in the glottis/transglottic region.

CONCLUSION

The accuracy and feasibility of SLNB may be related to the location of the tumors in the larynx. For supraglottic tumors, the technique seems to be feasible with a low false negative rate. For glottis/transglottic tumors, both the detection rate and false negative rate seem to be suboptimal. Further studies are needed to validate our results.

Sarcopenia predicts postoperative complications in head and neck cancer: a systematic review and meta-analysis

PURPOSE

We performed this systematic review and meta-analysis to explore the impact of preoperative sarcopenia on postoperative complication risks after head and neck cancer (HNC) surgery.

METHODS

We identified eligible studies by searching Ovid-MEDLINE, Ovid-Embase, EBM Reviews-Cochrane Central Register of Controlled Trials, Web of Science Core Collection, and Scopus. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

RESULTS

Twenty-one studies with a total of 3480 patients met our inclusion criteria. The presence of sarcopenia significantly increased the incidence of overall postoperative complications (OR = 1.72, 95% CI 1.23, 2.41; P = 0.002; I2 = 59%). Subgroup analyses showed a higher risk of postoperative complications in the populations in which sarcopenia was diagnosed with low L3-skeletal muscle index (L3-SMI) or low cross-sectional area of the rectus femoris, but not in the group that sarcopenia was diagnosed with low C3-SMI. Preoperative sarcopenia also substantially increased the risk of severe postoperative complications (OR = 2.26), pharyngocutaneous fistulas (OR = 2.15), free flap-related complications (OR = 1.63), and surgical site infections (OR = 1.84). We also found a tendency toward a higher incidence of wound complications and 30-day mortality in patients with sarcopenia.

CONCLUSION

Preoperative sarcopenia is a negative prognostic indicator for postoperative complications in patients with HNC after surgery. To reduce the incidence of postoperative complications and improve poor prognosis, further attention needs to be paid to the evaluation and management of preoperative sarcopenia.

Delayed oral feeding reduces pharyngocutaneous fistula formation after open surgical treatment of primary hypopharyngeal cancer: A case-control study

OBJECTIVES

Pharyngocutaneous fistula (PCF) formation following open surgical treatment of hypopharyngeal cancer (HPC) is a common and troublesome complication. To date, the postoperative protocol of restarting oral intake is not clear, and vast discrepancies exist in the literature and among institutions. This study aimed to explore the impact of a postoperative protocol of restarting oral intake on PCF formation after open surgical treatment of primary HPC, and its impact on overall survival (OS) and swallowing function based on the functional outcome swallowing scale (FOSS).

MATERIALS AND METHODS

This was a prospective observational study of 42 patients who received open surgical treatment for primary HPC at Beijing Friendship Hospital between April 2019 and August 2021. This cohort included two groups: patients who restarted oral intake on the 10th postoperative day (Group 1), and those who started on the 20th (Group 2). The Chi-square test and Fisher's exact chi-squared test were used for comparing qualitative data among the groups.

RESULTS

Group 1 (n = 27) and Group 2 (n = 15) were comparable in clinical characteristics. PCF occurred in 7 (25.9%) patients in Group 1, while none occurred in Group 2 (P = 0.038). The 2-year OS of all 42 patients was 75.6%; 65.8% and 93.3% for Groups 1 and 2, respectively (P = 0.07). The swallowing function was satisfactory (FOSS Grades 0-III) for 19 (70.4%) patients in Group 1 and 15 (100%) patients in Group 2 (P = 0.035). Laryngeal preservation was achieved in 25 (59.5%) patients, while decannulation was successful in 22 (88.0%) patients.

CONCLUSIONS

Delayed oral feeding significantly reduces PCF after open surgical treatment of primary HPC, and improves the swallowing function outcome without jeopardizing the OS.

Prophylactic pectoralis major flap to compensate for increased risk of pharyngocutaneous fistula in laryngectomy patients with low skeletal muscle mass (PECTORALIS): study protocol for a randomized controlled trial

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).

Outcome Comparison of Functional Laryngectomy for the Dysfunctional Larynx to Salvage Laryngectomy

OBJECTIVE

To compare functional outcomes of total laryngectomy (TL) with microvascular free tissue transfer (MVFTT) reconstruction in the treatment of dysfunctional larynx (DL) versus salvage therapy for locally recurrent disease in patients with a history of laryngeal squamous cell carcinoma (SCC).

METHODS

Retrospective review from a tertiary medical center between August 2015 and August 2022.

RESULTS

Sixty-nine patients underwent TL with MVFTT following primary laryngeal radiation or chemoradiation; 15 (22%) patients underwent functional laryngectomy (FL) and 54 (78%) underwent a salvage laryngectomy (SL). There were no total flap failures. Four (6%) patients developed a pharyngocutaneous fistula; one (7%) FL patient and 3 (6%) in the SL cohort. There was no significant difference in average hospital length of stay (LOS) between the cohorts (8.6 ± 3.0 days vs. 12.8 ± 10.1 days, p = 0.12). All patients (100%) in the FL cohort achieved a total oral diet compared to 41 (76%) in the SL cohort (p = 0.03). Two (13%) and 10 (19%) patients developed pharyngoesophageal stenosis in the FL and SL cohorts, respectively (p = 1.0). Nine (60%) and 23 (43%) patients in the FL and SL cohorts underwent tracheoesophageal puncture (TEP) placement, with 89% and 91% achieving fluency, respectively (p = 0.23).

CONCLUSION

Although the role of TL for the definitive treatment of laryngeal SCC has decreased over the past 30 years, organ-preservation protocols can impact speech, swallowing, and airway protection with life-threatening consequences. The use of elective FL with MVFTT for the treatment of DL results in similar or better functional outcomes compared to SL for recurrent disease.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:222-227, 2024.

Classifying and Predicting Surgical Complications After Laryngectomy: A Novel Approach to Diagnosing and Treating Patients

OBJECTIVES

The total laryngectomy is one of the most standardized major surgical procedures in otolaryngology. Several studies have proposed the Clavien-Dindo classification (CDC) as a solution to classifying postoperative complications into 5 grades from less severe to severe. Yet more data on classifying larger patient populations undergoing major otolaryngologic surgery according to the CDC are needed. Predicting postoperative complications in clinical practice is often subject to generalized clinical scoring systems with uncertain predictive abilities for otolaryngologic surgery. Machine learning offers methods to predict postoperative complications based on data obtained prior to surgery.

METHODS

We included all patients (N = 148) who underwent a total laryngectomy after diagnosis of squamous cell carcinoma at our institution. A univariate and multivariate logistic regression analysis of multiple complex risk factors was performed, and patients were grouped into severe postoperative complications (CDC ≥ 4) and less severe complications. Four different commonly used machine learning algorithms were trained on the dataset. The best model was selected to predict postoperative complications on the complete dataset.

RESULTS

Univariate analysis showed that the most significant predictors for postoperative complications were the Charlson Comorbidity Index (CCI) and whether reconstruction was performed intraoperatively. A multivariate analysis showed that the CCI and reconstruction remained significant. The commonly used AdaBoost algorithm achieved the highest area under the curve with 0.77 with high positive and negative predictive values in subsequent analysis.

CONCLUSIONS

This study shows that postoperative complications can be classified according to the CDC with the CCI being a useful screening tool to predict patients at risk for postoperative complications. We provide evidence that could help identify single patients at risk for complications and customize treatment accordingly which could finally lead to a custom approach for every patient. We also suggest that there is no increase in complications with patients of higher age.

Reconstruction using a free jejunal patch flap in salvage head and neck surgery after radiotherapy

BACKGROUND

Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of postoperative complications.

AIMS/OBJECTIVES

We report the usefulness of reconstruction using a free jejunal patch flap in treating recurrence or residual head and neck carcinoma after radiotherapy. Furthermore, we investigated the factors for the occurrence of postoperative complications in patients who underwent salvage surgery using a free flap transfer.

MATERIAL AND METHODS

This study included 41 patients with head and neck carcinoma who underwent salvage surgery using a free flap transfer, including 11 patients who underwent reconstruction using a free jejunal patch flap. Prognostic analysis was performed for the development of complications.

RESULTS

Ten jejunal patch flaps survived without microvascular problems. One patient underwent revision reconstructive surgery because of flap failure. However, no patient had a pharyngocutaneous fistula. Oral intake could be resumed in all patients at a median 14 days postoperatively. Multivariate logistic regression analysis indicated that the use of cutaneous flaps was significantly associated with the development of complications.

CONCLUSIONS AND SIGNIFICANCE

Free jejunal patch flaps can be considered useful for head and neck reconstruction after radiotherapy for early intake resumption and complication prevention.

Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula

BACKGROUND

Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF.

METHODS

We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test.

RESULTS

There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test).

CONCLUSION

TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

The Larry Tube: Customized 3D Printed Laryngectomy Tubes Following Total Laryngectomy

OBJECTIVE

To determine whether a custom laryngectomy tube can improve airway symptoms in total laryngectomy patients with atypical anatomy who are unable to use commercial laryngectomy tubes. Furthermore, to exemplify the power of customizable 3D printed medical devices when combined with the expanded access pathway through the FDA.

METHODS

A custom-fabricated laryngectomy tube, manufactured at in-house clinical engineering labs, was utilized for each patient following typical laryngectomy tube protocols. All participants had previously undergone a total laryngectomy. Patients were selected based on critical airway obstruction posing potentially life-threatening scenarios while using commercially available laryngectomy tubes.

RESULTS

For all patients involved, there were no further airway obstruction complications or events, and they reported a subjective, significant improvement in comfort after placement of the custom laryngectomy tube.

CONCLUSION

Custom laryngectomy tubes can provide patients with atypical anatomy relief from airway obstructions and improve comfort when commercial options fail to address the anatomic restriction. The process used to develop custom laryngectomy tubes may be relevant for other diseases and patients with atypical anatomies through the expanded access pathway.

Clinical factors associated with severe surgical complications in patients with hypopharyngeal cancer: a single-center case-cohort study

BACKGROUND

Surgical complications are a major concern in the surgical treatment of hypopharyngeal cancer.

OBJECTIVE

To identify clinical factors that predispose patients with hypopharyngeal cancer to severe surgical complications.

MATERIALS AND METHODS

The data of 449 patients who were underwent surgery as a part of the initial treatment with curative intent or as salvage treatment were retrospectively reviewed. The Chi-square test and logistic regression were used to evaluate the association of different factors with severe surgical complications.

RESULTS

The incidence of severe complications was 22% (99/449), and 10 patients (2.2%) experienced rupture of the carotid artery. Multivariate analysis identified T3/4 stage (p = .002, odds ratio (OR) = 1.58, 95% confidence interval (CI) 1.177-2.122), radiotherapy (RT) (p < .001, OR = 2.744, 95% CI 1.680-4.482), diabetes mellitus (DM) (p = .007, OR = 2.697, 95% CI 1.308-5.56), and nonprimary closure (p = .008, OR = 1.992, 95% CI 1.193-3.327) as significant risk factors for severe surgical complications.

CONCLUSIONS AND SIGNIFICANCE

T3/4 stage, RT, nonprimary closure, and DM were independent predisposing factors for severe surgical complications in our study population of hypopharyngeal cancer patients. Taking measures to lower the tumor stage and simplify the surgical procedure may be crucial in reducing the incidence of severe surgical complications among these patients.

Risk factors for adverse events associated with endoscopic submucosal dissection for superficial pharyngeal cancer

BACKGROUND

Superficial pharyngeal cancer can be treated with curative intent while preserving function using minimally invasive peroral endoscopic resection techniques such as endoscopic submucosal dissection (ESD). However, severe adverse events occasionally occur, such as laryngeal edema requiring temporary tracheotomy and fistula formation. Therefore, we investigated the risk factors for adverse events associated with ESD for superficial pharyngeal cancer.

METHODS

This retrospective observational study was conducted at a single institution, and 63 patients who underwent ESD were enrolled. The primary outcome was the risk factors for adverse events associated with ESD. The secondary outcomes were adverse events associated with ESD and their frequency.

RESULTS

The overall adverse event rate was 15.9% (10/63). The incidence of laryngeal edema requiring prophylactic temporary tracheotomy was 11.1%, while laryngeal edema requiring emergency temporary tracheotomy, postoperative bleeding, aspiration pneumonia, fistula, abscess, and stricture formation occurred in 1.6% of patients, respectively. Logistic regression analyses showed that a history of radiotherapy for head and neck cancer was a risk factor for adverse events (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.04-91.34; p = 0.001). After adjusting the model for differences in the baseline risk factors using the inverse probability of treatment weighting method, the adverse events were found to increase in association with a history of radiotherapy for head and neck cancer (OR, 39.66; 95% CI,5.85-268.72; p < 0.001).

CONCLUSION

History of radiotherapy for head and neck cancer is an independent risk factor for adverse events associated with ESD for superficial pharyngeal cancer. Among adverse events, laryngeal edema requiring prophylactic temporary tracheotomy was particularly high.

Perioperative Factors Aggravating Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Center Retrospective Analysis Using the Clavien-Dindo Classification

BACKGROUND

Pharyngocutaneous fistula formation represents a major postoperative complication following total laryngectomy. We aimed to investigate the risk factors for pharyngocutaneous fistula development after total laryngectomy and to identify factors that lead to severe cases of pharyngocutaneous fistula.

METHODS

Patients who underwent total laryngectomy between January 2013 and February 2021 were included in the study and were divided into 2 groups: Those with and without pharyngocutaneous fistula. The severity of pharyngocutaneous fistula was graded using the Clavien-Dindo classification.

RESULTS

Patients with pharyngocutaneous fistula experienced longer operative time, greater intraoperative blood loss, greater decrease in perioperative hemoglobin level, and longer postoperative hospitalization. Unlike in lower-severity cases, patients with grade IIIb pharyngocutaneous fistula underwent preoperative radiotherapy or chemoradiotherapy; preoperative treatment was thus a risk factor for higher severity of pharyngocutaneous fistula (odds ratio, 35; P = 0.004).

CONCLUSION

Salvage laryngectomy was found to be a predictor of severe pharyngocutaneous fistula development. Prolonged operative time, increased intraoperative blood loss, and decreased postoperative hemoglobin level were found to be predictors of postlaryngectomy pharyngocutaneous fistula formation.

Current Approaches to Salvage Surgery for Head and Neck Cancer: A Comprehensive Review

Salvage surgeries of head and neck cancer are often complicated and do not always show decent results. This type of procedure is tough on the patient, as many crucial organs can be affected. A long period of reeducation usually follows the surgery because of the need to rehabilitate functions such as speech or swallowing. In order to lighten the journey of the patients, it is important to develop new technologies and techniques to ease the surgery and limit its damages. This seems even more crucial since progress has been made in the past years, allowing more salvage therapy to take place. This article aims at showing the available tools and procedures for salvage surgeries, such as transoral robotic surgery, free-flap surgery, sentinel node mapping, and many others, that help the work of the medical team to operate or obtain a better understanding of the status of the cancer when taken in charge. Yet, the surgical procedure is not the only thing determining the outcome of the operation. The patient themself and their cancer history also play an important part in the care and must be acknowledged.

Salvage Surgery

The Department of Veterans Affairs Laryngeal Cancer Study propelled the combination of chemotherapy and radiation therapy to the forefront of strategies used for the management of locally advanced laryngeal cancer. The organ preservation rate was 84%. However, over the past 30 years that these approaches have been in place, there have been concerns regarding long-term survival and high failure rates requiring salvage. Furthermore, salvage laryngectomy, if feasible when considering increased morbidity after CRT, is fraught with a higher risk of wound complications including fistula, longer hospitalization, and reduced quality of life.

Effects of Prior Tracheostomy on Total Laryngectomy Outcomes

OBJECTIVE

To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital between 2007 and 2020.

METHODS

Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi-square test or Fisher exact test, and continuous variables were compared with an independent t test. Multivariable regression was conducted to assess predictors of complications after laryngectomy.

RESULTS

A total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days, P = .008).

CONCLUSION

PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes.

Predictive Value of Risk Factors for Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES

To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool.

RESULTS

A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84).

CONCLUSION

Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023.

Factors predicting pharyngocutaneous fistula in patients after salvage laryngectomy for laryngeal malignancy - A multicenter collaborative cohort study

OBJECTIVES

Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada.

RESULTS

In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (<5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis.

CONCLUSION

We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.

Can Red Blood Cell Distribution Width Predict Laryngectomy Complications or Survival Outcomes?

OBJECTIVE

Red blood cell distribution width (RDW), a reported biomarker for morbidity and mortality in chronic disease and following certain surgeries, has not been well-studied in head and neck cancer patients. The aim of the study was to examine the association of RDW with postoperative complications and survival among patients who underwent primary or salvage laryngectomy.

METHODS

We analyzed a retrospective case series study of patients diagnosed with squamous cell carcinoma of the larynx treated with total laryngectomy. Survival outcomes were examined using Kaplan-Meier analysis.

RESULTS

One hundred seventy-seven patients were included in the final analysis. The most common tumor subsite was the supraglottis (60%). On bivariate analysis, patients with RDW ≥14.5 had higher prevalence of non-surgical, systemic complications, including deep venous thrombosis, pneumonia, cardiovascular events, and difficulty weaning from mechanical ventilation. However, there was no significant difference in laryngectomy-specific post-operative complications, including pharyngocutaneous fistula, wound infection, stoma complications, and chyle leak. RDW was not found to be associated with survival outcomes following laryngectomy.

CONCLUSIONS

Among laryngectomy patients, RDW ≥14.5 is associated with higher prevalence of systemic morbidity, but not with specific local surgical complications or decreased survival.

Real-world treatment patterns and outcomes in Japanese patients with cervical esophageal cancer

BACKGROUND

Cervical esophageal cancer (CEC) carries a poor prognosis; however, due to its low incidence, optimal treatment for CEC remains to be established. The purpose of this study was to clarify the current status of treatment of CEC in Japan and obtain evidence for establishing the appropriate treatment method.

PATIENTS AND METHODS

We asked specialist training facilities accredited by the Japanese Broncho-Esophageal Society to register data on CEC cases that received curative treatment from January 2009 to December 2014, and conducted a retrospective review of the clinical data of 302 cases registered from 27 facilities.

RESULTS

In regard to the initial therapy, of the 302 patients, 33 had undergone endoscopic resection, 41 had undergone surgery, 67 had received induction chemotherapy (IC), and 143 had received chemoradiotherapy (CRT). There were no significant differences in the 5-year overall survival rates among the patient groups that had received surgery, IC or CRT as the initial treatment; advanced stage and recurrent nerve invasion were identified as independent poor prognostic factors. Among the patients who had received IC or CRT as laryngeal-preserving surgery was not indicated at the time of the initial diagnosis, the functional laryngeal preservation rate at the end of the observation period was 34.8%.

CONCLUSION

Even in patients with advanced CEC, there is the possibility of preserving the larynx by adopting IC or CRT. However, if the laryngeal function cannot be preserved, there is a risk of complications from aspiration pneumonia, so that the choice of treatment should be made carefully.

Pharyngocutaneous Fistula Following Primary and Salvage Laryngectomy: Aetiology and Predictive Factors

Laryngeal cancer treatment is often wrought with challenges, pharyngocutaneous fistula formation (PCF) in patients undergoing either primary or salvage laryngectomy for laryngeal and hypopharyngeal for squamous cell carcinoma is an important one. We aimed to study the factors before and at the surgery that are associated with PCF formation in a South Indian tertiary care hospital. A retrospective chart review of 127 patients who underwent total laryngectomy (TL) between May 2014 and April 2019 at our centre were done. Data was collected, including patient age and gender, comorbidities (Diabetes mellitus, COPD and hypothyroidism), smoking, tumor stage and site, prior tracheostomy, prior radiation, concurrent neck dissection and type of pharyngoplasty, Preoperative hemoglobin and albumin levels, surgical margin status and development of a PCF was also done. Further details specific to the development of a PCF were recorded for that subset of patients including the length of time to fistula, mode of closure, time of closure and modality of management. The overall incidence of PCF was 16.5% (21 of 127 patients), and the median time from TL to the diagnosis of PCF was 6 days (range, 3-20 days). The analysis was done separately for laryngectomies without any pharyngeal reconstruction (112/127 patients). In patients treated with a primary TL, the incidence of PCF was 12.20% (10 of 82) and 26.66% (8 of 30) after salvage TL. Subset analysis for type of pharyngoplasty repair showed 12% (15/127) underwent different types of vascularised/muscular flap for smaller residual pharyngeal mucosa, of which 20% (3/15) developed PCF and one patient developed haematoma needing exploration and re-suturing. The predictive factors for PCF were hypopharynx cancer (P < 0.05), surgical margin positivity (P < 0.0001), female gender (P < 0.05), absence of prior tracheostomy (P < 0.05) and tumor extension into pyriform sinus mucosa (P < 0.05). Preoperative patient factors of gender and site of primary along with histological margin positivity and extension of tumor to the pyriform sinus mucosa were significant risk factors for PCF formation. Pre-Op radiotherapy remains a strong clinical suspicion but not statistically significant.

Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC.

METHODS

200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined.

RESULTS

Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521).

CONCLUSION

ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.

Pharyngocutaneous fistula in irradiated patients: systematic review and our experience

Objective

Radiotherapy is considered a risk factor for pharyngocutaneous fistula after a total laryngectomy. This study aimed to analyse the impact of exclusive radiotherapy versus chemoradiotherapy and the time interval between radiotherapy and surgery on the risk of pharyngocutaneous fistula.

Method

This study was a retrospective revision of 171 patients treated with a total laryngectomy after radiotherapy or chemoradiotherapy.

Results

Pharyngocutaneous fistula occurred in 33 patients (19.3 per cent). Patients previously treated with chemoradiotherapy showed a non-significant higher pharyngocutaneous fistula rate compared with patients treated with radiotherapy (25.0 per cent vs 18.0 per cent; p = 0.455). Patients with a pharyngocutaneous fistula after chemoradiotherapy treatment required a surgical repair more frequently than patients treated with radiotherapy (p = 0.005). There were no significant differences in the pharyngocutaneous fistula rate depending on the time interval between radiotherapy and surgery (p = 0.580).

Conclusion

There were no differences in the pharyngocutaneous fistula rate after total laryngectomy depending on the previous treatment with radiotherapy or chemoradiotherapy, or depending on the interval between radiotherapy treatment and surgery.

Comparison of Patients With Total and Salvage Laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P = .000) and between fistula and infection (P = .000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P = .038), T4 (P = .026), lymphovascular invasion (P = .019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P = .005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P = .026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

The effect of salivary bypass tube use on the prevention of pharyngo-cutaneous fistulas after total laryngectomy

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.

Novel hybrid endoscopy-assisted larynx-preserving esophagectomy for cervical esophageal cancer (with video)

Hybrid endoscopy-assisted larynx-preserving esophagectomy is developed for cervical esophageal squamous cell carcinoma encroaching or extending above the upper esophageal sphincter. First, a cervical incision was surgically performed followed by cervical lymph node dissection. Second, the margin of cervical esophageal squamous cell carcinoma was endoscopically identified with iodine staining and marked endoscopically followed by semi-circumferential or circumferential endoscopic full-thickness excision around the lumen of the esophagus. The distal margin was surgically resected and reconstruction was performed. Among six consecutive patients with cervical esophageal squamous cell carcinoma undergoing hybrid endoscopy-assisted larynx-preserving esophagectomy, proximal surgical margin was histologically negative in five patients. During a median follow-up period of 15.5 months, all patients tolerated oral intake and were alive without evidence of recurrence. None of the patients experienced aspiration pneumonia, vocal disorder or postoperative anastomotic stricture. Hybrid endoscopy-assisted larynx-preserving esophagectomy could be a clinically feasible treatment for cervical esophageal squamous cell carcinoma providing accurate proximal resection margin with the benefit of laryngeal function preservation.

Prognostic significance of hypoxia-inducible factor-1α expression in advanced pharyngeal cancer without human papillomavirus infection

OBJECTIVE

This study aimed to clarify the association between both hypoxia-inducible factor-1α and glucose transporter type-1 expression and survival outcome in advanced pharyngeal cancer without human papillomavirus infection.

METHOD

Twenty-five oropharyngeal and 55 hypopharyngeal cancer patients without human papillomavirus infection were enrolled. All patients had stage III-IV lesions and underwent concurrent chemoradiotherapy or surgery. Hypoxia-inducible factor-1α and glucose transporter type-1 expression were investigated in primary lesions by immunohistochemistry.

RESULTS

There were 41 and 39 cases with low and high hypoxia-inducible factor-1α expression, and 28 and 52 cases with low and high glucose transporter type-1 expression, respectively. There was no significant correlation between hypoxia-inducible factor-1α and glucose transporter type-1 expression. In univariate analysis, nodal metastasis, clinical stage and high hypoxia-inducible factor-1α expression, but not glucose transporter type-1 expression, predicted significantly worse prognosis. In multivariate analysis, hypoxia-inducible factor-1α overexpression was significantly correlated with poor overall survival, disease-specific survival and recurrence-free survival.

CONCLUSION

High hypoxia-inducible factor-1α expression was an independent risk factor for poor prognosis for advanced human papillomavirus-unrelated pharyngeal cancer.

Prognostic imaging variables for recurrent laryngeal and hypopharyngeal carcinoma treated with primary chemoradiotherapy: A systematic review and meta-analysis

Background

In this systematic review, we aim to identify prognostic imaging variables of recurrent laryngeal or hypopharyngeal carcinoma after chemoradiotherapy.

Methods

A systematic search was performed in PubMed and EMBASE (1990–2020). The crude data and effect estimates were extracted for each imaging variable. The level of evidence of each variable was assessed and pooled risk ratios (RRs) were calculated.

Results

Twenty‐two articles were included in this review, 17 on computed tomography (CT) and 5 on magnetic resonance imaging (MRI) variables. We found strong evidence for the prognostic value of tumor volume at various cut‐off points (pooled RRs ranging from 2.09 to 3.03). Anterior commissure involvement (pooled RR 2.19), posterior commissure involvement (pooled RR 2.44), subglottic extension (pooled RR 2.25), and arytenoid cartilage extension (pooled RR 2.10) were also strong prognostic factors.

Conclusion

Pretreatment tumor volume and involvement of several subsites are prognostic factors for recurrent laryngeal or hypopharyngeal carcinoma after chemoradiotherapy.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

Influence of Preoperative Radiation Therapy on the Occurrence of Pharyngocutaneous Fistula After Total Laryngectomy

Introduction

Chemo-radiotherapy (CRT) has increasingly been employed for the treatment of laryngeal cancer at T3 or higher rather than total laryngectomy (TL), in order to preserve the larynx. However, TL is still frequently performed in patients with advanced laryngeal cancer, especially T4 disease. When CRT is performed for advanced cancer, there is a certain rate of residual disease or relapse, and TL is conducted as salvage surgery for those patients, but TL following CRT is associated with a high incidence of postoperative complications.

Objective

The purpose of this study was to investigate the influence of preoperative radiation therapy on the occurrence of postoperative complications of TL, particularly pharyngocutaneous fistula (PCF).

Methods

We retrospectively investigated 142 patients who underwent TL for laryngeal cancer whether postoperative complications were related to a history of radiation therapy or neck dissection. Detailed investigation of the 32 patients who underwent radiation therapy was also conducted.

Results

PCF was significantly higher after radiation therapy. Neck dissection was not related. As the time from radiation therapy to TL decreased, the incidence rate of postoperative PCF increased and the time to closure became significantly longer. Preoperative laboratory tests did not show a significant difference in Hb and Alb, but the lymphocyte count was significantly lower in patients with PCF.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

Comparison of patients with total and salvage laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P=.000) and between fistula and infection (P=.000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P=.038), T4 (P=.026), lymphovascular invasion (P=.019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P=.005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P=.026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Implications of limited exolaryngeal disease and cricoarytenoid joint involvement in organ conservation protocols for laryngopharyngeal cancers: Results from a prospective study

BACKGROUND

To identify clinicoradiological factors that determine functional outcomes in laryngopharyngeal cancers treated with chemoradiotherapy.

METHODS

One hundred patients of locally advanced laryngopharyngeal cancers who were treated with chemoradiotherapy were accrued in this prospective study. The coprimary endpoint of the study was local control (LC) and functional larynx preservation survival (FLPS).

RESULTS

The median follow-up was 39 months. Thirty-nine patients had a local failure of which 17 underwent a salvage laryngectomy. A dysfunctional larynx with clinic-radiologically disease was seen in only 1 patient. Factors significant for LC were thyroid cartilage erosion/lysis and cricoarytenoid joint involvement. Within the T4a subset, patients with exolaryngeal disease through the soft tissue framework had significantly better LC and FLPS than those with cartilage erosion/lysis.

CONCLUSIONS

Patients with limited exolaryngeal disease through the soft-tissue framework can be considered for functional organ preservation, while those with thyroid cartilage involvement and cricoarytenoid joint involvement are not suitable.

Larynx-preserving hybrid surgery with endoscopic laryngopharyngeal surgery and open surgery for cervical esophageal cancer invading pharynx

Larynx preserving hybrid surgery with endoscopic laryngopharyngeal surgery and open surgery (HELPS) was created for resectable cervical esophageal cancer (CEC) invading the hypopharynx. This study aimed to verify the effectiveness and to evaluate the feasibility of the new HELPS treatment method. Between 2014 and 2018, 19 patients with CEC invading the hypopharynx were treated with HELPS. The postoperative complications and survival rates were reviewed. Postoperative recurrent laryngeal nerve paralysis occurred in four patients. All patients consumed food orally without a feeding tube at the time of the discharge. The median follow-up period was 27 months. The 2- and 3-year overall survival rates were 94.7 and 71.5%, respectively. HELPS, a new surgical treatment method that utilizes endoscopic surgery, is effective, feasible and beneficial for preserving the larynx in patients with CEC even if the tumor invaded the pharynx.

Accuracy of fine-needle aspiration cytology in detecting cervical node metastasis after radiotherapy: Systematic review and meta-analysis

PURPOSE

To define the accuracy of fine-needle aspiration cytology (FNAC) in diagnosing persistent or recurrent neck metastases in previously irradiated patients.

METHODS

The study was performed according to the PRISMA-DTA guidelines.

RESULTS

A total of 382 FNACs were used for calculation of diagnostic accuracy parameters. The overall pooled sensitivity and specificity in detecting malignant nodes were 69.1% (95% CI: 56.3%-80.7%; I² = 79.5%) and 84.2% (95% CI: 71.8%-93.5%; I² = 87.0%), respectively. Cumulative diagnostic odds ratio (DOR) was 16.54 (95% CI: 4.89-38.99; I² = 65.8%), while cumulative positive and negative likelihood ratio (PLR and NLR) were 5.4 (95% CI: 2.3-11.2) and 0.37 (95% CI: 0.22-0.54), respectively.

CONCLUSIONS

FNAC alone could not guide the decision to perform a salvage neck dissection in previously irradiated patients, but its results should be assessed in relation to the specific clinical context.

Transoral Laser-Assisted Total Laryngectomy: Expanding the TLM's World

Introduction

The introduction of laryngeal transoral procedures has created a shift in the treatment of laryngeal cancers towards the primary surgical management of patients. In this study, we aimed to evaluate the safety, efficacy, and feasibility of the transoral laser-assisted total laryngectomy (TLM-TL) in advanced laryngeal cancer. Case presentation. In this case report, we describe a case of a 50-year-old male patient presented to the otorhinolaryngology clinic with a history of hoarseness and odynophagia since 6 months. Based on the pathological and imaging findings, the diagnosis of stage IVa laryngeal squamous cell carcinoma with the involvement of the base, tongue, and left palatine tonsil was made for the patient, and transoral total laryngectomy with partial glossectomy via the TLM technique was planned.

Result

The tumor was successfully resected by TLM-TL with clear surgical margins. No complication was observed after the surgery. Good functional recovery was obtained regarding swallowing and speech. The patient's oncologic and functional outcomes were evaluated for 2 years. Everything was satisfactory with good long-term cosmetic and laryngopharyngeal functional outcome and no sign of tumor recurrence.

Conclusions

TLM-TL is a minimally invasive and cost-benefit endoscopic surgical procedure feasible in advanced laryngeal cancer with good long-term oncological and functional outcome. It could limit postoperative complications, mainly the incidence of pharyngocutaneous fistulae. It is also associated with better satisfaction after TL due to cosmetic benefits.

Pectoralis Major Onlay vs Interpositional Reconstruction Fistulation After Salvage Total Laryngectomy: Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the difference in pharygocutaneous fistula (PCF) development between pectoralis major flap onlay and interpositional reconstructions after salvage total laryngectomy (STL).

DATA SOURCES

Medline, Cochrane, Embase, Web of Science, CINAHL, and ClinicalTrials.gov.

REVIEW METHODS

A systematic review was performed during January 2020. English articles were included that described minor and major PCF rates after STL reconstructed with pectoralis major onlay or interposition. PCFs were classified as major when conservative therapy was unsuccessful and/or revision surgery was needed. Articles describing total laryngopharyngectomies were excluded. Meta-analyses of the resulting data were performed.

RESULTS

Twenty-four articles met final criteria amassing 1304 patients. Three articles compared onlay with interposition, and 18 compared onlay with primary closure. Pectoralis interposition demonstrated elevated odds ratio (OR) of PCF formation as compared with onlay (OR, 2.34; P < .001). Onlay reconstruction reduced overall (OR, 0.32; P < .001) and major (OR, 0.21; P < .001) PCF development as compared with primary pharyngeal closure alone. Data were insufficient to compare interposition against primary closure.

CONCLUSIONS

This research shows evidence that pectoralis onlay after STL diminishes the odds of total and major PCF development. Pectoralis interposition reconstruction showed elevated odds of PCF formation as compared with pectoralis onlay.

Incidence and risk factors of pharyngocutaneus fistula formation after total laryngectomy. Review

Introduction and objective: The pharyngocutaneous fistula is a troublesome complication after total laryngectomy, increasing morbidity and mortality. We aimed to determine the incidence of pharyngocutaneus fistula after total laryngectomy and to define the possible predictors for pharyngocutaneus fistula formation. Method: We conducted a review of 31 articles with a total of 1100 patients, to evaluate the incidence of fistula in patients with total laryngectomy and risks factors involved. Results: The overall incidence of pharyngocutaneus fistula is 22,3%, and ranges from 3 to 65%. The review revealed that prior radiation treatment was the most common antecedent, following this associated comorbidity, hypoalbuminemia, anemia, and history of tracheotomy prior to laryngectomy. Discussion: Among the series studied, there is significant heterogeneity in the results, because although irradiated patients have a greater number of pharyngostomas, in some studies no relationship was found, which could explain the association with other risk factors. Conclusions: The incidence of pharyngocutaneus fistula is very variable and there are a large number of risk factors involved, the most frequent is radiotherapy associated or not with chemotherapy.

Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation.

Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis.

Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins.

Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

Pharyngocutaneous fistulas after total laryngectomy or pharyngolaryngectomy: Place of video-fluoroscopic swallowing study

BACKGROUND

Specify place of video-fluoroscopic swallowing study (VFS) in the decision of oral refeeding after total pharyngolaryngectomy.

METHODS

At postoperative day 7, a blue dye testing was performed. If negative, a VFS was performed looking for a blind fistula. If this exam was negative, oral refeeding was started, but if a blind fistula was observed, cervical compression bandage was performed.

RESULTS

In 186 patients, a VFS was performed for 142 patients with negative blue dye testing. It was negative for 98 patients (69%) and positive for 44 patients (31%) (blind fistula). Patients had a probability of 7.1% to have a secondary pharyngocutaneous fistula (PCF) if the VFS was negative, and 15.9% if it was positive. No risk factor for the development of a secondary PCF or a blind fistula emerged from our analysis.

CONCLUSION

VFS should be performed before any oral refeeding in all patients operated with a total pharyngolaryngectomy.

Application of the Supraclavicular Artery Island Flap for Fistulas in Patients With Laryngopharyngeal Cancer With Prior Radiotherapy

OBJECTIVE

To evaluate the effect of the supraclavicular artery island flap (SAIF) in reconstructing pharyngocutaneous fistula in patients with laryngopharyngeal cancer with prior radiotherapy.

METHODS

Six patients with laryngopharyngeal cancer with pharyngocutaneous fistula due to previous radiotherapy and surgery during 2016 to 2019 were retrospectively analyzed. Initially, the fistula was treated conservatively. The SAIF was applied with double folding technique to reconstruct fistula in the patients who failed to heal after conservative treatment.

RESULTS

The fistulae closed in 4 patients after conservative treatment. After SAIF operation, fistula closure was achieved in the other 2 patients who received highest dose of radiation and had largest fistulae size. The flaps grew well and there were no donor-site complications in these 2 patients. All patients achieved oral feeding without any complications.

CONCLUSION

The SAIF is an effective and safe approach to reconstruct the pharyngocutaneous fistula after laryngopharyngeal surgery in patients with laryngopharyngeal cancer with previous radiotherapy, especially for those who have received high-dose radiation and have large fistula.

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

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.

Predictors of hospital expenses and hospital stay among patients undergoing total laryngectomy: Cost effectiveness analysis

Objective

To determine the predictive factors of postoperative hospital stay and total hospital medical cost among patients who underwent total laryngectomy.

Methods

A total of 213 patients who underwent total laryngectomy in a tertiary referral center for tumor ablation were enrolled retrospectively between January 2009 and May 2018. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and outcomes. The outcomes of interest including postoperative length of hospital stay and inpatient total medical cost. Logistic regression analyses were performed to reveal the relationship between clinical factors and postoperative length of hospital stay or total inpatient medical cost.

Results

Preoperative radiotherapy (p = 0.007), method of wound closure (p < 0.001), postoperative serum albumin level (p = 0.025), and postoperative serum hemoglobin level (p = 0.04) were significantly associated with postoperative hospital stay in univariate analysis. Postoperative hypoalbuminemia (odds ratio [OR]: 2.477; 95% confidence interval [CI]: 1.189–5.163; p = 0.015) and previous radiotherapy history (OR 2.194; 95% CI: 1.228–3.917; p = 0.008) are independent predictors of a longer postoperative hospital stay in multiple regression analysis. With respect to total inpatient medical cost, method of wound closure (p < 0.001), preoperative serum albumin level (p = 0.04), postoperative serum albumin level (p < 0.001), and history of liver cirrhosis (p = 0.037) were significantly associated with total inpatient medical cost in univariate analysis. Postoperative hypoalbuminemia (OR: 6.671; 95% CI: 1.927–23.093; p = 0.003) and microvascular free flap reconstruction (OR: 5.011; 95% CI: 1.657–15.156; p = 0.004) were independent predictors of a higher total inpatient medical cost in multiple regression analysis.

Conclusions

Postoperative albumin status is a significant factor in predicting prolonged postoperative hospital stay and higher inpatient medical cost among patients who undergo total laryngectomy. In this cohort, the inpatient medical cost was 48% higher and length of stay after surgery was 35% longer among hypoalbuminemia patients.

Long-term outcomes of trans-oral robotic surgery-assisted total laryngectomy for recurrent laryngeal cancers

OBJECTIVE

For recurrent laryngeal cancers, trans-oral robotic surgery has been used to perform total laryngectomy, but limited cases had been reported without long-term outcome follow-up. This study aims at presenting the largest longitudinal retrospective cohort in a single tertiary referral medical center.

METHODS

From November 2013 to August 2017, seven patients with recurrent laryngeal cancers without evidence of neck metastasis were selected to receive trans-oral robotic surgery-assisted TL without neck dissection. The para-operative details including the surgical success rates, surgical methods, resection extent, drainage tube placement, pharyngeal wound closure, console surgical time, pathologic findings and long-term complications were reviewed and described. The study end points include survival rates and preservation of swallowing function without tube feeding.

RESULTS

Trans-oral robotic surgery-assisted total laryngectomy was successfully performed on all seven patients with mean surgical console time of 111 ± 66 min. Strap muscles and hyoid bone were resected like open surgery in six and five patients, respectively. For all the seven patients, there was no severe pharyngo-cutaneous fistula formation requiring repair in a second surgery, but tracheostoma stenosis was not uncommon (57%). Three patients received adjuvant chemotherapy/radiotherapy. After follow-up of 36.1 ± 15.8 months, two patients had neck recurrence, and one patient died 19 months after surgery, but the other five patients were alive without disease recurrence. The overall survival rate was 85.7% (6/7), and all patients had good swallowing function without tube feeding.

CONCLUSIONS

Trans-oral robotic surgery-assisted total laryngectomy is a feasible approach for selected patients with recurrent laryngeal cancers. The oncologic and functional outcomes were satisfactory. Further larger cohort study is worthwhile to further elucidate the value of trans-oral robotic surgery-assisted total laryngectomy.

Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy

INTRODUCTION

Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol.

METHODS

Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent.

RESULTS

Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%).

CONCLUSION

The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Salvage total laryngectomy: is a flap necessary?

Introduction

Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy.

Objective

Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors.

Methods

We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed.

Results

We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes.

Conclusions

Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.

3D Printed Fistula Plug: A Novel Bridge to Definitive Reconstruction

A case is presented showcasing the feasibility of three-dimensional (3D) printing patient-specific fistula plugs as a bridge therapy to definitive management of pharyngocutaneous fistulae. For this patient, a set of 3D printed fistula plugs was successfully used with low morbidity and positive results in the management of this postoperative issue. Utilizing 3D printed fistula plugs could represent a novel yet safe therapy for patients requiring long-term management of similar wounds. Further studies are warranted to evaluate implementation of this practice on a widespread scale. Laryngoscope, 131:111-114, 2021.

Post-operative complications due to salvage total laryngectomy for recurrent laryngeal cancer after radiotherapy - a multicentre retrospective study

Background: Few studies have demonstrated the utility of pharyngeal interposition graft (PIG) applying pectoralis major myocutaneous flap (PMMCF) by comparing pharyngocutaneous fistula (PCF) rates.Objective: The objective of this retrospective study was to clarify the utility of PIG applying PMMCF in reducing post-operative complications due to salvage total laryngectomy (STL).Material and methods: STL was performed in 59 patients with recurrent laryngeal cancer after radiotherapy, comprising 37 non-PMMCF patients and 22 PMMCF patients. The primary endpoint was PCF rate. Comparisons were made between two groups: a group with simple closure not using PMMCF (non-PMMCF group), and the other with PMMCF used in a PIG (PMMCF group).Results: PCF occurred in 15 of the 59 subjects (25.4%), including 13 of the 37 patients in the non-PMMCF group (35.1%) and 2 of the 22 patients in the PMMCF group (9.1%). PCF rate was significantly lower in the PMMCF group than in the non-PMMCF group (p = .033).Conclusions and significance: We demonstrated that PIG applying PMMCF significantly reduced the PCF rate due to STL. In the future, surgeons need to conduct research focused on additional innovations to reduce post-operative complications as much as possible.

Management of the irradiated N0-neck during salvage pharyngo-laryngeal surgery

BACKGROUND

Salvage surgeries are challenging procedures, with an associated poor prognosis. Management of the N0 neck in those situations remains controversial. We aim to compare oncologic outcomes regarding neck management after surgery for N0 pharyngo-laryngeal carcinoma occurring after loco-regional radiotherapy.

METHODS

We conducted a multicentric retrospective study, including all patients undergoing surgery for persistent, recurrent or new primary N0 carcinoma of the oropharynx, hypopharynx or larynx between 2005 and 2015, following loco-regional radiotherapy.

RESULTS

A total of 239 patients were included, concerning respectively 44%, 34% and 22% oropharyngeal, laryngeal and hypopharyngeal tumors operated. A neck dissection was performed in 143 patients (60%), with an occult nodal metastasis rate of 9%. This rate was higher for hypopharyngeal carcinomas (18%, p = 0.16) and tumors with initial nodal involvement (16%, p = 0.05). With a median follow-up of 60 months, the median overall survival (OS) and progression-free survival rates (PFS) were 34 months and 25 months. We identified negative margin excision status, age at the time of surgery (under 60) and delay between RT and surgery over 2 years as the only variables associated with better OS (p < 0.0001 and p = 0.004) and PFS (p < 0.0001 and p = 0.010) in multivariable analysis, with no difference regarding neck management. Regional progression (alone or with distant metastasis) was noted in 10 cases: 4 in the neck observation group (4%) versus 6 in the neck dissection group (4%).

CONCLUSION

Elective lymph node dissection of irradiated neck should not be routinely performed in patients undergoing surgery for persistent, recurrent or new primary pharyngo-laryngeal carcinomas.