Prognostic significance of postoperative wound infections after total laryngectomy

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 Incidence and the Risk Factors for Pharyngocutaneous Fistula following Primary and Salvage Total Laryngectomy

The pharyngocutaneous fistula (PCF) is the most common complication following a total laryngectomy (TL) with a wide range of incidence and various potential risk factors. The aim was to analyse the incidence and potential risk factors for PCF formation in a large study set collected over a longer period of time. In the retrospective study at the Department of Otorhinolaryngology and Cervicofacial Surgery of Ljubljana, 422 patients who were treated for head and neck cancer by TL between 2007 and 2020 were included. The comprehensive clinicopathologic data were collected including potential risk factors related to the patient, disease, surgical treatment and post-operative period for the development of fistulae. The patients were categorized into a group with the fistula (a study group) and one without it (a control group). The PCF then developed in 23.9% of patients. The incidence following a primary TL was 20.8% and 32.7% following salvage TL (p = 0.012). The results demonstrated that surgical wound infection, piriform sinus invasion, salvage TL, and total radiation dose were determined as independent risk factors for PCF formation. A diminishing surgical wound infection rate would contribute to a further reduction of the PCF rate.

Post-Operative Infections in Head and Neck Cancer Surgery: Risk Factors for Different Infection Sites

Background: Post-operative infections in head and neck cancer (HNC) surgery represent a major problem and are associated with an important increase in mortality, morbidity, and burden on the healthcare system. The aim of this retrospective observational study was to evaluate post-operative infections in HNC surgery and to analyze risk factors, with a specific focus on different sites of infection. Methods: Clinical data about 488 HNC patients who underwent surgery were recorded. Univariate and multivariate analyses were performed to identify risk factors for post-operative infections. Results: Post-operative infections were observed in 22.7% of cases. Respiratory and surgical site infections were the most common. Multiple site infections were observed in 3.9% of cases. Considering all infection sites, advanced stage, tracheotomy, and higher duration of surgery were risk factors at multivariate analysis. Median hospital stay was significantly longer in patients who had post-operative infection (38 vs. 9 days). Conclusions: Post-operative infections may negatively affect surgical outcomes. A correct identification of risk factors may help the physicians to prevent post-operative infections in HNC surgery.

Association of Pharyngocutaneous Fistula With Cancer Outcomes in Patients After Laryngectomy: A Multicenter Collaborative Cohort Study

Importance

Pharyngocutaneous fistula (PCF) results in an inflammatory reaction, but its association with the rate of locoregional and distant control, disease-free survival, and overall survival in laryngeal cancer remains uncertain.

Objective

To determine if pharyngocutaneous fistula after salvage laryngectomy is associated with locoregional and distant control, disease-free survival, and/or overall survival.

Design, Setting, and Participants

A multicenter collaborative retrospective cohort study conducted at 5 centers in Canada and the US of 550 patients who underwent salvage laryngectomy for recurrent laryngeal cancer from January 1, 2000, to December 31, 2014. The median follow-up time was 5.7 years (range, 0-18 years).

Main Outcomes and Measures

Outcomes examined included locoregional and distant control, disease-free survival, and overall survival. Fine and Gray competing risk regression and Cox-proportional hazard regression models were used for outcomes. Competing risks and the Kaplan-Meier methods were used to estimate outcomes at 3 years and 5 years.

Results

In all, 550 patients (mean [SD] age, 64 [10.4] years; men, 465 [85%]) met inclusion criteria. Pharyngocutaneous fistula occurred in 127 patients (23%). The difference in locoregional control between the group of patients with PCF (75%) and the non-PCF (72%) group was 3% (95% CI, -6% to 12%). The difference in overall survival between the group with PCF (44%) and the non-PCF group (52%) was 8% (95% CI, -2% to 20%). The difference in disease-free survival between PCF and non-PCF groups was 6% (95% CI, -4% to 16%). In the multivariable model, patients with PCF were at a 2-fold higher rate of distant metastases (hazard ratio, 2.00; 95% CI, 1.22 to 3.27). Distant control was reduced in those with PCF, a 13% (95% CI, 3% to 21%) difference in 5-year distant control.

Conclusions and Relevance

This multicenter retrospective cohort study found that development of PCF after salvage laryngectomy is associated with an increased risk for the development of distant metastases.

Clinical effect of postoperative chemoradiotherapy in resected advanced laryngeal squamous cell carcinoma

Laryngeal squamous cell carcinoma (LSCC) is one of the most prevalent types of head and neck malignancies. Advanced LSCC has failed to demonstrate a satisfactory prognosis, despite the progresses in the diagnosis and treatment, and the optimal treatment modality continues to be debated. To evaluate the clinical utility and survival outcomes of adjuvant chemoradiotherapy (CRT) for patients with resected advanced LSCC, a retrospective analysis of 232 patients with LSCC who had undergone total laryngectomy and neck dissection between 2005 and 2010 was conducted. Of the 232 eligible patients, 167 patients (72%) received surgery alone, whereas 65 patients (28%) received surgery + adjuvant CRT. In the overall cohort, the 5- and 10-year overall survival (OS) rates were 55.2 and 48.3%, respectively. Multivariate analysis revealed that the clinical stage was significantly associated with OS. However, the N classification was an independent indicator in disease-free survival and laryngeal cancer-specific survival. In those patients with stage IV disease, patients receiving adjuvant CRT exhibited a markedly improved survival benefit compared with patients receiving surgical treatment only, following propensity score matching of the data (P<0.05). The application of adjuvant CRT confers additional survival benefits in comparison with surgery-only treatment regimens for advanced LSCC. However, additional prospective studies are required.

Clinical application of decellularized and lyophilized human amnion/chorion membrane grafts for closing post-laryngectomy pharyngocutaneous fistulas

Background and Objectives

Squamous cell carcinoma is the most common pathological type among the cancers of the larynx. Standard treatment for squamous cell carcinoma of the larynx is the combination of chemotherapy, radiotherapy, and laryngectomy. Pharyngocutaneous fistula is a common complication of laryngectomy. We hypothesized that decellularized and lyophilized human amnion/chorion membrane can be an effective, non‐invasive method of treating pharyngocutaneous fistula.

Methods

A total of 67 patients with laryngeal squamous cell carcinoma were retrospectively analyzed after treatment in a prospective trial. After preoperative chemotherapy, radiotherapy, and total or extended laryngectomy, primary wound healing occurred in 42 (62.7%) patients. Pharyngocutaneous fistula developed in 8 (11.9%) patients. Decellularized and lyophilized human amnion/chorion membrane grafts were used to reconstruct the fistulas.

Results

The average time for the full healing of the wound in all patients after transplantation of these grafts was 18 days.

Conclusion

The advantages of using these grafts over other existing methods of pharyngocutaneous fistula treatment are that they are non‐invasive, prevent donor morbidity, and enable management of the wound without using classical wound gauze. J. Surg. Oncol. 2016;113:538–543. © 2016 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc.

Lymph node density as an independent predictor of cancer-specific mortality in patients with lymph node-positive laryngeal squamous cell carcinoma after laryngectomy

BACKGROUND

We examined the prognostic value of lymph node density in predicting cancer-specific mortality (CSM) for patients with lymph nodes positive (pN+) laryngeal squamous cell carcinoma (SCC) after laryngectomy.

METHODS

The records of 156 patients with laryngeal SCC who initially underwent curative resection of the primary tumor combined with neck dissection were reviewed.

RESULTS

The 5-year cumulative incidence of CSM was 20.4%. N classification and extralaryngeal spread (ELS) were independent variables for CSM in all patients. Univariate analyses in 71 pN+ patients showed that ELS, number of positive lymph nodes >4, and lymph node density >0.044 were significantly associated with increased CSM, whereas pN classification was not (p = .218). On multivariate analysis, lymph node density ≥0.044 remained an independent predictor of CSM (p = .001).

CONCLUSION

Among the pN+ patients with laryngeal SCC, no pN classification but lymph node density was noted to have an independent impact on CSM.

Relationship between postoperative complications and survival after free flap reconstruction for oral cavity squamous cell carcinoma

BACKGROUND

Current literature on the effect of postoperative complications on survival outcomes in head and neck cancers remains contradictory. This study assesses whether postoperative complications adversely affect survival in cases of complex surgical ablation and reconstruction of oral squamous cell carcinoma.

METHODS

In all, 255 consecutive patients with complete clinicopathologic data were included. Survival was determined using the log-rank test and Kaplan-Meier survival curves were generated. A Cox proportional hazards model was used to adjust for the effect of other significant covariates to determine the independent effect of complication variables for overall survival (OS). A competing risk model was used for disease-specific survival (DSS).

RESULTS

On multivariable analysis, major complications independently prognosticated for reduced OS [hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.1-3.2, p = .02]. There was no evidence for an association between any complication-variable and DSS or recurrence.

CONCLUSIONS

Major postoperative complications are independently associated with decreased OS.

Retrospective analysis of prognostic factors in 205 patients with laryngeal squamous cell carcinoma who underwent surgical treatment

Objectives

To investigate the most important factors affecting the prognosis of the patients with squamous cell carcinoma (SCC) of the larynx.

Methods

Based on the clinical and follow-up data, 205 patients with SCC of the larynx receiving total laryngectomy, partial laryngectomy, or CO₂ laser surgery in GuangDong General Hospital were retrospectively analyzed. A survival analysis was performed by the Kaplan-Meier method and a multivariable analysis of prognostic factors was carried out using the Cox proportional hazard model.

Results

Subtypes of carcinoma included 69.8% glottic and 30.2% supraglottic. Most patients were in N0 stage (77.6%), and 22.4% patients were in N1∼N3 stage. Over half of the patients were in T1∼T2 stage (55.1%), 20.0% in T3, and 24.9% in T4. Mean follow-up duration was 49.2 months. The survival rates 1, 2, and 3 years after the surgery were 99.0%, 91.7%, and 81.5%, respectively. The survival rate for those patients with clinical stage IV was significantly lower than for those with clinical stage I and II (p<0.001 and p = 0.013, respectively). The disease-free progression rates 1, 2, and 3 years after the surgery were 83.9%, 74.6%, and 71.2%, respectively. Futhermore, those patients with a Charlson score of 1 to 2 and ≥3 had higher risk of mortality than those with a Charlson score of 0 (hazard ratios of 1.8 and 2.41 p = 0.042 and p = 0.008). Multivariable analysis revealed that clinical stage, surgical margin, and comorbidity were significantly associated with both mortality and disease-free progression.

Conclusion

The surgical resection margin, clinical stage, and comorbidity were independent factors affecting the laryngeal cancer prognosis. The survival rates were lower for patients with advanced laryngeal cancer, positive surgical margins, or severe comorbidity, suggesting the importance of early diagnosis, early treatment, negative surgical margins, and conditions of comorbidity.