The role of upper airway ultrasonography in tracheal necrosis diagnosis: a case report

BACKGROUND

Tracheal necrosis post endotracheal intubation is a rare life-threatening disease that can compromise airway patency. We demonstrated a novel usage of upper airway ultrasonography (USG) to diagnose tracheal necrosis.

CASE PRESENTATION

A middle-aged smoking male presented with productive cough, noisy breathing and exertional dyspnea for 2 weeks. He was intubated one month prior due to a traumatic brain injury. Upper airway USG findings showed irregular air-mucosal interface (AMI) and comet tail artefacts over the 1st and 2nd tracheal ring. A direct laryngoscopy in the operating room showed thick mucopus inferior to the vocal cords, with necrotic tracheal cartilages and debris obstructing the airway. He was successfully treated with parenteral antibiotics, wound debridement and tracheostomy.

CONCLUSION

Our case highlights the first documented USG findings of tracheal necrosis. Upper airway USG serves as a potential diagnostic modality in managing the condition.

Machine learning approach to predict tracheal necrosis after total pharyngolaryngectomy

BACKGROUND

Tracheal necrosis is a potentially severe complication of total pharyngolarynjectomy (TPL), sometimes combined with total esophagectomy. The risk factors for tracheal necrosis after TPL without total esophagectomy remain unknown.

METHODS

We retrospectively reviewed data of 395 patients who underwent TPL without total esophagectomy. Relevant factors associated with tracheal necrosis were evaluated using random forest machine learning and traditional multivariable logistic regression models.

RESULTS

Tracheal necrosis occurred in 25 (6.3%) patients. Both the models identified almost the same factors relevant to tracheal necrosis. History of radiotherapy was the most important predicting and significant risk factor in both models. Paratracheal lymph node dissection and total thyroidectomy with TPL were also relevant. Random forest model was able to predict tracheal necrosis with an accuracy of 0.927.

CONCLUSIONS

Random forest is useful in predicting tracheal necrosis. Countermeasures should be considered when creating a tracheostoma, particularly in patients with identified risk factors.

Primary tracheobronchial necrosis after esophagectomy: A nationwide multicenter retrospective study in Japan

Background

The clinical features of postoperative primary tracheobronchial necrosis (P‐TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P‐TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort.

Methods

As a study of the Japan Broncho‐Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P‐TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation.

Results

P‐TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P‐TBN for pharyngo‐laryngo‐cervical esophagectomy (PLCE; n = 1650), total pharyngo‐laryngo‐esophagectomy (TPLE; n = 205), and subtotal esophagectomy (SE; n = 4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P = 0.016) and the higher level of the tracheal resection (P = 0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P = 0.009) and Grade 3 (P = 0.004) than in those with Grade 1.

Conclusion

The incidence of TBN restricted to P‐TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P‐TBN, especially in PLCE and TPLE. Our new P‐TBN severity grade may predict the outcome of patients with P‐TBN.

Primary tracheobronchial necrosis after esophagectomy: A nationwide multicenter retrospective study in Japan

Background

The clinical features of postoperative primary tracheobronchial necrosis (P-TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P-TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort.

Methods

As a study of the Japan Broncho-Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P-TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation.

Results

P-TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P-TBN for pharyngo-laryngo-cervical esophagectomy (PLCE; n = 1650), total pharyngo-laryngo-esophagectomy (TPLE; n = 205), and subtotal esophagectomy (SE; n = 4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P = 0.016) and the higher level of the tracheal resection (P = 0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P = 0.009) and Grade 3 (P = 0.004) than in those with Grade 1.

Conclusion

The incidence of TBN restricted to P-TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P-TBN, especially in PLCE and TPLE. Our new P-TBN severity grade may predict the outcome of patients with P-TBN.

A survey of the clinical outcomes of cervical esophageal carcinoma surgery focusing on the presence or absence of laryngectomy using the National Clinical Database in Japan

BACKGROUND

One upside of cervical esophageal carcinoma is that radical surgery can be performed by laryngectomy, even for tumors with tracheal invasion. However, this approach drastically reduces the quality of life, such as by losing the vocal function. Cervical esophageal carcinoma is rare, and no comprehensive reports have described the current state of surgery. Using a Japanese nationwide web-based database, we analyzed the surgical outcomes of cervical esophageal carcinoma to evaluate the impact of larynx-preserving surgery.

METHODS

Based on the Japan National Clinical Database, 215 surgically treated cases of cervical esophageal carcinoma between January 1, 2018, and December 31, 2019, were enrolled. Clinical outcomes were compared between the larynx-preserved group and the laryngectomy group.

RESULTS

Ninety-four (43.7%) patients underwent larynx-preserving surgery. A total of 177 (82.3%) patients underwent free jejunum reconstruction. More T4b patients and more patients who underwent preoperative radiotherapy were in the laryngectomy group. There were no significant differences in the frequency and the severity of morbidities between the two groups. However, in the laryngectomy group, in-hospital death within 30 days after surgery was observed in 1 patient, and the postoperative hospital stay was significantly longer (P = 0.030). In the larynx-preserved group, recurrent nerve paralysis was observed in 24.5%. Re-operation (35.3%, P = 0.016), re-intubation (17.6%, P = 0.019) and tracheal necrosis (17.6%, P = 0.028) were significantly more frequent in patients who underwent pharyngolaryngectomy with total esophagectomy and gastric tube reconstruction than in others.

CONCLUSION

Larynx-preserving surgery was therefore considered to be feasible because it was equivalent to laryngectomy regarding the short-term surgical outcomes.

Postoperative Complications Following Pharyngolaryngectomy With Total Esophagectomy: Comparison Between Cervical and Anterior Mediastinal Tracheostomy

OBJECTIVES

Pharyngolaryngectomy with total esophagectomy (PLTE) is associated with high morbidity and mortality rates. Cervical tracheostomy (CT) is the first choice of tracheostomy, whereas anterior mediastinal tracheostomy (AMT) is sometimes required due to tumor extension or insufficient blood supply to the tracheal tip. However, the differences in the outcomes between CT and AMT after PLTE remain unclear.

METHODS

We retrospectively reviewed 67 patients who underwent PLTE and compared the clinical features and postoperative complications between patients with CT and AMT. The characteristics and the outcomes were compared between the groups stratified by the causes of AMT.

RESULTS

Of the 67 patients, 42 (62.7%) patients underwent PLTE with CT (CT group), whereas 25 (37.3%) underwent PLTE with AMT (AMT group). The AMT group included more cervicothoracic esophageal cancers and had showed an advanced T stage compared to the CT group (P < .01 and .01, respectively). The incidences of pneumonia and surgical site infection (SSI) were more frequent in the AMT group than in the CT group (P = .03 and .01, respectively). Surgery-related mortality was only observed in the AMT group. In the AMT group, 17 (68.0%) and 8 (32.0%) patients underwent AMT because of tumor extension and insufficient supply to the tracheal tip. The latter cases underwent transthoracic esophagectomy more frequently than former cases (P = .03).

CONCLUSION

AMT after PLTE had more postoperative complications and mortality than CT. In cases that may need AMT, a transthoracic approach is preferable over transhiatal esophagectomy to avoid fatal complications when oncologically permissive.

Surgical technique for the prevention of tracheal necrosis following total pharyngolaryngectomy

Total pharyngolaryngectomy with cervical esophagectomy (TPLCE) is an invasive procedure with various post-operative complications. Tracheal necrosis (TRN) is a fatal complication of TPLCE. The present study aimed to identify a surgical technique which may be used to prevent TRN. The post-operative complications of 48 patients who underwent TPLCE from January, 2010 to December, 2019 were retrospectively investigated. The incidence of TRN was examined and measures against TRN were reviewed. The results revealed that 3 patients (6%) experienced TRN within 1 week following surgery. In addition, 2 patients required the surgical debridement of the necrotic tissue and tracheoplasty. The other patient underwent conservative treatment. Stomal recurrence developed in 1 patient (2%). On the whole, the present study demonstrates that the incidence of TRN following TPLCE is lower than that observed in previous reports, and only one stomal recurrence was reported. Preserving the blood supply to the trachea is essential for the prevention of TRN. The eight surgical processes used herein effectively preserved the blood supply. Further investigations however, are necessary in order to confirm the present findings and to ensure effective measures are found with which to prevent TRN following TPLCE.

Ivor-Lewis esophagectomy for patients with squamous cell carcinoma of the thoracic esophagus with a history of total pharyngolaryngectomy

BACKGROUND

Synchronous or metachronous esophageal, and head and neck cancers are often observed, and we occasionally encounter esophageal cancer cases with a past history of total pharyngolaryngectomy (TPL) for head and neck cancers. Total esophagectomy after TPL may impair blood supply to the trachea and may cause tracheal necrosis. Meanwhile, Ivor-Lewis esophagectomy can prevent the above-mentioned risks, but there is a concern about an anastomosis with the remnant upper esophagus that lost blood supply after two surgical procedures. The surgical outcomes of Ivor-Lewis esophagectomy after TPL remain unclear. Therefore, we investigated the surgical outcomes.

METHODS

This study included patients who underwent Ivor-Lewis esophagectomy for esophageal cancer with a history of TPL at our institution between 2005 and 2017. We retrospectively investigated the patients' background characteristics and short-term surgical outcomes.

RESULTS

Twelve consecutive patients (8 men and 4 women) were included in this study. The median period between TPL and esophagectomy was 32 months (range 2-185 months). All patients underwent esophagectomy via right open thoracotomy and reconstruction using a gastric tube with intrathoracic anastomosis. Although the esophagogastric anastomosis was made on the remnant upper esophagus, which had already lost blood supply from the inferior thyroid artery, there was no case of anastomotic leakage or esophageal necrosis, and hospital mortality was not observed.

CONCLUSION

Ivor-Lewis esophagectomy for patients with a history of TPL is a safe procedure, which can prevent severe complications including anastomotic leakage or tracheal necrosis.

Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula

BACKGROUND

Post-esophagectomy tracheo-bronchial-esophageal fistula (PETEF) most often develops after anastomotic disruption or gastric conduit necrosis. Ideal surgical management and outcomes for this complication are uncertain.

METHODS

A retrospective review of 11 patients undergoing surgical repair of PETEF was performed.

RESULTS

The median time between esophagectomy and surgical repair of PETEF was 61 days (range, 7 days to 28 years). Anastomotic leak or gastric conduit necrosis was responsible for PETEF in 6 patients (54.5%), whereas other causes were erosion of a tracheal appliance (n = 2), gastric conduit staple line erosion (n = 1), anastomotic stricture dilation (n = 1), and recurrent esophageal cancer (n = 1). Membranous airway defects were repaired primarily and buttressed with muscle or omental flaps in 8 patients (72.7%), whereas two (18.2%) were repaired with bio-prosthetic patches and one (9.1%) was repaired with a sleeve resection of the bronchus. Anastomotic and neo-esophageal conduit defects were repaired primarily in 3 patients (27.3%), whereas 7 patients (63.6%) underwent conduit take-down and esophageal or pharyngeal diversion, and 1 patient (9.1%) underwent simultaneous fistula repair and colon interposition. Two patients (18.2%) had recurrent fistulas, with 1 patient dying after second fistula closure and the other was discharged with no further attempt at repair. Three patients (27.3%) died postoperatively. Only 3 patients (27.3%) resumed an oral diet after fistula repair.

CONCLUSIONS

Surgical treatment is effective for most patients undergoing operative repair of PETEF, notwithstanding a considerable risk of postoperative morbidity and death. Although fistula repair is life saving and prevents further respiratory deterioration, return to oral alimentation is not ensured.

Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.

Postoperative delirium after pharyngolaryngectomy with esophagectomy: a role for ramelteon and suvorexant

BACKGROUND

Postoperative delirium is common after extensive surgery, and is known to be associated with sleeping medications. In this study, we aimed to investigate the relationships between sleeping medications and postoperative delirium after pharyngolaryngectomy with esophagectomy.

METHODS

We performed a retrospective analysis of 65 patients who underwent pharyngolaryngectomy with esophagectomy at Shizuoka Cancer Center Hospital between January 2012 and March 2016. All data were assessed by two psychiatrists, and univariate and multivariate analyses were performed.

RESULTS

Postoperative delirium developed in 9 (13.8%) patients, with most cases (77.8%) occurring between postoperative day (POD) 1 and POD 3. Of the 24 patients taking a minor tranquilizer after surgery, 8 (33.3%) became delirious, but, of the remaining 41 patients taking ramelteon with or without suvorexant, only one (2.4%) became delirious after surgery. Moreover, of the 16 patients taking both ramelteon and suvorexant, no postoperative delirium was observed. Ramelteon with or without suvorexant was significantly associated with a decreased rate of postoperative delirium compared with minor tranquilizer use (p = 0.001). Multivariate analysis confirmed that the use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium (odds ratio 0.060, p = 0.013).

CONCLUSION

The use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium after pharyngolaryngectomy with esophagectomy. However, using minor tranquilizers was associated with postoperative delirium. We recommend ramelteon with or without suvorexant for preventing postoperative delirium after pharyngolaryngectomy with esophagectomy.

Comparison of Salvage Total Pharyngolaryngectomy and Cervical Esophagectomy Between Hypopharyngeal Cancer and Cervical Esophageal Cancer

BACKGROUND

Total pharyngolaryngectomy and cervical esophagectomy (TPLCE) after chemoradiotherapy remains a challenge because of the high rate of complications and few available data on outcomes and safety. The purpose of this study was to evaluate the clinical significance of salvage TPLCE and to compare treatment outcomes between hypopharyngeal cancer and cervical esophageal cancer.

METHODS

Data from 37 consecutive patients who were diagnosed with potentially resectable hypopharyngeal and cervical esophageal cancer after chemoradiotherapy were retrospectively analyzed. The survival and surgical outcomes were investigated between the hypopharyngeal cancer and cervical esophageal cancer groups.

RESULTS

Twenty-six patients were included in hypopharyngeal cancer group and 11 patients were included in cervical esophageal cancer group. The baseline characteristics were balanced between the two groups. Compared to the hypopharyngeal cancer group, the cervical esophageal cancer group had significantly more frequent tracheal-related complications (p < 0.05) and stronger association of distal margin of the cervical esophagus and radiation field with tracheal ischemia after salvage surgery.

CONCLUSIONS

Salvage TPLCE can offer the exclusive chance of prolonged survival. Association of tracheal ischemia with salvage TPLCE was seen more frequently for cervical esophageal cancer. Therefore, the indication for salvage TPLCE must be carefully considered to maintain the balance between curability and safety.

Salvage pharyngolaryngectomy with total esophagectomy following definitive chemoradiotherapy

Historically, total pharyngolaryngectomy with total esophagectomy has been the standard radical surgical treatment for synchronous cancer of the thoracoabdominal esophagus and pharyngolaryngeal region, and for cancer of the cervical esophagus that has invaded as far as the thoracic esophagus. Although definitive chemoradiotherapy that enables preservation of the larynx has often been the first choice of treatment for cancers involving the cervical esophagus, total pharyngolaryngectomy with total esophagectomy is required as a salvage therapy for cases involving failure of complete remission or locoregional recurrence after chemoradiotherapy. However, salvage esophageal surgery after definitive high-dose chemoradiotherapy is generally associated with high morbidity and mortality. The aim of this study was to examine the short-term outcome of salvage total pharyngolaryngectomy with total esophagectomy. From 2001 to 2014, nine patients underwent salvage total pharyngolaryngectomy with total esophagectomy at the Department of Gastroenterological Surgery, Nagoya University. The mortality and morbidity rates were high at 22% and 89%, respectively. Four patients (44%) developed tracheal necrosis, which in two patients eventually led to lethal hemorrhage. Salvage total pharyngolaryngectomy with total esophagectomy is an uncommon and highly demanding surgical procedure that should be carefully planned and conducted in selected centers of excellence. Measures must be taken to preserve the tracheal blood supply, thus avoiding fatal complications.

Risk factors for complications after pharyngolaryngectomy with total esophagectomy

BACKGROUND

Pharyngolaryngectomy with total esophagectomy (PLTE) is an effective surgical treatment for synchronous or metachronous hypopharyngeal or laryngeal cancer and thoracic esophageal cancer, although it is more invasive than esophagectomy and total pharyngolaryngectomy. The aim of this study was to identify risk factors for complications after PLTE.

METHODS

From November 2002 to December 2014, a total of 8 patients underwent PLTE at the Shizuoka Cancer Center Hospital, Shizuoka, Japan. We investigated the clinicopathological characteristics, surgical procedures, and postoperative complications of these patients.

RESULTS

Of the 8 patients, 5 underwent one-stage PLTE and 3 underwent staged PLTE. There was no mortality in this study. Two cases of tracheal necrosis, two of anastomotic leakage, and one of ileus were observed as postoperative complications. Two patients who underwent one-stage PLTE with standard mediastinal lymph node dissection developed tracheal necrosis and severe anastomotic leakage.

CONCLUSION

One-stage PLTE and standard mediastinal lymph node dissection were identified as the risk factors for severe postoperative complications. Staged PLTE or transhiatal esophagectomy should be considered when PLTE is performed and standard mediastinal lymph node dissection should be avoided when one-stage PLTE is performed with transthoracic esophagectomy.