Evaluation of routine contrast swallow following total pharyngolaryngectomy and free jejunal transfer

Videofluoroscopic swallowing study to detect pharyngeal leak after total (pharyngo-) laryngectomy: Retrospective assessment of a single-institution protocol

BACKGROUND

We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL).

METHODS

This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL.

RESULTS

Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases.

CONCLUSION

This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF.

Second free jejunum transfer after flap loss does not affect oral intake: A retrospective case-control study

PURPOSE

Free jejunum transfer is one of the standard procedures for restoring oral intake after total pharyngo-laryngo-esophagectomy. Flap loss leading to a second free jejunum transfer rarely occurs. This study investigated the impact of a second free jejunum transfer on post-operative oral intake.

METHODS

A retrospective review was conducted on patients who underwent a first free jejunum transfer between July 1998 and December 2019. A total of 367 patients were included in the study. Among them, 17 patients who underwent a second free jejunum transfer because necrosis constituted the second free jejunum transfer group, whereas 350 patients who did not require a second free jejunum transfer formed the first free jejunum transfer group. The incidence of dysphagia requiring tube feeding and post-operative complications was compared between the two groups. Moreover, risk factors for dysphagia and complications were estimated.

RESULTS

There were no statistically significant differences in the incidence of dysphagia post-operation between the two groups. A second free jejunum transfer was a statistically significant factor for complications at 2- and 6-months post-operation; however, there were no significant differences in complication rates at the 12-month follow-up. Furthermore, there were no significant differences in the incidence of severe complications between the two groups.

CONCLUSION

Although a second free jejunum transfer increases early complications, it is not associated with major complications and does not negatively impact oral intake. These findings support the conclusion that free jejunum transfer is safe and helps maintain post-operative quality of life.

Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer

Background:

The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer.

Methods:

We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46–88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation.

Results:

One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed.

Conclusion:

Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.

Prevention of anastomotic leak using an advanced pectoral flap in total pharyngolaryngectomy and free jejunal reconstruction for hypopharyngeal or laryngeal carcinoma

BACKGROUND

We devised an advanced pectoral flap (APF) to prevent anastomotic leak after total pharyngolaryngectomy (TPL) and free jejunal reconstruction (FJR) in patients with hypopharyngeal or laryngeal carcinoma. The APF alleviates tension on the skin in the neck, reduces the subcutaneous dead space, and promotes adhesion between the neck skin and the anastomosis.

OBJECTIVE

To investigate whether an APF is effective for prevention of anastomotic leak associated with TPL/FJR.

PATIENTS AND METHODS

Anastomotic leak was compared between APF (n = 65) and non-APF groups (n = 25). Patients who had received preoperative radiotherapy or undergone tracheostomy or skin infiltration requiring neck reconstruction using a pedicle flap were excluded.

RESULTS

There were significantly fewer cases of anastomotic leak in the APF group than in the non-APF group (1.5% [1/65] vs. 16.0% [4/25]; p = .02). An APF could be created bilaterally within approximately 15 minutes. Unlike a deltopectoral flap, an APF does not require a skin graft.

CONCLUSIONS

The postoperative anastomotic leak rate was 1.5% in patients who underwent TPL and FJR for hypopharyngeal or laryngeal carcinoma with an APF.

SIGNIFICANCE

An APF is easily created and can reduce the incidence of anastomotic leak after TPL and FJR.