Clinical outcomes of tracheoesophageal diversion for intractable aspiration

Outcomes of Aspiration Prevention Surgery: A Retrospective Cohort Study Using a Japanese Claims Database

Aspiration prevention surgeries, such as laryngotracheal separation and total laryngectomy are performed to prevent aspiration pneumonia. We aimed to investigate the outcomes of surgery for intractable aspiration and relevant factors. This retrospective cohort study used a nationwide insurance claims database that included company employees and their family members aged < 75 years in Japan. We extracted the data of patients who underwent aspiration prevention surgeries between January 2005 and March 2019. We identified 127 patients (males, 55.9%), of whom 59.8% were aged < 18 years at the surgery. The most common comorbidity was neurological disease (99.2%). The frequency of pneumonia episodes decreased by 1.5 per year after surgery compared with before surgery (p < 0.001). Among patients who received parenteral and enteral nutrition before surgery (n = 92), the adjusted hazard ratio (aHR) for oral intake without parenteral and enteral nutrition was lower in the longer preoperative duration (≥ 14.7 months) for the parenteral and enteral nutrition. However, the difference was not statistically significant (aHR 0.55; 95% confidence interval: 0.15-2.08, p = 0.38). The aHR for oral intake was higher in the ≥ 30 years group than in the < 30 years group (aHR 13.76; 95% confidence intervals: 4.18-42.24; p < 0.001). This study demonstrated that postoperative oral intake was achieved more frequently in patients aged ≤ 30 years than in those aged > 30 years, and supported the effectiveness of aspiration prevention surgery for reducing aspiration pneumonia. Further research is necessary to investigate factors related to postoperative oral intake.

Tracheoesophageal Diversion and Puncture for Preserving Phonation in Intractable Aspiration: A Case Series

OBJECTIVE/HYPOTHESIS

Tracheoesophageal diversion (TED) can prevent damage to the respiratory system in patients with swallowing disorders and/or repetitive aspiration pneumonia; however, TED may cause the loss of phonation. Our previous study demonstrated that TED with tracheoesophageal puncture (TEP) prevents aspiration while retaining phonation. In this study, we aimed to further evaluate the feeding status and phonation of patients who underwent TED with TEP to verify the reproducibility of this procedure.

STUDY DESIGN

Case series study.

METHODS

We retrospectively reviewed the medical records of 11 patients who underwent TED with TEP for intractable aspiration from February 2017 to August 2019 at Fukuoka Sanno Hospital. We evaluated the preoperative penetration aspiration score (PPAS), daily activities, preoperative and postoperative food intake level scale (FILS) score, nutrition route, maximum phonation time(MPT), and postoperative communication method.

RESULTS

The study population included 10 men and 1 woman (mean age, 66 years; range, 44-81) with a PPAS of 6.8 ± 1.0. The FILS score changed from 2.1 ± 0.5 preoperatively to 7.5 ± 2.0 postoperatively (paired t-test, P < .05), while the MPT changed from 7.9 ± 4.1 to 10.3 ± 4.2 s (paired t-test, P = .9). Preoperatively, a gastric fistula (eight patients [73%]) was the main nutrition route, followed by a gastric tube (two patients [18%]). Postoperatively, the main nutritional route for eight patients (73%) was oral, while the remaining three patients (27%) used the oral route occasionally. All patients maintained laryngeal phonation function, and eight (73%) used only laryngeal phonation for communication.

CONCLUSIONS

Patients with intractable aspiration who wish to retain phonatory function should be advised to undergo TED with TEP.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1965-E1970, 2021.

Choice of Aspiration Prevention Surgery for Patients With Neuromuscular Disorders: Report of Three Cases

Dysphagia, one of the major complications of neuromuscular diseases such as Parkinson's disease and amyotrophic lateral sclerosis (ALS), decreases quality of life and may lead to malnutrition or aspiration pneumonia. Although recent reports have suggested that surgical aspiration prevention improves quality of life and enables oral intake, the selection of appropriate aspiration prevention techniques has rarely been discussed. In this report, we present the cases of three patients with neuromuscular diseases who underwent surgical aspiration prevention; we selected the surgical techniques based on analysis of the dysphagia mechanisms, disease progression, and general condition in each case. Case 1 was a 55-year-old man with multiple system atrophy (MSA) and presented with dysphagia associated with insufficient upper esophageal sphincter (UES) relaxation. We performed central-part laryngectomy, which was able to improve UES relaxation. Case 2 was a 79-year-old man with progressive supranuclear palsy who presented with respiratory disorder and dysphagia. Glottic closure under local anesthesia was selected because he also had acute hepatobiliary dysfunction and methicillin-resistant Staphylococcus aureus pneumonia with pleural effusion. Case 3 was a 75-year-old man with ALS and presented with respiratory disorder and mild dysphagia. Subglottic closure with total cricoidectomy was selected because his dysphagia was expected to worsen due to tracheostomy and disease progression. We also summarize the characteristics of the aspiration prevention surgical techniques based on our cases and on literature review. The causes of dysphagia, including insufficient UES opening during swallowing, weak pharyngeal constriction, velopharyngeal insufficiency, and inadequate laryngeal elevation, should be assessed by detailed examination before surgery, and the type of aspiration prevention surgery should be selected based on patient swallowing function and general condition.