Horizontal (vs. vertical) closure of the neo-pharynx is associated with superior postoperative swallowing after total laryngectomy

Rehabilitation Program for Postlaryngectomy Patients Following Ileocolon Flap Transfer for Voice Reconstruction: An Essential Part of Success

BACKGROUND

 Speech restoration is important for communication and social activities after pharyngolaryngectomy in head and neck cancer or corrosive injury. Several techniques of voice restoration have been developed to improve life quality. The aim of this paper was to focus on the microsurgical transfer of ileocolon flap and outcome of further voice rehabilitation.

PATIENTS AND METHODS

 From 2010 to 2022, 69 patients had ileocolon flap at our hospital with postoperative speech training and regular follow-up for over 1 year. The patients received deglutition training first, followed by voice rehabilitation. Voice outcomes were evaluated at an interval of 3 months and finally at 12 months of voice training rehabilitation. Among other examinations, the speech function was evaluated using a 4-point Likert scale and senior surgeon (H-c.C.) scoring system.

RESULTS

 The results showed that speech function reached 13.1% of excellent voice, 65.1% of good voice, 13.1% of fair result, and 8.7% of poor result by Likert scales. Meanwhile, the senior surgeon (H-c.C.) score showed 17.4% of excellent, 63.8% of moderate, and 18.8% of poor results. About voice laboratory results, maximal phonation time was 11.0 seconds, and the average number counted in one breath was 15. Loudness and frequency showed 56.0 dB and 105.0 Hz, respectively.

CONCLUSION

 The study showed that after voice reconstruction with ileocolon flap followed by the voice rehabilitation program, the patients would have a better understanding of the altered anatomical structures and practice in a more efficient way. Adequate recommendation by the therapists to plastic surgeons for revision surgeries optimized voice function of the patients.

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

INTRODUCTION

The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario.

METHODS

A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included.

RESULTS

A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce.

CONCLUSION

We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.

Incidence of Pharyngocutaneous Fistula After Total Laryngectomy and Its Relationship With the Shapes of Mucosa Closure: A Meta-Analysis

Background and objective

Pharyngocutaneous fistula is the most common complication after total laryngectomy. The aim of this study was to examine the incidence of fistula and the association between fistula and the shape of mucosal closure (T-shaped, vertical, or horizontal closure).

Method

A search of English language databases from 1979 to 2021 was undertaken for studies of total laryngectomy that commented on pharyngeal closure techniques and fistulas. Pooled estimates for fistula incidence and odds ratios were calculated.

Results

A total of 24 retrospective studies were included. The pooled fistula rates in primary total laryngectomy were 19.9% with T-shaped closure, 16.1% with vertical closure, and 16.4% with horizontal closure. In salvage total laryngectomy, the pooled fistula rates were 35.1%, 36.1%, and 17.9% with T-shaped, vertical, and horizontal closure, respectively. In the analysis of association, the risk of fistula formation in the T-shaped closure was not significantly different compared to that in the vertical closure, (odds ratio, 0.96; 95% confidence interval, 0.46-2.00). The horizontal closure, when compared to vertical closure, was significantly associated with lower risk of fistula formation (odds ratio, 0.31; 95% confidence interval, 0.12-0.78), but had nonsignificant lower risk of fistula formation when compared to the T-shaped closure (odds ratio, 0.46; 95% confidence interval, 0.19-1.12).

Conclusion

Horizontal closure seems to be the best closure shape for primary repair after total laryngectomy. However, analysis bias may have occurred because of the lack of well-controlled studies.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

Reconstruction technique following total laryngectomy affects swallowing outcomes

OBJECTIVES

How reconstruction affects function following total laryngectomy is unclear. This study seeks to determine whether reconstruction method is associated with differences in swallowing outcomes.

METHODS

Retrospective review of reconstruction technique in patients undergoing TL was compared by pharyngeal transit time (PTT), patient-reported dysphagia (EAT-10), and diet-tolerated (FOIS).

RESULTS

Ninety-five patients met inclusion criteria, with 40 patients (42.1%) undergoing primary closure and 55 patients (57.9%) undergoing tissue transfer. There was no difference in EAT-10 scores between the groups (P = .09). There was a significantly higher proportion of patients achieving oral diet (FOIS >3) with primary closure (P = .003). Patients undergoing PMC vs free flap had similar rates of g-tube dependency. Primary closure had the shortest PTT (1.89 seconds) compared to free flap (3.47-4.65 seconds) or PMC (5.1 seconds; P = .035).

CONCLUSIONS

When primary closure is achievable, these results suggest improved swallowing outcomes with better tolerance of oral diet and shorter pharyngeal transit times.

LEVEL OF EVIDENCE

IV.