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Monroe D, Pyne JM, McLennan S, Kimmis R, Yoon J, Biron VL. Characteristics and outcomes of transoral robotic surgery with free-flap reconstruction for oropharyngeal cancer: a systematic review. J Robot Surg 2023:10.1007/s11701-023-01572-4. [PMID: 36964850 DOI: 10.1007/s11701-023-01572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/11/2023] [Indexed: 03/26/2023]
Abstract
Transoral robotic surgery (TORS) approach for the treatment of oropharyngeal cancer allows for reduced patient morbidity, amongst other advantages over the traditional lip-splitting mandibulotomy method. Free-flap reconstruction is commonly utilized in head and neck cancer surgeries; however, safety and outcomes of this technique in TORS procedures have not been well studied. The objective of this study was to perform a systematic review to evaluate the efficacy and safety of TORS with free-flap reconstruction (TORS-FFR) for oropharyngeal cancer. A systematic search of Scopus, EMBASE, CINAHL and PubMed databases was completed. Following PRISMA guidelines, case series/reports, retrospective and prospective cohort studies were included. Primary outcomes measured were deaths and complication rates associated with TORS-FFR for oropharyngeal cancers. Secondary outcomes included functional swallowing and airway outcomes, operative time and length of hospital stay. Twenty-one studies met the inclusion criteria comprising a total of 132 patients. The mean patient age was 58.4 years. The most frequent complication was infection (8.9%) followed by flap wound dehiscence (4.2%). The average total operative time was 710 min (n = 48), while average length of hospital stay was 13.5 days (n = 48). Reconstructions were most commonly fashioned from radial forearm free flaps (RFFF), with anterolateral thigh flaps (ALT) representing the second most common free-flap subtype. TORS-FFR procedures for oropharyngeal cancer are safe, with low serious complication rates. This surgical approach may be associated with decreased length of hospital stay; however, further studies are required to better characterize post-operative outcomes.Level of evidence 1a.
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Affiliation(s)
- Damon Monroe
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Edmonton, AB, Canada
| | - Justin M Pyne
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Edmonton, AB, Canada
| | - Steffane McLennan
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ryan Kimmis
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jenny Yoon
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Edmonton, AB, Canada
| | - Vincent L Biron
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Edmonton, AB, Canada.
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Oropharyngeal reconstruction after transoral robotic surgery. Curr Opin Otolaryngol Head Neck Surg 2022; 30:384-391. [PMID: 36004787 DOI: 10.1097/moo.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Transoral robotic surgery (TORS) has experienced an evolution in recent years. This technique has proved to be a safe and effective method for extirpation of select oropharyngeal tumors. Advances in technology as well as improved surgeon experience allow for the resection of larger, more complex cancers. Although healing by secondary intention remains the current standard for limited oropharyngeal defects, larger resections demand reconstruction with vascularized tissue to minimize morbidity and optimize functional outcomes. The objective of this review is to evaluate recent literature regarding oropharyngeal reconstruction after TORS. RECENT FINDINGS A variety of reconstructive options to manage oropharyngeal defects exist. Several reconstructive algorithms have been suggested; however, careful consideration must be used to select the most ideal flap type. Locoregional flaps have shown excellent functional outcomes with limited morbidity. An increase in free flap reconstruction has been demonstrated, particularly among patients with larger TORS defects and following chemoradiation therapy. Despite limited data, robotic-assisted flap inset and microvascular anastomosis has recently shown promise. SUMMARY Reconstruction and flap selection following TORS should be tailored to the patient and unique oropharyngeal defect. Functional outcomes are promising with low complication rates among these patients.
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Choi JW, Alshomer F, Kim YC. Evolution and current status of microsurgical tongue reconstruction, part II. Arch Craniofac Surg 2022; 23:193-204. [PMID: 36373253 PMCID: PMC9663260 DOI: 10.7181/acfs.2022.00857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/18/2022] [Accepted: 10/11/2022] [Indexed: 01/25/2023] Open
Abstract
Tongue reconstruction remains a major aspect of head and neck reconstructive procedures. Surgeons planning tongue reconstruction should consider several factors to optimize the overall outcomes. Specifically, various technical aspects related to tongue reconstruction have been found to affect the outcomes. Multidisciplinary teams dedicated to oncologic, reconstructive, and rehabilitative approaches play an essential role in the reconstructive process. Moreover, operative planning addressing certain patient-related and defect-related factors is crucial for optimizing functional speech and swallowing, as well as quality of life outcomes. Furthermore, tongue reconstruction is a delicate process, in which overall functional outcomes result from proper flap selection and shaping, recipient vessel preparation and anastomosis, surgical approaches to flap insetting, and postoperative management. The second part of this review summarizes these factors in relation to tongue reconstruction.
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Affiliation(s)
- Jong-Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Feras Alshomer
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Chul Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Barrette LX, De Ravin E, Carey RM, Mady LJ, Cannady SB, Brody RM. Reconstruction following transoral robotic surgery for head and neck cancer: Systematic review. Head Neck 2022; 44:1246-1254. [PMID: 35137993 DOI: 10.1002/hed.26998] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/30/2022] [Accepted: 02/01/2022] [Indexed: 12/17/2022] Open
Abstract
We performed a systematic review to characterize reconstructive modalities and postoperative surgical outcomes following TORS resection. A search of the PubMed, SCOPUS, and EMBASE databases was conducted to identify studies describing patients undergoing reconstruction of TORS defects. Twenty-six studies met inclusion criteria, consisting of 260 patients who underwent TORS resection followed by reconstruction. Twenty-one studies reported tumor classification information, with TORS performed for 44 (23.0%) T1, 86 (45.0%) T2, 33 (17.3%) T3, and 28 (14.7%) T4 tumors. Eighteen distinct reconstructive modalities were described in the studies identified, including nine unique free flap types. The most commonly performed reconstruction was the radial forearm free flap (RFFF), accounting for 121/260 (46.5%) of reconstructions performed. Reported surgical complications included 5 pharyngocutaneous fistulae, 13 hemorrhagic complications, 24 infectious complications, and 5 free flap failures. Our findings demonstrate favorable surgical outcomes but minimal quantitative functional data to compare reconstructive options following TORS.
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Affiliation(s)
- Louis-Xavier Barrette
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emma De Ravin
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan M Carey
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leila J Mady
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Brody
- Department of Otorhinolaryngology, Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Meccariello G, Maniaci A, Bianchi G, Cammaroto G, Iannella G, Catalano A, Sgarzani R, De Vito A, Capaccio P, Pelucchi S, Vicini C. Neck dissection and trans oral robotic surgery for oropharyngeal squamous cell carcinoma. Auris Nasus Larynx 2021; 49:117-125. [PMID: 34092436 DOI: 10.1016/j.anl.2021.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/21/2021] [Accepted: 05/18/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was planned to determine whether Selective Neck Dissection (SND) is oncological safe procedure even in patients with lymph node metastases. METHODS OPSCC patients were divided into Modified Radical Neck Dissection (MRND) and SND groups. The outcome measures were overall survival (OS), disease-free survival (DFS) and regional recurrence free survival (RRFS). RESULTS Thirty-seven SNDs and 18 MRNDs were performed. Regional relapse rate was 6.1% in SND group whilst 18.8% in MRND group(p=0.19). The 5-year OS, DFS and RRFS rates' differences were not statistically significant between SND and MRND groups (p=0.40, p=0.42 and p=0.18, respectively). At multivariate analysis, advanced stage impacted the 5-year OS and DFS(HR=9.39, p<0.01 and HR=11.03, p=0.04). CONCLUSIONS The SND seems to be effective in a TORS framework. The indication should be accurately discussed by the multidisciplinary tumor board.
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Affiliation(s)
- Giuseppe Meccariello
- Otolaryngology and Head-Neck Surgery Unit, Department of Head-Neck Surgeries, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy.
| | - Antonino Maniaci
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", ENT Section, University of Catania, Catania, Italy
| | - Giulia Bianchi
- Otolaryngology Unit, University of Ferrara, Ferrara, Italy
| | - Giovanni Cammaroto
- Otolaryngology and Head-Neck Surgery Unit, Department of Head-Neck Surgeries, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Giannicola Iannella
- Otolaryngology and Head-Neck Surgery Unit, Department of Head-Neck Surgeries, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | | | - Rossella Sgarzani
- Burn Unit, Maurizio Bufalini Hospital, Azienda USL della Romagna, Cesena, Italy
| | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Head-Neck Surgeries, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
| | - Pasquale Capaccio
- Department of Biomedical, Surgical and Dental Sciences - University of Milan, Milan, Italy
| | - Stefano Pelucchi
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", ENT Section, University of Catania, Catania, Italy
| | - Claudio Vicini
- Otolaryngology and Head-Neck Surgery Unit, Department of Head-Neck Surgeries, Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì, Italy
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Calabrese L, Accorona R, Gazzini L, Giorgetti G, Tagliabue M, Bruschini R, Pietrobon G, Ansarin M. Platysma myocutaneous flap revised in the free flaps era: clinical experience in 61 patients. ACTA ACUST UNITED AC 2021; 40:173-180. [PMID: 32773778 PMCID: PMC7416368 DOI: 10.14639/0392-100x-n0538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Luca Calabrese
- Division of Otorhinolaryngology, "San Maurizio" Hospital, Bolzano, Italy
| | - Remo Accorona
- Division of Otorhinolaryngology, "San Maurizio" Hospital, Bolzano, Italy
| | - Luca Gazzini
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Verona, Italy
| | - Giovanni Giorgetti
- Department of Medicine, Surgery and Dentistry, University of Salerno, "Scuola Medica Salernitana", Salerno, Italy
| | - Marta Tagliabue
- Division of Otorhinolaryngology and Head and Neck Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Bruschini
- Division of Otorhinolaryngology and Head and Neck Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Giacomo Pietrobon
- Division of Otorhinolaryngology and Head and Neck Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Mohssen Ansarin
- Division of Otorhinolaryngology and Head and Neck Surgery, European Institute of Oncology IRCCS, Milan, Italy
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[Surgical therapy of oropharyngeal cancer-state of the art]. HNO 2020; 68:657-661. [PMID: 32767069 DOI: 10.1007/s00106-020-00901-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Surgical therapy, regardless of the procedure, remains of great importance for today's treatment of oropharyngeal carcinomas, despite advances in radiation and immunotherapy. The individual treatment plan should be defined in discussion with the patient and in an interdisciplinary tumor conference, taking into account the likelihood of achieving of tumor-free resection margins and an acceptable postoperative quality of life. With regard to conventional and possibly also open surgical procedures, a good overview of the surgical site-particularly in the case of more extensive carcinomas and challenging patient anatomy-and simplified reconstructability of the defect region are decisive aspects. Endoscopically, microsurgically, or even robot-assisted minimally invasive procedures have the advantage of precise and gentle removal of tumor tissue with improved maintenance of function. Overall, selection of the appropriate surgical procedure remains an individual decision based on tumor size, the facilities at the tumor center, and the surgeon's experience. The extent of surgical intervention, also with regard to simultaneous neck dissection, depends on tumor stage. In the case of oropharyngeal carcinomas, there will be an increasing distinction between human papillomavirus (HPV)-negative and HPV-positive tumors in the future; however, the therapeutic strategy is currently identical. Upcoming clinical trials will show whether treatment de-escalation is appropriate depending on HPV infection status.
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Facial artery musculomucosal flaps in oropharyngeal reconstruction following salvage transoral robotic surgery: a review of outcomes. The Journal of Laryngology & Otology 2019; 133:884-888. [PMID: 31475640 DOI: 10.1017/s002221511900183x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE There has been little reported on the transoral reconstructive options following salvage transoral robotic surgery. This paper describes the facial artery musculomucosal flap as a method to introduce vascularised tissue to a previously irradiated resection bed. METHODS A facial artery musculomucosal flap was used to reconstruct the lateral pharyngeal wall in 13 patients undergoing salvage transoral robotic surgery for oropharyngeal squamous cell carcinoma. Outcomes recorded include flap and donor site complications, length of stay, and swallowing and speech outcomes. RESULTS There were no immediate or late flap complications, or cases of delayed wound healing in this series. There were two facial artery musculomucosal related complications requiring surgical management: one bleed from the facial artery musculomucosal donor site and one minor surgical revision. Healing of the flap onto the resection bed was successful in all cases. CONCLUSION The facial artery musculomucosal flap provides a suitable transoral local flap option for selected patients undergoing salvage transoral robotic surgery for oropharyngeal malignancies.
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