Prevention of wound complications following salvage laryngectomy using free vascularized tissue

BACKGROUND: Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative complications in salvage laryngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complications in this difficult patient population. The purpose of this study was to outline our technique and determine the effectiveness of this new approach. METHODS: We conducted a retrospective review of a prospective cohort and compared it with a historical group (surgical patients of Radiation Therapy Oncology Group (RTOG)-91-11 trial). Eligibility criteria for this study included patients undergoing salvage total laryngectomy following failed attempts at organ preservation with either high-dose radiotherapy or concurrent chemo/radiation therapy regimen. Patients were excluded if the surgical defect required a skin paddle for pharyngeal closure. The prospective cohort consisted of 14 consecutive patients (10 males, 4 females; mean age, 58 years) who underwent free tissue reinforcement of the pharyngeal suture line following total laryngectomy. The historical comparison group consisted of 27 patients in the concomitant chemoradiotherapy arm of the RTOG-91-11 trial who met the same eligibility criteria (26 males, 1 female; mean age, 57 years) but did not undergo free tissue transfer or other form of suture line reinforcement. Minimum follow-up in both groups was 12 months. RESULTS: The overall pharyngocutaneous fistula rate was similar between groups-4/14 (29%) in the flap group, compared with 8/27 (30%) in the RTOG-91-11 group. There were no major wound complications in the flap group, compared with 4 (4/27, 14.8%) in the RTOG-91-11 group. There were no major fistulas in the flap group, compared with 3/27 (11.1%) in the RTOG-91-11 group. The rate of pharyngeal stricture requiring dilation was 6/14 (42%) in the flap group, compared with 7/27 (25.9%) in the RTOG-91-11 group. In our patients, the rate of tracheoesophageal speech was 14/14 (100%), and complete oral intake was achieved in 13/14 (93%) patients. Voice-Related Quality of Life Measure (V-RQOL) and Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) scores suggest that speech and swallowing functions are reasonable following free flap reinforcement. CONCLUSIONS: Free vascularized tissue reinforcement of primary pharyngeal closure in salvage laryngectomy following failed organ preservation is effective in preventing major wound complications but did not reduce the overall fistula rate. Fistulas that developed following this technique were relatively small, did not result in exposed major vessels, and were effectively treated with outpatient wound care rather than readmission to the hospital or return to operating room. Speech and swallowing results following this technique were comparable to those following total laryngectomy alone.     

Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow

The modified barium swallow is currently the most comprehensive, widely available, and easily interpreted technique for the evaluation of patients with dysphagia by the head and neck surgeon. However, it requires the facilities, personnel, and use of a radiology suite, a trained speech pathologist, and exposure of the patient to radiation. It would therefore be helpful to have an adjunctive, physician based, nonradiographic method of examination that could provide information similar to and possibly even more complete than that supplied by the modified barium swallow. Such an adjunctive method could help otolaryngologist-head and neck surgeons confronted by a new patient with swallowing difficulties to orient themselves to the nature and severity of the problem while waiting for the modified barium swallow to be scheduled, performed, and reviewed. It could also be a helpful tool for management of patients with cancer of the head and neck, whose swallowing function may change rapidly in the early postoperative period. In such cases, intervals between modified barium swallow examinations (dictated by concern over radiation exposure) may be too far apart to allow up-to-the-minute decisions on case management. Finally, some patients who may be too ill to travel to the radiology suite might benefit from a bedside procedure that would yield information about swallowing function similar to that provided by the modified barium swallow. Videoendoscopic evaluation of dysphagia (VEED) is a protocol I developed and have used regularly since 1984. Experience with this method of dysphagia evaluation has shown that it answers the needs outlined above. Its usefulness also goes beyond that of the modified barium swallow by providing a more detailed understanding of the component anatomic and functional deficits that comprise a given patient's swallowing problem, information about upper aerodigestive tract sensory deficits, and a means for visual feedback training of pharyngeal and laryngeal musculature. The protocol is reviewed here. Case reports illustrating the clinical usefulness of VEED as an adjunct to the modified barium swallow are also presented, and the relative strengths and weaknesses of VEED and the modified barium swallow are compared.     

Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy

BACKGROUND: Pharyngocutaneous fistula is the most common complication following total laryngectomy. The present study was designed to determine the incidence and predisposing factors and to describe the management of the complication. METHODS: The records of 246 consecutive patients who underwent total laryngectomy for squamous cell carcinoma were reviewed. We evaluated 23 factors potentially predisposing to fistula formation (age, sex, smoking and drinking habits, hypertension, diabetes, chronic bronchitis, chronic congestive heart failure, anesthesiologic risk, cholinesterase level, pre- and postoperative hemoglobin and albumin levels, previous treatment, previous tracheotomy, site of origin of the tumor, surgical procedure, concurrent neck dissection, suture material, status of surgical margins, clinical stage, and histologic grade) using the chi-squared test and logistic regression analysis. RESULTS: A pharyngocutaneous fistula developed in 16% of patients within a mean time of 11 days from surgery. Spontaneous closure with local wound care was achieved in 70% of cases. Ten patients required surgical closure by direct suture of the pharyngeal mucosa; a deltopectoral flap and a pectoralis major myocutaneous flap were used in one case each. The mean healing time was 39+/-46 days in the group of patients requiring surgical closure, compared with 19+/-12 days in the group in which spontaneous closure occurred. The definitive model of logistic regression analysis showed that pharyngolaryngectomy, chronic congestive heart failure, and postoperative hemoglobin level lower than 12.5 g/dL carried respectively a two-, five-, and ninefold increase in the risk of fistula development. The model, with a specificity of 81%, is fairly good in identifying patients with a low risk of fistula. CONCLUSIONS: The results observed in the group of patients under analysis corroborated the relevance of factors such as the extension of laryngectomy and postoperative hemoglobin level on fistula occurrence. However, chronic congestive heart failure, which is an expression of disturbance of the organism, emerged for the first time as an additional statistically significant risk factor for pharyngocutaneous fistula formation. Our experience confirmed that most fistulas can be successfully managed with conservative treatment. Except for the rare cases in which large defects are present, direct suture is appropriate when conservative treatment has failed.     

Early detection and treatment of postoperative pharyngocutaneous fistula.

Fever during the early postoperative period traditionally has not been considered an indication of a postoperative wound infection or breakdown. Atelectasis is considered the most likely source for these early fevers. We studied 200 consecutive patients who underwent major head and neck surgery that involved reconstruction with a pharyngeal suture line. Patients were divided into 2 groups: those who had preoperative irradiation and those who did not. All patients had prophylactic antibiotic coverage, and all patients had identical suture material for closure. We showed a high correlation between fever (>101.5 degrees F) that developed in the first 48 hours and eventual fistula formation and wound infection. We also studied length of hospitalization and number of days until decannulation and resumption of oral feedings. Our data indicate that in those patients in whom fistulas developed, early detection led to earlier healing and rehabilitation.     

Examination of swallowing after total laryngectomy using manofluorography

Investigation of postlaryngectomy dysphagia is usually limited to the standard barium swallow. Manofluorography (mano, manometry; fluoro, videofluoroscopy; graphy, picture) is a new technique that permits analysis of simultaneous manometry and videofluoroscopy of deglutition. Manofluorography provides more detailed analysis of the swallowing dynamics during the pharyngeal stage of deglutition than either barium studies or manometry used alone. This study uses manofluorography to examine swallowing in two patient groups, total laryngectomees and total laryngectomees with tongue impairment, to analyze the role of various anatomic components in the swallowing process. Pharyngeal transit times were prolonged in both patient groups studied, with the tongue impairment group exhibiting the longest times. The postlaryngectomy pharynx offered greater resistance to bolus flow. The laryngectomy patients compensated by using increased lingual propulsion, whereas the patients with tongue impairment and total laryngectomy could not. This emphasizes the importance of the tongue in bolus propulsion in the pharynx. Other postoperative changes in swallowing are discussed.     

Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records.

Pharyngocutaneous fistula is the most common complication of total laryngectomy. The management of this problem increases hospitalization time and delays initiation of postoperative radiotherapy, where indicated. To identify factors predisposing to the development of pharyngocutaneous fistula, we reviewed the postoperative courses of 293 patients who underwent total laryngectomy at our clinic. General factors taken into account were concurrent diseases such as diabetes, liver diseases, or chronic anemia; local factors included radiotherapy before and after surgery, preoperative tracheostomy, type of cervical lymph node removal, and method of pharyngeal closure. We then compared our data with those reported in the literature by other authors. Last, we applied the Fisher exact test to a correlation we found between the higher incidence of fistula in patients with diabetes, liver diseases, or anemia. The local factor that turned out to be statistically most significant for the development of fistula was preoperative radiotherapy.     

Acute suppurative thyroiditis with bilateral piriform sinus fistulae.

Although there are many possible routes of infection in AST, the clinician must be aware of a possible fistula between the piriform sinus and the perithyroidal space--especially in patients with recurrent episodes of AST. Diagnosis of this congenital tract requires a high index of suspicion and radiographic demonstration by a barium swallow or endoscopic visualization. Effective treatment of AST with intravenous antibiotics and appropriate surgical intervention have greatly reduced the mortality and secondary complications. Complete fistulectomy, however, is required for permanent cure.     

Treatment of pharyngocutaneous fistulae with a cork-design radial forearm free flap

Pharyngocutaneous fistula is a dreaded complication after ablative surgery of the aerodigestive tract including the pharynx and larynx. This is a common problem for the surgeon. Two cases are presented with pharyngocutaneous fistula developing after total laryngectomy and radiation therapy. The fistula was reconstructed using a cork-design radial forearm free flap. Total obliteration of the fistula was obtained without complications. This new design provides the following advantages: extensive contact area between the flap and the inflamed surrounding tissue, discontinuity between the suture lines of the inner lining and the outer cover, and reinforcement of the suture line of the outer covering with skin graft. This method can be useful in reconstructing irradiated pharyngocutaneous fistulas.     

Aspiration: cause and implications.

The purpose of this investigation was to determine the overall prevalence of aspiration in dysphagic individuals referred for a modified barium swallow and the underlying anatomic and/or physiologic causes. A total of 166 patients were seen during a 1-month period at 5 participating institutions. Aspiration was detected in 51.2% of the patients. The most common causes were decreased laryngeal elevation and delayed triggering of the pharyngeal motor response. A history of aspiration pneumonia was significantly associated with the presence of aspiration on modified barium swallow study. The presence of a protective cough was present in only 53% of patients who aspirated, reinforcing the need for appropriate radiologic assessment in patients with suspected dysphagia.     

Recurrent tracheoesophageal fistula

Three cases of recurrent tracheoesophageal fistula have been added to the 64 reported in the literature. Recurrence is suspected in patients with a previous repair who develop recurrent pneumonia, asthmatic attacks, or choking spells. The diagnosis can be established by barium swallow roentgenography or, in difficult cases, by staining of the esophagus by contrast medium introduced into the trachea. Prevention is best accomplished by an accurate repair without tension, by strict adherence to aseptic techniques, and by using fine, nonabsorbable suture material. The interposition of a pleural flap between the trachea and esophagus diminishes the chance of an initial recurrence and is very useful at the time of reoperation for a recurrent fistula.     

A modified method of laparoscopic side-to-side esophagojejunal anastomosis: report of 14 cases

Background  Alimentary tract reconstruction after laparoscopic total gastrectomy is a technical challenge. Although feasible, reconstruction through a small incision has several drawbacks. The authors therefore report a modified method of laparoscopic side-to-side esophagojejunal anastomosis developed at their hospital. Methods  The side to side esophagojejunal anastomosis was completed with a endo-GIA firing, followed by transection of the jejunum and esophagus with another firing of endo-GIA. Results  This modified procedure was performed successfully for 14 patients with gastric cancer. The mean operation time for this procedure was 42.5 ± 10.2 min. No postoperative death, fistula, or hemorrhage occurred. All the patients were followed up for a mean period of 14.5 months with no cancer recurrence at the anastomosis or anastomotic stricture. All the patients had a barium swallow test 6–2 months after the operation. The mean maximum diameter of the anastomosis was 3.8 cm (range, 3.0–4.2 cm). Four patients experienced temporary symptoms of dumping syndrome or dysphagia, which disappeared 6 months postoperatively. Conclusion  The authors consider this modified laparoscopic side-to-side esophagojejunal anastomosis to be safe, less challenging, and more economical, providing an alternative for alimentary tract reconstruction after laparoscopic total gastrectomy.     

Esophageal perforation from anterior cervical screw migration

BACKGROUND: Esophageal perforation from anterior cervical instrumentation migration is an uncommon but potentially highly morbid or even fatal complication. Early recognition and aggressive investigation and treatment are essential to ensure good outcome. CASE DESCRIPTION: A 58-year-old man underwent C6 vertebrectomy and C5-7 interbody fusion with a cage and anterior cervical plate. After surgery he developed fever and recurrence of his symptoms and deficits, but was managed expectantly. He was then referred to the author's institution. A barium swallow demonstrated an esophageal fistula (a Gastrograffin swallow was falsely negative) caused by a migrated screw; serial radiographs confirmed its passage through the gastrointestinal tract. Revision surgery was required to repair the perforation and reconstruct the cervicothoracic spine. Intraoperative esophageal injection of methylene blue was helpful in demonstrating the site of leakage. Despite a prolonged postoperative course complicated by pulmonary embolus, the patient recovered with minimal residual deficit, and continues to do well 2 years later. CONCLUSIONS: A high index of suspicion followed by aggressive investigation are crucial in the setting of unexpected neck pain, new neurologic deficit, fever, or swallowing difficulties in the early postoperative period after anterior cervical spine instrumentation. If esophageal perforation is suspected, a barium swallow is recommended over Gastrograffin, which, although less irritating to the surrounding tissues, may be falsely negative. Intraoperative methylene blue injection into the esophageal lumen is useful in identifying the site of perforation.     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

Paraprosthetic-enteric fistula.

A case of paraprosthetic-enteric fistula is presented and the total reported literature of 21 cases is reviewed. Paraprosthetic-enteric fistula is a complication of aortic revascularization with synthetic prostheses. The entity is characterized by erosion of the gastrointestinal tract by an underlying prosthesis but absence of a true fistulous communication with the aortic lumen. It is both a distinct pathologic entity and a step in the formation of a true aortoenteric fistula with suture line involvement. The most frequent clinical manifestations are sepsis and gastrointestinal bleeding, but nonspecific abdominal pain is present occasionally as well. The distal duodenum is the portion of the gastrointestinal tract involved most commonly. Diagnostic evaluation should include endoscopy, aortography, and barium contrast studies. Venous and femoral arterial blood cultures also should be done in patients presenting with sepsis. Treatment should consist of either graft excision with extra-anatomic revascularization or graft excision alone when dealing with a previously thrombosed prosthesis.     

Recovery of postoperative swallowing in patients undergoing partial laryngectomy

This study assessed the achievement of postoperative swallowing in patients undergoing partial laryngectomy surgery. Oropharyngeal swallow efficiency was used to predict time to achievement of outcome. Fifty-five patients were followed for up to 1 year in two hemilaryngectomy and four supraglottic laryngectomy groups. Within 10 days of healing, a videofluoroscopic evaluation enabled the measurement of swallowing efficiency. Times to achievement of oral intake, removal of feeding tube, preoperative diet, and normal swallow were analyzed using actuarial curves. Patients with hemilaryngectomies achieved swallowing rehabilitation sooner than patients with nonextended supraglottic laryngectomies (p < .05) who, in turn, achieved swallowing function sooner than did patients undergoing supraglottic laryngectomies with tongue base resection (p < .05). Median time to attainment of preoperative diet in these three groups was 28 days, 91 days, and > 335 days, respectively. Higher early postoperative oropharyngeal swallow efficiency was related to earlier achievement of oral food intake and of preoperative diet (p < .05). Results show that the time course for swallowing rehabilitation covers an extended postoperative period. In some surgical groups, functional swallowing and eating may be achieved within 3 months of surgery while for other types, significant impairment remains up to 9 months postoperatively. Early radiographic assessments of swallowing function are useful in predicting the time to swallow recovery. Recovery of swallowing ability may be delayed in patients who have not achieved oral intake before radiotherapy is started.     

Oral feeding after total laryngectomy

Pharyngocutaneous fistulae occur in 15%-25% of patients after total laryngectomy. Factors that may predispose to fistulae formation include prior radiation, surgical technique, tumor size and location, and patient nutritional status. In addition, many surgeons believe that the timing of oral feeding after surgery contributes to fistula development. Thus, they advocate delaying feeding postoperatively, especially in high-risk patients. The traditional guideline has been to wait until the seventh postoperative day. The purpose of this study was to examine the relationship between the timing of postoperative oral feeding and the development of pharyngocytaneous fistulae after total laryngectomy with primary closure in patients with squamous cell carcinoma. A questionnaire was sent to 210 members of the American Society for Head and neck Surgery to determine practice patterns toward feeding after laryngectomy. We also reviewed the records of 137 patients who underwent total laryngectomy at the University of Colorado Health Sciences Center and the Denver VA Medical Center from January 1975 through December 1987. Of the surgeons polled, 84.5% waited at least 7 days after surgery to begin oral feeding. However, in reviewing 94 patients eligible for study, we found no difference in the rate of fistula formation between patients fed on or before the fifth postoperative day and those fed on or after the sixth postoperative day. In fact, most fistulae were evident before the patient started oral feeding. Pyriform sinus tumors were predisposed to fistulae but prior radiotherapy and neck dissection seemed to have no effect. Earlier oral feeding after total laryngectomy may improve patient comfort and shorten hospital stay without increasing the incidence of complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical repair of a vesicovaginal fistula guided by a black braided silk suture line

The purpose of the study was to evaluate the effect of the identification of the margins of a vesicovaginal fistula (VVF) during its repair by passing a black braided silk suture line through the fistula. During the repair of a VVF, a suture line was placed through the fistula. By passing the suture line from the vagina through the fistula tract into the bladder and hence to the outside through the urethral meatus, the circumference of the VVF opening can be easily identified after dissection and excision of the vaginal wall around the fistula opening. There were four VVF patients who underwent a modified Latzko procedure using the thread to guide surgical repair. The operation times and blood loss were 45–90 min and no more than 50 ml, respectively. This trick provides adequate identification of the fistula tract, thus permitting safe and easy fistula repair for a narrow, deep, or atrophic vagina.     

Guided digestive fistula. Complementary method in prophylactic and curative postoperative peritonitis

Guided fistula (or sinus tract) techniques, which are a nowadays a controversial topic, comprise a group of simple surgical methods of postoperative peritonitis treatment. This retrospective study is an attempt to bring further insights into the literature debate on the utility of the aforementioned techniques by presenting Craiova C.F.R. General Surgery Department 7 years (from 1991 through 1998) experience with 26 operated on patients, who underwent digestive guided fistulas too. In 16 of our study patients sinus tracts were created for postoperative peritonitis prophylactis purpose, whereas digestive guided fistulas, which were performed in the other 10 patients, were meant to treat peritonitis secondary to anastomosis breakdown. In 87% of pur series of digestive guided fistula patients the postoperative outcome was satisfactory. Three deaths were recorded only among the nonprophylactic sinus tract patients. Guided fistula method is an useful adjunct of the complex, well-codified management of postoperative peritonitis including its efficient prevention.     

25-year experience of using a linear stapler in laryngectomy

BACKGROUND: Stapler application for pharyngeal closure after total laryngectomy allows for rapid watertight closure without field contamination and for potentially reduced fistula rate. METHODS: One thousand four hundred fifteen patients underwent laryngectomy with linear stapler closure. In 98.6%, laryngectomy was performed after radiation failure. RESULTS: A relatively high incidence of pharyngeal fistulae (12%) was seen, although these rates were reduced to 5.5% during the recent decade. Simultaneous creation of tracheoesophageal fistula and myotomy by a novel technique was introduced. Swallowing problems were observed in 11 patients and local recurrences in nine patients (0.6%). CONCLUSION: The advantages of mechanical sutures with the closed stapling technique are simple and rapid application, watertight closure with good hemostasis, prevention of field contamination, good speech and deglutition, no increase in fistula rate, and low local recurrence rates. Operating room expenses may also be significantly reduced, rendering this method cost-effective as well.     

Repair of a large pharyngocutaneous fistula with a free jejunal patch flap after salvage laryngectomy: A case report

Preoperative chemoradiation therapy increases the risk of pharyngocutaneous fistula (PCF) after laryngectomy. In this report, we describe the use of a free jejunal patch flap and a deltopectoral flap for surgical treatment of a large PCF. A 52‐year‐old man underwent salvage laryngectomy and right neck dissection after concurrent radiotherapy for laryngeal carcinoma. On postoperative day 5, a pharyngeal fistula and neck abscess occurred with the right internal jugular vein thrombosis. We sutured the pharyngeal mucosa to the cervical skin to avoid carotid artery exposure, and we also ligated the right internal jugular vein. The PCF developed afterwards. The patient was being fed through a nasogastric tube and the fistula had increased in size. At the time of surgery, the external orifice became 5 cm × 5 cm in size. We performed the repair with a free jejunal patch flap and a deltopectoral flap. The harvested jejunum was opened along its antimesenteric border to design a sufficient free jejunal flap to cover the large PCF. A deltopectoral pedicled flap was used to reconstruct the neck skin defect to resurface the free jejunal patch flap. Both flaps survived. The patient could resume an oral diet 2 weeks after surgery. At 1 month after surgery, the skin pedicle of the deltopectoral flap was divided. There was no contracture or stricture 3 years after surgery and he maintained a regular diet. Reconstruction with a free jejunal patch flap and a deltopectoral flap may be a suitable method for repair of a large PCF. © 2014 Wiley Periodicals, Inc. Microsurgery 37:61–65, 2017.