Cancer recurrence after total laryngectomy: treatment options, survival, and complications

BACKGROUND: A follow-up schedule to detect asymptomatic cancer recurrence is offered to all patients with laryngeal cancer. In this study, the therapeutic options, prognosis, and morbidity of patients with total laryngectomy, who were found to have cancer recurrence during this follow-up schedule were determined. METHODS: Patients who had undergone a total laryngectomy between January 1, 1990, and January 1, 2000, and had cancer recurrence were included. Data from this group were analyzed retrospectively. RESULTS: The prognosis was poor after the development of cancer recurrence. Curative therapy could only be offered to 27.5% of these patients. Only 5% of the patients were disease free at the end of the study period. Many patients with cancer recurrence needed interventions. A large proportion of them had complications. CONCLUSIONS: The follow-up schedule offered to patients after total laryngectomy should put greater emphasis on care than on early detection of cancer recurrence.     

Conservation laryngeal surgery versus total laryngectomy for radiation failure in laryngeal cancer

BACKGROUND: Total laryngectomy is the standard of care for surgical salvage of radiation failure in laryngeal cancer. However, the role of conservation laryngeal surgery in this setting remains unclear. The objective was to compare the efficacy of conservation versus total laryngectomy for salvage of radiation failure in patients who initially presented with T1 or T2 squamous cancer of the larynx. METHODS: A 21-year retrospective analysis of patients who received surgery at a single comprehensive cancer center after definitive radiation therapy is reported. At recurrence, the patients were reevaluated and then underwent a total laryngectomy or, if possible, a conservation laryngeal procedure. The charts of 105 patients who failed radiation treatment for primary laryngeal cancer and who subsequently underwent surgical salvage were reviewed for this study. Eighty-nine were male (84.8%). The mean age was 60.3 years. The median follow-up time after surgery was 69.4 months. Most patients with recurrence after radiotherapy required total laryngectomy (69.5%; 73/105). Conservation laryngeal surgery was performed for 32 patients (31.5%). Concomitant neck dissections were performed on 45 patients (45.5%). RESULTS: In 14 patients, local or regional recurrence developed after salvage surgery: 9 patients after total laryngectomy (12.3%; 9/73), and 5 patients (15.6%; 5/32) after conservation laryngeal surgery. This difference was not statistically significant, nor was there a difference in disease-free interval for the two procedures (p = .634, by log-rank test). Distant metastasis developed in 13 patients. Most developed in the setting of local and/or regional recurrence, but distant metastasis occurred as the only site of failure in 6 of the patients who had undergone total laryngectomy but in 1 of the conservation surgery patients treated for a supraglottic laryngeal cancer. The overall mortality for patients who underwent total laryngectomy was also higher: 73.74% (54/73) versus 59.4% (19/32) for patients who underwent a conservation approach (p = .011 by log-rank test). CONCLUSIONS: Although conservation laryngeal surgery was possible in a few patients with local failure after radiotherapy, conservation laryngeal surgery is an oncologically sound alternative to total laryngectomy for these patients.     

Comparison of pharyngoesophageal segment pressure in total laryngectomy patients with and without pharyngeal neurectomy

BACKGROUND: To compare pharyngoesophageal segment (PES) pressure values in total laryngectomy patients with and without pharyngeal neurectomy (PN) in the early postoperative period. METHODS: Forty-five previously untreated laryngeal carcinoma patients were enrolled into this prospective randomized study. Twenty of them underwent total laryngectomy with PN, and 25 underwent total laryngectomy without PN. PES pressures were measured on the tenth postoperative day with a four-channel catheter. RESULTS: Average PES pressures in patients with and without pharyngeal neurectomy were 12.82 +/- 6.11 mmHg and 17.40 +/-.72 mmHg respectively (p <.05). When compared with the critical point of 20 mmHg that is closely related to voice attainment in the group without pharyngeal neurectomy, 10 (40%) patients had pressure levels greater than 20 mmHg and in the other group only 1 (5%) patient had a pressure level greater than 20 mmHg. The difference between the groups with pressure levels greater than 20 mmHg was found to be statistically significant (p <.05). CONCLUSIONS: Pharyngeal neurectomy results in a statistically significant decrease of PES pressures in total laryngectomy patients.     

Isolated cervical esophageal reconstruction for rare esophageal tumors

BACKGROUND: Isolated defects in the cervical esophagus in patients who have not undergone total laryngectomy are uncommon. We report 2 cases of rare esophageal tumors requiring reconstruction of the cervical esophagus after tumor resection. METHODS AND RESULTS: The patients were a 51-year-old woman with an esophageal granular cell tumor and a 54-year-old woman with an esophageal schwannoma. Both defects were reconstructed with a radial forearm flap. A small subclinical leak developed in 1 patient and healed spontaneously within 2 weeks. At 1 year and 2 years of follow-up, both patients were consuming a normal diet and had normal voices. CONCLUSIONS: A thin and well-vascularized flap such as the radial forearm flap is essential for reconstructing an isolated cervical esophageal defect so as to maximize functional outcome.     

Prognosis of recurrent laryngeal carcinoma after laryngectomy

Background. Recurrence is common after total laryngectomy for advanced laryngeal carcinoma. The aim of the present study was to review the prognosis of recurrent laryngeal carcinoma after total laryngectomy. Methods. The records of 165 patients who developed recurrences after total laryngectomy for laryngeal squamous cell carcinoma between January 1971 and December 1990 were reviewed. Results. Of the 165 patients who developed recurrences, 34 (21%) patients had surgical salvage. The sites of recurrence of these 34 operable patients included 11 pharyngeal, 3 tracheostomal, 15 nodal, 2 pharyngeal with nodal, and 3 pulmonary metastasis. Pharyngeal recurrence had the highest salvage rate, followed by nodal and pulmonary recurrence. All patients with tracheostomal had recurrence after salvage surgery. After the surgical salvage, the tumor recurrence rate was 44% and the 5-year actuarial survival rate was 42%. Of the other 131 patients who had palliative treatment without surgical salvage, the 5-year actuarial survival rate was 2%. Conclusions. The present study showed that patients who had surgical salvage for recurrent tumor after total laryngectomy had satisfactory prognosis. Close follow-up of patients after initial operation is essential to detect recurrence early, while surgical salvage is still feasible.     

Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx.

OBJECTIVE: Stomal recurrence after total laryngectomy is one of the most serious issues in the management of laryngeal carcinoma. The management of stomal recurrence, including chemotherapy, radiotherapy, and surgery, has been reported as unsatisfactory. STUDY DESIGN AND SETTING: From 1985 to 1995, 69 patients underwent total laryngectomy for the treatment of laryngeal cancer at the University of Tokyo Hospital. To identify the risk factors for stomal recurrence, we analyzed these patients according to various clinicopathological factors. RESULTS: Stomal recurrence developed in 6 of 69 patients who underwent total laryngectomy for laryngeal carcinoma. Statistical analysis reveals that primary site, preoperative tracheotomy, and paratracheal lymph node metastasis are significant risk factors for stomal recurrence. CONCLUSION: Intensive follow-up should be performed for patients with glottic carcinoma who had preoperative tracheotomy, paratracheal lymph node metastasis, or both to detect stomal recurrence at an early stage.     

Is total glossectomy for advanced carcinoma of the tongue justified?

Total glossectomy (with or without total laryngectomy) followed by postoperative radiotherapy remains the principal treatment method for advanced base of tongue carcinoma. The procedure remains controversial owing to poor cure rates and the inevitable functional deficits associated with it. However, even though total glossectomy is a major surgical procedure that impacts on speech, deglutition and quality of life, it may offer patients the best chance of cure in many centres, especially in the developing world. METHODS: We did a retrospective chart review of all patients at Groote Schuur Hospital, Cape Town, who had undergone total glossectomy, with or without total laryngectomy, for stage IV squamous cell carcinoma (SCC) of the tongue between 1998 and 2004. RESULTS: Eight patients had a total glossectomy performed during the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients respectively were alive without disease. No patient required permanent nasogastric or gastrostomy feeding, and all returned to a full oral diet. Three of 5 patients who had laryngeal preservation and could be assessed for speech had intelligible speech. All but 1 patient (88%) reported pain relief following surgical excision. Perineural invasion was present in 75%, and 38% had positive resection margins. Five patients had recurrence, 2 cervical, 1 local, and 2 local and cervical. CONCLUSION: Advanced SCC of the tongue is a devastating disease causing severe pain and disorders of speech and swallowing. Total glossectomy (with or without total laryngectomy) and postoperative radiotherapy is a reasonable treatment option, particularly in the developing world setting. It has cure rates superior to primary radiotherapy, and provides motivated patients with excellent pain relief and a reasonable quality of life.     

Clinical and histologic follow-up after antireflux surgery for Barrett's esophagus.

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett's esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett's esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett's esophagus required preoperative endoscopic evidence of columnar-lined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett's esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett's esophagus. A substantial number of patients with Barrett's esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy.     

Randomized trial of argon plasma coagulation versus endoscopic surveillance for barrett esophagus after antireflux surgery: late results

OBJECTIVE: To determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett esophagus. SUMMARY BACKGROUND DATA: APC has been used to ablate Barrett esophagus. However, the long-term outcome of this treatment is unknown. This study reports 5-year results from a randomized trial of APC versus surveillance for Barrett esophagus in patients who had undergone a fundoplication for the treatment of gastroesophageal reflux. METHODS: Fifty-eight patients with Barrett esophagus were randomized to undergo either ablation using APC or ongoing surveillance. At a mean 68 months after treatment, 40 patients underwent endoscopy follow-up. The efficacy of treatment, durability of the neosquamous re-epithelialization, and safety of the procedure were determined. RESULTS: Initially, at least 95% ablation of the metaplastic mucosa was achieved in all treated patients. At the 5-year follow-up, 14 of 20 APC patients continued to have at least 95% of their previous Barrett esophagus replaced by neosquamous mucosa, and 8 of these had complete microscopic regression of the Barrett esophagus. Five of the 20 surveillance patients had more than 95% regression of their Barrett esophagus, and 4 of these had complete microscopic regression (1 after subsequent APC treatment). The length of Barrett esophagus shortened significantly in both study groups, although the extent of regression was greater after APC treatment (mean 5.9-0.8 cm vs. 4.6-2.2 cm). Two patients who had undergone APC treatment developed a late esophageal stricture, which required endoscopic dilation, and 2 patients in the surveillance group developed high-grade dysplasia during follow-up. CONCLUSIONS: Regression of Barrett esophagus after fundoplication is more likely, and greater in extent, in patients who undergo ablation with APC. In most patients treated with APC the neosquamous mucosa remains stable at up to 5-year follow-up. The development of high-grade dysplasia only occurred in patients who were not treated with APC.     

CO2-laser treatment of recurrent glottic carcinoma.

BACKGROUND: Evaluation of the results of CO2 laser treatment of recurrent glottic carcinoma after radiotherapy. METHODS: Records of all patients treated in the University Hospital Rotterdam and the Dr. Daniel den Hoed Cancer Center between 1980 and 1996 by CO2 laser for recurrent glottic carcinoma were studied. RESULTS: Forty patients were treated by laser surgery. Average follow-up was 77 months. Twenty-three patients (58%) had another recurrence develop after laser surgery. Three were cured by a second laser procedure. Therefore, 20 patients (50%) were successfully treated with laser surgery. In 23 patients the recurrence did not extend into the anterior commissure; in 57% a total laryngectomy could be avoided. In 17 patients the recurrence did extend into the anterior commissure; in 41% a total laryngectomy was avoided. CONCLUSION: Most patients with recurrent carcinoma of the larynx after radiotherapy can be cured by laser surgery if the tumor does not extend into the anterior commissure.     

Outcome after partial frontolateral laryngectomy

The purpose of this study was to determine the recurrence rate and the long-term survival of patients treated with frontolateral laryngectomy for early glottic cancer. The study is a retrospective analysis of a cohort of patients who underwent frontolateral laryngectomy from 1995 to 2002 with a median follow-up of 48 months. This was a consecutive series of 30 patients with T1bN0 and T2N0 vocal fold carcinoma. Previously treated patients were excluded. Surgical treatment consisted of frontolateral partial vertical laryngectomy and reconstruction with bipedicle sternohyoid muscle flap. Twenty-five patients have been alive with no evidence of the disease. The median follow-up was 48 months (range, 6-85 months). Five patients experienced local recurrence. One of them underwent salvage partial hemilaryngectomy, and 4 underwent wide-field total laryngectomy with adjuvant postoperative radiation therapy. Four of five patients with retreatment were ultimately salvaged, with a median follow-up of 30 months. We had one death caused by the disease. Frontolateral laryngectomy is an efficient treatment for selected cases of early glottic carcinoma.     

Clinical and histologic follow-up after antireflux surgery for Barrett’s esophagus

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett’s esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett’s esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett’s esophagus required preoperative endoscopic evidence of columnarlined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett’s esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett’s esophagus. A substantial number of patients with Barrett’s esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation).     

How are those “lost to follow-up” patients really doing? A compliance comparison in arthroplasty patients

AIM: To determine whether there is a functional difference between patients who actively follow-up in the office (OFU) and those who are non-compliant with office follow-up visits (NFU).METHODS: We reviewed a consecutive group of 588 patients, who had undergone total joint arthroplasty (TJA), for compliance and functional outcomes at one to two years post-operatively. All patients were given verbal instructions by the primary surgeon to return at one year for routine follow-up visits. Patients that were compliant with the instructions at one year were placed in the OFU cohort, while those who were non-compliant were placed in the NFU cohort. Survey mailings and telephone interviews were utilized to obtain complete follow-up for the cohort. A χ² test and an unpaired t test were used for comparison of baseline characteristics. Analysis of covariance was used to compare the mean clinical outcomes after controlling for confounding variables.RESULTS: Complete follow-up data was collected on 554 of the 588 total patients (93%), with 75.5% of patients assigned to the OFU cohort and 24.5% assigned to the NFU cohort. We found significant differences between the cohorts with the OFU group having a higher mean age (P = 0.026) and a greater proportion of females (P = 0.041). No significant differences were found in either the SF12 or WOMAC scores at baseline or at 12 mo postoperative.CONCLUSION: Patients who are compliant to routine follow-up visits at one to two years post-operation do not experience better patient reported outcomes than those that are non-compliant. Additionally, after TJA, older women are more likely to be compliant in following surgeon instructions with regard to follow-up office care.     

Supracricoid laryngectomy with CHEP: functional results and outcome.

OBJECTIVES: To assess whether supracricoid laryngectomy with cricohiodoepiglottopexy could successfully reach the cure and preserve the voice in glottic laryngeal cancer, we studied 27 patients with T2/T3 squamous cell carcinoma of the larynx treated in our institution with cricohiodoepiglottopexy. STUDY DESIGN: A retrospective analysis has been carried out between 1995 through 1997. We classified 11 patients as T2N0M0 and 16 patients as T3N0M0. Nineteen patients had bilateral selective lateral neck dissection, 3 patients had unilateral lateral neck dissection, and 5 patients had undissected neck. Survival was analyzed under the Kaplan-Meyer method. RESULTS: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3. CONCLUSIONS: This technique is useful in the treatment of selected cases of T3/T2 glottic cancer regarding the extent of disease. The incidence of complications in need of a complete laryngectomy does not compromise the functionality of this technique. The survival is comparable to patients who submitted to total laryngectomy and near-total laryngectomy, regarding the extent of the lesion.     

Long-term follow-up of cartilaginous tumors of the larynx.

BACKGROUND: Cartilaginous tumors of the larynx are uncommon. A literature review disclosed approximately 250 cases since 1816; the cricoid cartilage is the most common site. The rarity of these tumors has made for limited experience and, as a consequence, our knowledge is incomplete. OBJECTIVE: To report surgical results as well as long-term follow-up on 6 patients with cartilaginous tumors of the larynx. DESIGN: A 28-year retrospective study with the patients followed-up from 6 to 28 years (average, 17.8 years). METHODS: Six adult white male patients with cartilaginous tumors of the larynx: 4 low-grade chondrosarcoma (1 of the thyroid and 3 of the cricoid) and 2 chondroma of the cricoid. Surgical treatment included total laryngectomy of the thyroid and 1 of the cricoid chondrosarcoma, and conservation surgery of the other 4 cricoid tumors: the 2 patients with chondrosarcoma had total resection of the cricoid cartilage with thyrotracheal anastomosis, and the 2 patients with chondroma had local tumor resection using a laryngofissure approach. RESULTS: The margins of the specimen were negative for tumor in the 6 patients. On follow-up, none of the patients had regional or distant metastasis or tumor-related death. One of the patients with cricoid chondrosarcoma developed recurrence 8 years after conservation surgery, and required a total laryngectomy for salvage. Survival rate tumor-free at 5 years was 100% and at 10 years 67%, co-morbidity being responsible for the decrease in survival rate. CONCLUSIONS: Based on this small series of patients, the long-term follow-up of benign and low-grade malignant tumors suggests that the surgical approach and prognosis does not depend on histologic distinction and, importantly, underdiagnosed malignancy on tumor sampling and recurrent chondrosarcoma, managed with salvage surgery, have no adverse impact on patient survival. Total resection of the cricoid cartilage with thyrotracheal anastomosis over a stent proved an alternative surgical technique in chondrosarcoma who otherwise would have been treated by total laryngectomy.     

Primary placement of a voice prosthesis on transposed colon after total pharyngolaryngoesophagectomy.

BACKGROUND: Primary placement of a voice prosthesis may aid rehabilitation after total laryngectomy. Methods: We present a rare clinical situation of a T4 NO MO squamous cell carcinoma of the hypopharynx and esophagus in a patient who had previously undergone a transmesocolic Billroth II gastrectomy. RESULTS: The patient benefited from a total pharyngolaryngoesophagectomy, with reconstruction using a transverse-descending colon transposition, and primary placement of a low-pressure voice prosthesis. CONCLUSION: Primary placement of a voice prosthesis may be successful even in a patient who requires extensive pharyngoesophageal reconstruction using transposed colon. To our knowledge, there has been no previous report of primary placement of a voice prosthesis on a colon autograft.     

Radionecrosis or tumor recurrence after radiation of laryngeal and hypopharyngeal carcinomas

OBJECTIVE: To analyze the incidence and diagnostic difficulties of radionecrosis vs tumor recurrence of laryngeal and hypopharyngeal carcinomas. STUDY DESIGN AND SETTING: Retrospective study on 341 patients treated by radiation alone or radiochemotherapy. The clinicopathologic findings, work-up, treatment, and follow-up of 20 patients with symptoms suggestive but negative for tumor recurrence on initial imaging studies and endoscopy were analyzed. RESULTS: The incidence of chondroradionecrosis in 341 irradiated patients was 5%. Ten of 20 patients initially negative for tumor recurrence were treated by total laryngectomy; in all laryngectomy specimens, chondroradionecrosis was present, in six specimens associated with tumor recurrence. Ten patients were treated by tracheotomy and tumor recurrence was detected in one patient during follow-up. CONCLUSION: Chondroradionecrosis is a relatively rare treatment complication. Typical imaging findings suggestive of radionecrosis are often missing. Tumor recurrence may be present beneath an intact mucosa and missed by endoscopy.     

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.     

Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus in patients with fundoplications

Background Endoscopic endoluminal radiofrequency ablation using the Barrx device is a new technique to treat Barrett’s esophagus. This procedure has been used in patients who have not had antireflux surgery. This report is presents an early experience of the effects of endoluminal ablation on the reflux symptoms and completeness of ablation in post-fundoplication patients. Methods Seven patients who have had either a laparoscopic or open Nissen fundoplication and Barrett’s esophagus underwent endoscopic endoluminal ablation of the Barrett’s metaplasia using the Barrx device (Barrx Medical, Sunnyvale, CA). Preprocedure, none of the patients had significant symptoms related to gastroesophageal reflux disease. One to two weeks after the ablation, patients were questioned as to the presence of symptoms. Preprocedure and postprocedure, they completed the GERD-HRQL symptom severity questionnaire (best possible score, 0; worst possible score, 50). Patients had follow-up endoscopy to assess completeness of ablation 3 months after the original treatment. Results All patients completed the ablation without complications. No patients reported recurrence of their GERD symptoms. The median preprocedure total GERD-HRQL score was 2, compared to a median postprocedure score of 1. One patient had residual Barrett’s metaplasia at 3 months follow-up, requiring re-ablation. Conclusions This preliminary report of a small number of patients demonstrates that endoscopic endoluminal ablation of Barrett’s metaplasia using the Barrx device is safe and effective in patients who have already undergone antireflux surgery. There appears to be no disruption in the fundoplication or recurrence of GERD-related symptoms. Nevertheless, longer-term follow-up with more patients is needed. Presented in part at the 2006 Annual Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons     

Manofluorography of deglutition after supraglottic laryngectomy

Manofluorography (mano: manometry, fluoro: videofluoroscopy, graphy: picture) provides a simultaneous display of manometry and fluoroscopy on one video screen. This study uses manofluorography to analyze the swallowing patterns of nine patients who had undergone supraglottic laryngectomy. The results show that during swallowing the pharyngeal mechanism for preventing aspiration depends upon three processes: (1) tight lingual-laryngeal contact, (2) coordination of the swallowing reflex, and (3) tongue base and pharyngeal constrictor clearing of the hypopharynx and laryngeal inlet. Anterior suspension of the larynx under the tongue base serves to improve lingual-laryngeal contact. This close contact during deglutition protects the airway from the bolus and also opens the postcricoid region, aiding bolus passage into the esophagus. Impairment of the swallowing reflex, which can cause severe aspiration before the swallowing reflex is triggered, can be rehabilitated by swallowing therapy. Minor aspiration is commonly caused by impaired clearing of the superior hypopharynx after supraglottic laryngectomy.