Voice restoration after total laryngopharyngectomy and cervical esophagectomy using the duckbill prosthesis

We have presented a series of 10 patients who were successfully rehabilitated using the tracheoesophageal puncture technique for voice restoration. These patients underwent total laryngopharyngectomy or laryngopharyngoesophagectomy and reconstruction with visceral transposition (five patients), myocutaneous flaps (four patients), and skin graft and cervical flaps (one patient). All patients were able to produce adequate voice and carry on a conversation. Clinical evaluation of voice quality and acoustic analysis of voice samples indicate that the voice obtained in these patients was intelligible, and had adequate intensity, low pitch, and limited pitch variation. There were no complications related to the voice restoration procedure. It appears from our data and the limited experience reported in the literature that the tracheoesophageal prosthesis can be used successfully and safely for the speech rehabilitation of patients who undergo total laryngopharyngectomy, cervical esophagectomy, or both, regardless of the reconstructive method used.     

Inflatable penile prostheses in patients undergoing cystoprostatectomy with urethrectomy

When urethrectomy is indicated in the male patient in combination with cystoprostatectomy for diffuse transitional cell carcinoma, an additional challenge to reconstruction and sexual rehabilitation will be encountered. Inflatable penile prostheses were implanted in 19 patients who had undergone cystoprostatectomy with prophylactic urethrectomy. Of the patients 13 underwent cystoprostatectomy with en bloc urethrectomy and delayed placement of an inflatable penile prosthesis. The remaining 6 patients required urethrectomy and simultaneous implantation of an inflatable penile prosthesis 6 to 12 weeks after radical cystectomy. All 19 patients healed appropriately and had an adequate functioning prosthesis. However, results in patients in whom the glandular urethra could be preserved safely were far superior to those in patients requiring total urethrectomy. This was so because of easier and improved cylinder placement with better support to the glans, increased glandular sensation and a more acceptable penile appearance. The inflatable penile prosthesis can be used successfully in the cystourethrectomy patient with gratifying results, especially when the glandular urethra remains intact.     

Total upper and lower eyelid reconstruction using deltopectoral flap

Total upper and lower eyelid unilateral full thickness reconstruction is a surgical challenge. A case of right orbital haemangioma with unilateral complete defect of total upper and lower eyelids with right orbital exenteration is reported, together with the surgical technique of reconstruction. Patient was a 24-year-old female who underwent right orbital exenteration with total upper and lower eyelid excision for orbital haemangioma presented after 3 weeks of the above procedure. In the first stage split thickness skin grafting is used to resurface orbital cavity raw area followed by staged reconstruction of total upper and lower eyelid reconstruction using pedicle deltopectoral flap. This reconstruction provided stable eyelid reconstruction to retain ocular prosthesis with concealed and minimal donor area. After reconstruction patient underwent rehabilitation with ocular prosthesis, now the patient is satisfied with cosmetically acceptable results.KEY WORDS: Deltopectoral flap, total eyelid reconstruction, total upper and lower eyelid reconstruction with DP flap     

Voice quality after recurrent laryngeal nerve resection and immediate reconstruction

Objective To evaluate clinician perception of voice quality, patient self-reported psychosocial impact of dysphonia, and glottic closure in patients who have undergone resection of the recurrent laryngeal nerve (RLN) and immediate operative reconstruction during thyroid surgery. Study Design Prospective observational study. Setting Single tertiary care hospital. Subjects and Methods Nine patients underwent immediate operative reconstruction of the RLN by the senior author from 2002 to present. Outcome measures included (1) perceptual voice ratings assessed using the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, (2) psychosocial impact of dysphonia assessed using the Voice Handicap Index (VHI), and (3) assessment of glottic closure from laryngeal videostroboscopy. Results The RLN was reconstructed with primary anastomosis (4), free nerve graft (3), or vagus-RLN anastomosis (2). Seven patients had voice samples and videostroboscopy examinations obtained at a minimum of 9 months from surgery. Six were judged to have slight disturbance of voice based on overall Grade scoring (G = 1). Five rated their voice as normal or mild on the VHI instrument (score range 8-29). Laryngeal analysis revealed the immobile vocal fold in the median, physiologic phonating position with preserved bulk, recovered tension, and glottic closure during phonation. Three patients less than 9 months from surgery had an expected severe self-reported rating of dysphonia. Conclusion Primary anastomosis, free nerve grafting, and vagus-RLN anastomosis are viable options for RLN reconstruction. Patients who undergo resection and immediate reconstruction of the RLN are able to regain self-perceived functional voices.     

Determination of intestinal viability by Doppler ultrasound.

The Doppler ultrasonic flowmeter was used to determine intestinal serosal and mesenteric blood flows in 130 patients who underwent abdominal aortic vascular procedures and in 14 patients who underwent general surgical procedures. Temporary occlusion of the inferior mesenteric artery (IMA) during aortic surgery resulted in the absence or marked diminution of collateral blood flow over the left side of the colon in eight patients. One patient had the flow in the IMA preserved by proper placement of an end-to-side aortofemoral Dacron prosthesis, whereas the other seven patients underwent replantation of the IMA into the Dacron prosthesis. All patients did well postoperatively. In the 14 general surgical patients, intestinal viability and collateral mesenteric blood flows were determined, which demonstrated that the presence of audible arterial blood flow correlated with ultimate bowel viability. We recommend the use of the Doppler ultrasonic flowmeter in abdominal aortic revascularization procedures to determine the need for IMA reconstruction as well as in general surgical procedures where the surgeon desires a more objective assessment of intestinal viability.     

Trochanter/calcar preserving reconstruction in tumors involving the femoral head and neck

AIM: To evaluate the results of hip reconstruction with extensive excision for tumor confined to the femoral head and neck. METHODS: We designed a resection preserving the greater trochanter and lower portion of calcar femorale, and utilized conventional total hip prosthesis. We retrospectively reviewed 7 patients, who underwent a wide resection and reconstruction using conventional hip prosthesis. There were 3 men and 4 women and their mean age was 42.5 years(22 to 65 years). The histologic diagnosis of each patient was low-grade osteosarcoma, diffuse large B-cell lymphoma, liposclerosing myxofibroma, intraosseous lipoma, chondroblastoma, giant cell tumor and focal intramedullary fibrosis. RESULTS: One patient with lymphoma died due to disease dissemination at 10 mo postoperatively and the remaining 6 patients were followed for a mean of 4.7 years(3 to 6 years). All patients were able to return to their daily activities and no patient had local recurrence. No radiographic signs of loosening, wear, and osteolysis were found at the last follow-up. CONCLUSION: Trochanter/calcar-preserving resectionof the proximal femur and reconstruction using conventional total hip prosthesis, is a satisfactory treatment for tumors confined to the femoral head and neck.     

Laryngeal complications after type I thyroplasty

Type I thyroplasty has become a primary surgical choice for voice restoration in patients with glottal incompetence. This study examines factors associated with laryngeal complications after type I thyroplasty. Ten laryngoscopic variables were analyzed from preoperative, intraoperative, and postoperative videolaryngoscopies of 51 patients undergoing 58 medialization procedures. Ten patient and operative variables were examined by medical record review. Major complications were defined as wound hemorrhage, airway obstruction, or prosthesis extrusion. Minor complications were defined as vocal fold hematoma without airway obstruction or prosthesis movement. The major complication rate was 8.6%, and the minor complication rate was 29%. No delayed hemorrhage or airway obstruction occurred. Prosthesis extrusion occurred in five (8.6%) patients 1 week to 5 months after surgery. Extrusion was associated with suboptimal prosthesis placement in 80% of cases. Two patients retained excellent glottal closure despite extrusion. Vocal fold hematoma was identified in 14 (24%) cases and resolved within 1 week. Prosthesis movement occurred in three (5%) patients 1 week to 6 months after surgery and resulted in poor glottal closure. All patients with prosthesis extrusion or movement were female. Type I thyroplasty remains a safe outpatient procedure with few major complications. Prosthesis extrusion was associated with suboptimal prosthesis placement and may or may not result in poor glottal closure. Minor vocal fold hematomas were relatively frequent, resolved rapidly, and were not associated with airway obstruction. Female patients may be more prone to complications because of their small laryngeal size. (OTOLARYNGOL HEAD NECK SURG 1995;113:671-3.)     

Total upper and lower eyelid reconstruction using an expanded forehead flap

Surgical modalities have been described with varying success for the correction of eyelid defects. The reconstructive surgeon must choose the procedure on a case-by-case basis taking into consideration the following criteria: mechanism of injury, comorbidities, and goals of surgery. In this study, we describe a unique case of total upper and lower eyelid reconstruction using an expanded forehead flap technique in an adult patient who underwent left eye enucleation and radiation to the orbit for rhabdomyosarcoma in infancy. After this patient reached adulthood, examination revealed a contracted, anophthalmic left orbit with paper-thin upper and lower eyelids adhering to the concave walls of the orbit. There was absence of significant periorbital soft tissue. The expanded forehead flap procedure achieved our aims of providing not only an aesthetic result, but also adequate soft tissue support for placement of an ocular prosthesis.     

Aortoenteric fistula to the sigmoid colon-case report

Aortoenteric fistula is defined as a communication between the aorta and any adjacent segment of the bowel. It may be primary or secondary. The former occurs de novo in patients with intestinal or vascular diseases, whereas secondary aortoenteric fistula is a rare and dreadful complication of aortic reconstruction with vascular prosthesis. We report a case of a 62-year-old man who presented to the emergency department with acute rectal bleeding. The patient had previous aortoiliac surgery with the utilization of an aorto-bifemoral vascular graft. Diagnosis of secondary aortoenteric fistula was made between the aortoiliac graft and sigmoid colon. After exploratory laparotomy, Hartmann's procedure, excision of the graft, oversewing of the aortic stump, and axilobifemoral bypass were successfully performed. This study reports a rare type of secondary aortoenteric fistula to the left colon, and it describes an unusual and successful surgical treatment.     

Obstructing malignant lesions of the colon

Evidence has been presented to suggest that the patient with an obstructed carcinoma of the colon may have a more malignant form of the disease independent of lymph node status or tumor encirclement of the bowel. Rate of tumor growth is never consistent in patients with this disease. Patients who develop colon obstruction early in the course of the disease seem to have more aggressive tumors with rapid growth and a much poorer long-term prognosis. Perforations frequently accompany obstructions of the colon. Patients in this group have a dismal prognosis. Individuals with obstructed carcinoma of the colon have a higher operative mortality and morbidity and a shorter long-term survival. The higher operative mortality and morbidity may depend entirely on the choice of operative procedures. Tumor location affects prognosis. Obstructing tumors in the left colon have a more favorable prognosis than those in the right colon. Obstructing right colon tumors have a much poorer survival (three times worse) than nonobstructing carcinomas of the right colon. Obstructing tumors in the rectum have a very poor prognosis. Evidence exists that resection of the tumor without preliminary proximal decompression may reduce hospital mortality and morbidity and increase long-term survival. In selected cases, primary resection can be done as safely as staged operative procedures. Primary anastomosis with resection of the left colon carries a higher operative mortality because of anastomotic leaks. Resection without anastomosis is much safer. Primary resection with anastomosis is the procedure of choice in obstructing lesions of the right colon. This has a lower operative mortality and morbidity than a staged procedure. This primary resection with anastomosis is certainly as safe as an ileotransverse colostomy. It is important not to abandon the time-honored surgical principle of never suturing obstructed bowel. Primary resection without anastomosis confirms this surgical principle. Meticulous preoperative and postoperative care employing physiological monitoring, multiple antibiotics, total parenteral hyperalimentation, and respiratory and circulatory support will further reduce the hospital mortality and morbidity. Patients who initially appear to be obstructed on barium enema, but who in truth are only partially obstructed, can be properly managed so that an elective primary resection with anastomosis can be done with the same operative mortality and morbidity as in other elective colon cancer patients.     

Primäre Schulterendoprothetik nach Trauma

Indications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.     

Delayed two-stage breast reconstruction with implants: The authors�� recent experience

BACKGROUND:

Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient’s own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant).

OBJECTIVE:

To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy.

METHODS:

From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis.

RESULTS:

Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal.

CONCLUSIONS:

After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.     

Acoustic analysis of the voice in phonatory fistuloplasty after total laryngectomy.

A comparative study of the voice with sustained phonation of the vowel /a/ was made in 3 groups of male patients: (1) 20 patients receiving total laryngectomy for epidermoid carcinoma of the larynx who had acquired good voice quality after a phonatory fistuloplasty with a Herrmann voice prosthesis; (2) 20 patients undergoing total laryngectomy for epidermoid carcinoma of the larynx who had learned esophageal speech; and (3) 20 subjects with normal voices. Statistical analysis yielded significant differences in fundamental voice frequency between the 3 groups, with the patients with phonatory prostheses revealing the closest to a normal voice. For other parameters used, such as jitter, shimmer, and harmonics/noise ratio, voice quality with a phonatory prosthesis was similar to that obtained with esophageal speech.     

Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm)

Immediate breast reconstruction has become a standard of care following mastectomy for cancer, largely due to improved esthetic and psychologic outcomes achieved with this technique. However, the current historical standards--transverse rectus abdominis myocutaneous flap reconstruction and expander--implant surgery-still have limitations as regards patient morbidity, short-term body-image improvements, and even cost. To address these shortcomings, we employ a novel concept of human tissue replacement to enhance breast shape and provide total coverage, enabling immediate mound reconstruction without the need for breast expansion prior to permanent implant placement. AlloDerm (human acellular tissue matrix) is a human-derived graft tissue with extensive experience in various settings of skin and soft tissue replacement surgery. This report describes the success using acellular tissue matrix to provide total coverage over the prosthesis in immediate reconstruction, with limited muscle dissection. In this population, 49 patients (76 breasts) successfully underwent the acellular tissue matrix-based immediate reconstruction, resulting in durable breast reconstruction with good symmetry. These findings may predict that acellular tissue matrix-supplemented immediate breast reconstruction will become a new technique for the immediate reconstruction of the postmastectomy breast.     

Outcomes of immediate dental implants in vascularised bone flaps for mandibular reconstruction

Background

The aim of this study is to assess the outcomes of immediate implant placement for dental rehabilitation following mandibular reconstruction with vascularised bone flaps in a single Australian tertiary cancer centre.

Methods

A retrospective analysis of patients who underwent immediate dental implant or delayed placement in vascularised bone flaps was performed. Primary outcome measures assessed included the number of implants placed, operative time, complication rates, time to radiotherapy initiation, dental rehabilitation rates and time to dental rehabilitation.

Results

In total, 187 dental implants were placed in 52 patients, of which 34 patients underwent immediate implant placement and 18 had delayed implant placement. There were no significant differences in the postoperative complication rate (32% immediate vs. 33% delayed, P = 0.89) or time to postoperative radiotherapy (median 42 days immediate vs. 47 days delayed, P = 0.24). Dental rehabilitation was achieved in 62% of the immediate cohort versus 78% of the delayed cohort. The time to be fitted with a dental prosthesis was significantly shorter in the immediate cohort (median 150 days immediate vs. 843 days delayed, P = 0.002).

Conclusions

The placement of immediate dental implants at the time of primary reconstruction of the mandible is a safe procedure and facilitates timely dental rehabilitation.     

The Boiled-Egg Technique : A New Method for Obtaining Femoral Head Autograft Used in Acetabular Defect Reconstruction

Primary total hip arthroplasty can be complicated by acetabular bony defects, threatening the biomechanical integrity of the prosthesis. Traditionally, when autologous bone is used to pack these defects, it is obtained from thin slices of femoral head in addition to acetabular reamings. We report a novel technique for the acquisition of autologous femoral head bone graft used in the reconstruction of acetabular defects during primary total hip arthroplasty.     

Capsular contracture after breast reconstruction with tissue expansion

Tissue expansion before placement of an implant for breast reconstruction is said to lessen the chance of capsular contracture. Forty-nine patients who had undergone post-mastectomy breast reconstruction using tissue expansion were reviewed. Capsular contracture was assessed using the Baker scale and compared with the speed of expansion, the degree of over-expansion and the interval between full expansion and placement of the definitive prosthesis. The overall incidence of capsular contracture (Baker III or worse) was 29%. Only one patient, however, has required capsulotomy for capsular contracture alone. Neither the speed of expansion nor the degree of over-expansion influenced the onset of contracture. Those patients with breasts assessed in Baker group I had a significantly longer interval between full expansion and reconstruction than those in Baker group III (p = 0.05). A modification of Baker's scale is suggested for the assessment of reconstructed breasts. Prospective studies are required to define the optimum timing for tissue expansion procedures.     

Primary versus secondary tracheoesophageal puncture for speech rehabilitation in total laryngectomy: long-term results with indwelling voice prosthesis.

OBJECTIVE: To evaluate the long-term use of indwelling Blom-Singer voice prosthesis (VP) for vocal rehabilitation of patients submitted to total laryngectomy (TL). The influence of the timing (primary or secondary) of tracheoesophageal puncture (TEP), use of radiotherapy (xRT), patient age, and length of follow-up were studied to evaluate the success rate of VP use. STUDY DESIGN AND SETTING: Prospective clinical study in a tertiary referral center. Seventy-one patients were submitted to TL and rehabilitated with indwelling VP. All patients were evaluated for vocal functional issues by an otolaryngologist and a speech pathologist at 1 month, then at every 3 months up to 1 year, and then at every 6 months after 1 year of follow-up. The relative data on time of placement of VP, time of VP use, xRT, age, length of follow-up, and life span of each VP were recorded during the follow-up. RESULTS: Eighty-seven percent of the patients underwent primary and 13%, secondary TEP. The follow-up varied from 12 to 87 months, with an average of 38 months for primary and 51 months for secondary TEP. Fifty-nine percent of the patients were submitted to xRT. The general rate of success was 94%, with 97% for primary and 78% (P = 0.07) for secondary TEP; after 2 years, the success rate was 96% for primary and 75% for secondary (P = 0.07) TEP. The use of xRT and patient age had no influence on the success of VP use for primary and secondary TEP, independently of the length of follow-up. CONCLUSIONS: The success rate of voice rehabilitation with VP was 94%. In primary TEP, the success rate was 97%, whereas in secondary TEP it was 78%; 2 years later, it was 96% and 75%, respectively. A tendency for a higher success rate in voice rehabilitation after TL was observed in primary TEP. The use of xRT and age of patient had no influence on the success rate.     

Reconstruction after total en bloc sacrectomy for osteosarcoma using a custom-made prosthesis: a technical note

STUDY DESIGN: A report of an innovative technique to restore the lumbosacral junction after resection of primary highly malignant osteosarcoma of the sacrum involving the whole sacrum, soft tissues, and adjacent posterior parts of both iliac wings. OBJECTIVES: To describe the planning and design of a custom-made sacral prosthesis, the surgical technique, and clinical and functional outcome of the patient. SUMMARY OF BACKGROUND DATA: Although there have been case reports about reconstruction methods after total sacrectomy, to date, there has not been a reported clinical case of successful reconstruction using an individual designed prosthesis based on a three-dimensional real-sized model. METHODS: A 42-year-old woman was referred with progressive neurologic impairment due to primary osteosarcoma of the sacrum invading surrounding structures. Based on a three-dimensional real-sized model, a detailed surgical plan was developed to assure safe, wide surgical margins. In addition, the model enabled design and testing of a custom-made sacral prosthesis, to provide stable lumbosacral reconstruction. RESULTS: After induction chemotherapy, a staged anteroposterior resection-reconstruction was successfully performed. After surgery, a superficial wound dehiscence was promptly treated. Within 3 weeks after surgery, mobilization began, and the adjuvant chemotherapy was continued. At the 36-month follow-up, the patient was disease free, had a stable, painless spinopelvic junction, and could walk short distances using ankle orthoses and crutches. Radiographs show complete incorporation of the pelvic grafts and unchanged position of the implant. CONCLUSIONS: In planning and performing a total sacrectomy, including substantial parts of iliac wings, a three-dimensional real-sized model offers surgeons distinct advantages. Wide bony resection margins can be drawn on the model, and an individual custom-made prosthesis to re-establish spinopelvic continuity can be designed and tested before the intervention.     

An improved method of flexible endoscopic creation of tracheoesophageal fistula for voice restoration

We present improvements of a previously reported method of tracheoesophageal puncture for voice restoration in postlaryngectomy patients. Our method utilizes a flexible endoscope to enable the tracheoesophageal puncture to be made under direct visualization using only local anesthesia and intravenous sedation. After 3 days, the created tracheoesophageal fistula tract is mature enough to allow placement of a voice prosthesis in the office. This allows the entire procedure to be performed in an outpatient setting with minimal risk. Received: 24 October 1996/Accepted: 24 January 1997