Therapie der tracheoösophagealen und tracheopharyngealen Fisteln nach Laryngektomie

Tracheoesophageal (TEF) and tracheopharyngeal fistulas (TPF) after laryngectomy can mainly be divided into five types: “high TEF with leakage through the voice prosthesis (VP)” (Type Ia), “high TEF with leakage around the VP” (Type Ib), “enlarged high TEF” (Type II), “deep TEF” (Type III), “TPF” (Type IV) and “TPF associated with pharynx stenosis” (Type V). Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, as well as in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multi-layer sutures of the esophagus and trachea. In persisting TEF/TPF after unsuccessful surgical attempts revision surgery remains challenging. Tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.     

Cervical tracheoesophageal fistula

Four unusual cases of cervical tracheoesophageal fistula (TEF) are presented. The incidence, diagnosis and treatment of cervical TEF are discussed. Surgically, if the location is above the level of T2 a cervical approach may be utilized. The cases included a cervical "H" type TEF occurring in an adult. Congenital "H" type TEFs frequently occur in the neck. An adult presenting with a cervical "H" type TEF, having as an infant undergone repair of a thoracic TEF, is unique. Two layer closure of both trachea and esophagus with strap muscle interposition is preferred. The other cases include a TEF secondary to metastatic breast carcinoma, one associated with a stomal recurrence, and an acquired TEF following laryngectomy. Metastatic breast carcinoma resulting in a TEF is reported for the first time. Malignant TEF's are usually secondary to carcinoma of the esophagus, lung, or thyroid. Best palliation is achieved either by esophageal intubation, by colon bypass, or by gastric pull-up with esophageal exclusion. Stomal recurrence with TEF following laryngectomy is treated with one-stage resection and reconstruction with a pectoralis major myocutaneous flap and gastric pull-up. A patient 5 years post-laryngectomy illustrates an acquired non-malignant cervical TEF, a category which includes fistulas due to trauma, tracheotomy, or endotracheal tubes, instrumentation, and inflammatory disease. Prompt surgical closure as in congenital cases is the treatment of choice although select cases require medical therapy.     

Incompetent tracheoesophageal fistula following phonatory puncture. Surgical resolution

Large tracheoesophageal fistulas (TEF) following a total laryngectomy are rare. Most often are associated with the creation of a surgical speech fistula or puncture. We describe the surgical technique used in 3 patients with large TEF after a total laryngectomy and the creation of a speech fistula with a voice prosthesis, followed by radiation therapy. Pertinent literature is reviewed.     

Treatment of large pharyngotracheal fistulas after laryngectomy by a novel customized pharyngeal stent

Persisting tracheoesophageal (TEF) and/or tracheopharyngeal (TPF) fistulas after laryngectomy are incessant problems that can lead to a tremendous loss of quality of life among patients. As soon as surgical options for closing fistulas become impractical, then alternative approaches to stent the fistulas gain significant value. Conventional stents seldom seal the entire fistula, might dislocate and tend to induce tissue proliferation and cause discomfort to the patient. On the basis of these side effects a novel customized pharyngeal stent has been developed to completely seal the fistula without dislocation and discomfort. The anatomic dimensions of the neopharynx in two patients were obtained by a silicone cast of the respective neopharynx and the stent was manufactured according to this anatomical model. The soft silicone edges of the stent match the pharyngeal anatomic structures and follow the changes of the base of the tongue during the process of swallowing. Nevertheless, the stents are rigid enough to remain in place. The reported two patients were able to subsist by themselves orally most of the time without any signs of leakage at all. One stent had to be explanted after 7 months due to an enlargement of the fistula. The second stent is still in place for 10 months up to now without any side effects.     

The indwelling voice prosthesis for speech rehabilitation after total laryngectomy: a safe approach

Primary prosthetic voice restoration by performing tracheoesophageal puncture (TEP) and immediate insertion of a voice prosthesis at the time of total laryngectomy (TLE) is presently the method of choice. This enables the easiest and most comfortable voice rehabilitation with the patient still under general anesthesia when the first prosthesis is inserted. Reconstruction of the pharynx with e.g. free revascularized or pedicled flaps does not preclude surgical prosthetic voice restoration. The TEP can even be done as a primary procedure after total laryngectomy and total pharyngectomy when the full circumference of the neopharynx has to be reconstructed, provided the esophagus is still present at the level of the trachea. Since indwelling devices may have a more robust construction, their device-life generally is longer than that of their non-indwelling counterparts. Indwelling devices have the unique advantage in that patient's dexterity plays a lesser role in the daily maintenance of the device. With a few refinements in the surgery of TLE several postlaryngectomy problems can be avoided or diminished such as hypertonicity of the pharyngoesophageal (PE) segment and a poor contour of the stoma. The combination of Heat and Moisture Exchanger (HME) and indwelling voice prosthesis contributes to a significant improvement of both pulmonary function and voice quality. The solution of the majority of prosthesis and TE-fistula related problems by the well trained physician, make prosthetic voice restoration a safe procedure.     

Prevention of pharyngoesophageal spasm after laryngectomy with a half-muscle closure technique

Because pharyngoesophageal spasm can limit successful voice restoration after total laryngectomy, 24 patients underwent a modified pharyngeal closure in an effort to avoid this problem. All patients underwent total laryngectomy with appropriate neck dissections and pharyngeal closure with a half-muscle closure technique in which only one side of the remnant constrictor muscles was used to reinforce the primary closure. Twenty-three patients underwent voice restoration. Twenty-two (96%) had a functional voice, and 1 patient (4%) had pharyngoesophageal spasm that required a secondary myotomy. One fistula (4%) occurred and resolved with conservative measures. Quantitative voice analysis demonstrated no significant differences between half-closure patients and control patients for fundamental frequency (96 Hz versus 101 Hz) or intensity (57 dB versus 64 dB). Extensive qualitative analysis by trained and naive listeners revealed no differences. This preliminary report indicates the half-muscle closure modification of the pharyngeal closure at primary laryngectomy may provide a simple and effective means of avoiding pharyngoesophageal spasm and maintaining an effective voice without increased complications.     

Incidence of tracheo-oesophageal fistulas after primary voice rehabilitation with the Provox or the Eska-Herrmann voice prosthesis

Salivary leakage can be a major symptom of valve failure or incorrect positioning of indwelling voice rehabilitation valves in a tracheo-oesophageal fistula. Usually, removal of the valve for a short time leads to shrinking of the fistula or a simple valve replacement procedure resolves the problem. If the fistula, however, does not close spontaneously, symptoms persist and the fistula may have to be closed surgically. In a retrospective study, data of 103 patients who underwent laryngectomy and primary voice rehabilitation between 1989 and 1998 with either the Provox or the Eska-Herrmann prosthesis were compared with regard to surgical fistula closure requirement. A total of 55 patients underwent laryngectomy and primary voice rehabilitation with the Eska-Herrmann and 48 with the Provox prosthesis. Initial tumour treatment also included post-operative radiotherapy for all patients in the study. In total, surgical fistula closure had to be performed in three patients, all of whom had been treated with the Provox prosthesis. The time span between initial voice rehabilitation and surgical closure of the fistula was 5 months, 21 months and 24 months in all three patients respectively. None of the fistulas developed in relation to recurring tumour disease. The Provox prosthesis seem to have a higher risk of developing fistulas necessitating surgical intervention, even years after initial tumour therapy, than the Eska-Herrman prosthesis. These complications may be due to the larger tracheo-oesophageal fistula necessary to fit the larger diameter of the Provox prosthesis. Received: 19 December 2000 / Accepted: 10 April 2001     

气管食管裂隙状发声孔发声机制研究

目的：探讨气管食管裂隙状发声孔的发声机制。方法：用大功率遥控X线机和动态频闪喉镜观察40例行全喉切除，Ⅰ期或Ⅱ期发声重建术患者发声时的贮气相、送气相、发声相。结果：患者吸气时肺部膨隆，食管黏膜闭拢；食管入口黏膜内翻呈环形缩小；随之，下咽腔增大呈一尖端向下的三角锥形；食管上端迅速膨大。发声开始时，食管上端扩张如球，食管人口黏膜以冠状位呈唇样外翻，气体从咽食管部冲出；黏膜、黏液发生振动，发出基音。后胸廓缩小，食管入口黏膜再次内翻，发声结束。结论：气管食管音发声的动力器官是肺，气管-食管造瘘口的通畅对发声至关重要。发声时，下咽黏膜、食管口黏膜与黏液均参与振动。     

Management of persistent tracheoesophageal puncture

Tracheoesophageal puncture with placement of a voice prosthesis (VP) provides successful speech rehabilitation after total laryngectomy. However, enlargement of the tracheoesophageal puncture is a challenging complication as it results in leakage around the VP into the airway and may eventually lead to aspiration pneumonia and respiratory complications. It necessitates removal of the VP and permanent closure of the tracheoesophageal fistula. We present our own experience for surgical closure of persistent tracheoesophageal puncture. A non-controlled prospective study was conducted at the Department of Oto-Rhino-Laryngology and Head and Neck Surgery, Zagazig University Hospitals, Zagazig, Egypt. This study included five patients with an enlarged tracheoesophageal puncture. They had persistent leakage around the VP with resulting recurrent chest infections. None of the patients underwent previous surgical intervention for closure of the tracheoesophageal fistula. This surgical technique involved identification and exposure of the tracheoesophageal fistula tract by blunt dissection and its ligation by non-resorbable sutures at two points close to the posterior wall of the trachea without dividing the fistula tract. The mean follow-up period was 14.4 months. Successful closure of the fistula was achieved in all patients (100 %). All patients tolerated full diet well and had uneventful recovery and no further episodes of aspiration. This surgical technique is simple, easily feasible technically, and effective. It enables early oral feeding and allows a short hospital stay, thus increasing the patient’s comfort.     

Chirurgische Therapie von Stimmshunt-Komplikationen unter besonderer Berücksichtigung eines supraösophagealen Refluxes

Approximately a quarter of all patients who undergo prosthetic voice restoration develop periprosthetic leakage with aspiration symptoms within 1 to 4 years following surgery. Depending on the severity of fistula enlargement, treatment ranges from conservative approaches to surgical procedures. In some cases, however, these measures prove unsuccessful. The causes of treatment failure and fistula enlargement are not fully understood. There is growing evidence, however, that the presence of coexisting supraesophageal reflux can contribute to fistula complications. We report the case of two patients with voice prostheses and simultaneous severe reflux disease who underwent multiple failed attempts at fistula closure. After effective reflux therapy, the fistulas could eventually be closed successfully.     

Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap

Tracheoesophageal fistula (TEF) constitutes a rare, but serious complication in laryngectomized patients, usually occurring after radiotherapy. TEF may occur spontaneously or may be due to enlargement of the TEF created for placement of a voice prosthesis. Surgical treatment of TEF can be complex, especially in the presence of a concomitant pharyngoesophageal stenosis (PES), and is associated with a high failure rate. In this article, we describe the surgical reconstruction technique for TEF associated with PES using a double skin paddle fasciocutaneous radial forearm free flap. The key points of this technique consist of correct positioning of the 2 skin paddles in order to reconstruct the anterior pharyngoesophageal wall and posterior tracheal wall, as well as de-epidermization of the intermediate part of the flap, which is then placed in the tracheoesophageal space.     

A new prosthesis for voice rehabilitation after laryngectomy

Summary Since the first laryngectomy, several surgical and prosthetic techniques have been developed in order to restore voice. Problems encountered with these techniques include: Leakage through the tracheoesophageal fistula, spontaneous closure of the fistula, dislodgement of the prosthesis, and the use of adhesives for fixation. We now introduce a new silicone voice prosthesis that overcomes these problems. The prosthesis is easily inserted as a one-stage procedure during total laryngectomy. Successful acquisition of voice was achieved in 30 of 33 patients, irrespective of preoperative or postoperative radiotherapy. Average device life proved to be approximately 100 days. The high rate of success with minimal morbidity merits further investigation of this one-stage voice rehabilitation technique.     

Chronic aspiration secondary to a Staffieri fistula: successful therapy with Provox voice prosthesis

BACKGROUND: The Staffieri technique is a method for surgical rehabilitation of the voice after laryngectomy. A fistula between trachea and esophagus is created to achieve a so-called "Neoglottis phonatoria". The assignment of the neoglottis is to protect the airways during ingestion and to give the patient a chance to phonate during expiration. PATIENT: The case of a 71-year-old man with aspiration via his Staffieri fistula is presented. The fistula was created in 1979 after laryngectomy because of a laryngeal carcinoma. He also suffered from a metastasized gastric carcinoma which was cured by a 2/3 resection of the stomach in 1970. He is free of recurrence with regard to his oncologic diseases. Until 2003 the patient had no problems with the fistula and was able to phonate well. In 2003 the patient had progressive aspiration via the fistula and the Staffieri fistula was therefore reduced in diameter by surgery. In 2005 the patient presented himself again because of a recurrence of the aspiration. Endoscopy of the upper aerodigestive tract showed healthy mucosa, contrast imaging of the esophagus showed a significant aspiration of the contrast medium into the trachea. Due to these findings a voice prosthesis was inserted into the fistula. This therapy cured the patient from aspiration. He is able to phonate well and has no further complaints. CONCLUSION: Aspiration via a Staffieri fistula is described in about 25 % of cases and therapy is sometimes difficult. Surgical narrowing of the diameter of the fistula is inadequate in most cases and many patients would lose their restored voice if the fistula was closed permanently. Through the insertion of a voice prosthesis aspiration could be stopped and voice was immediately restored.     

咽食管括约肌切开术在喉全切除术后发音重建中的作用

目的：探讨咽食管括约肌切开术对减少咽食管括约肌失弛缓对喉全切除术后安装Blom-Singer发音管发音重建的影响。方法：喉全切除术后，咽食管括约肌收缩或是痉挛都会不同程度地影响食管的气流并阻碍发音。咽食管括约肌的解剖位置是环咽肌以及其上的下咽缩肌的一部分和颈段食管上段的一部分。手术操作是在喉全切除术中、术后于气管造瘘口外上方切除长5cm，宽1cm的咽食管括约肌。结果：33例喉全切除术的患者进行咽食管括约肌切开术后有32例发音成功，发音重建的成功率是97％。其中包括12例喉全切除术中I期进行环咽肌切开术，21例是Ⅱ期进行咽食管括约肌切开术的，后者又有9例是安装Blom-Singer发音管后发音不能再行咽食管括约肌切开术的。患者3年存活25例，5年存活18例。同期行喉全切除术和咽食管括约肌切开术的12例患者，Kaplan-Meier法统计3年生存率81．82％，5年生存率42．86％。结论：咽食管括约肌切开术能提高Blom-Singer发音管发音重建的成功率。     

Downsizing of voice prosthesis diameter in patients with laryngectomy: an in vitro study

In patients with laryngectomy, voice prostheses inserted into a tracheoesophageal fistula (TEF) are widely used for vocal rehabilitation. Gradual dilation of the TEF may cause bothersome leakage around voice prostheses. Prosthesis-related weight and mechanical trauma possibly exacerbate TEF dilation. If prosthesis size were to be decreased, with a concomitant decrease in prosthesis weight and diameter, dilation of the TEF would probably lessen. We performed in vitro tests to study the effects on aerodynamic prosthesis function when the prosthesis size-in particular, the inner diameter-was decreased. The effects on airflow and pressure were specifically studied in the airflow range of patients with laryngectomy. A 1-mm decrease of the regular inner prosthesis diameter from 5 mm to 4 mm showed no significant aerodynamic consequences at the average laryngectomized airflow point. Also, such a 1-mm decrease in diameter involved a prosthesis weight reduction of 18%. In view of these findings, downsizing the standard prosthetic diameter should be considered in future voice prosthesis development.     

Operative prevention and management of voice-limiting pharyngoesophageal spasm

Voice-limiting pharyngoesophageal spasm presents a challenge to the surgeon who is trying to optimize functional voice outcomes in the laryngectomy patient. Modified closure techniques, adjunctive myotomy, and pharyngeal plexus neurectomy have the ability to improve or prevent pharyngoesophageal spasm. Attempts to maximize vocal outcome should be considered at the original time of laryngectomy and tracheoesophageal voice restoration because salvage treatment can be challenging.     

Incidence and predisposing factors of pharyngocutaneous fistula formation after total laryngectomy. Is there a relationship with tumor recurrence?

Pharyngocutaneous fistula is the most common complication (8.7 to 22%) in the immediate postoperative period following total laryngectomy. The study's objective was to determine the incidence of post-laryngectomy fistulas in patients operated on in our department to establish whether specific factors predispose to fistula formation and to determine whether fistulas and tumor recurrence are related. Between 1992 and 2001, 377 cases of laryngeal carcinoma were diagnosed, and the patients underwent total laryngectomy in our department. Of these patients, 291 had total laryngectomy as the primary management of their disease, while in 86 patients the operation treated recurrence of the disease. In 92 patients, total laryngectomy was combined with radical or eclectic neck dissection. The presence of early postoperative fistula was established in 49 of the 377 patients (13%) studied. The cancerous stage, exact localization of the tumor, degree of differentiation, previous irradiation, patient's age, performance or not of neck dissection or emergency tracheostomy and fitting of voice prostheses were all factors that, after statistical analysis, did not appear to significantly influence the incidence of postoperative fistulas. Factors that did show statistical significance were the histological infiltration of the tumor's surgical margins (11% negative vs. 38% with positive margins) and coexisting early complications. Fistula management was conservative in the majority of cases. The necessary closure period for a fistula varied between 5 and 81 days (mean: 29 days). Postoperative follow-up of all patients revealed that fistulas did not influence the incidence of tumor recurrence. The incidence of postoperative fistulas in our study was 13%. Incomplete excision of the tumor and coexisting complications were related, among other things, to a higher rate of fistula formation. The rate of tumor recurrence after total laryngectomy was not related to the presence of a fistula during the postoperative period.     

Acquired tracheoesophageal fistula following disc-battery ingestion: can we watch and wait?

Acquired tracheoesophageal fistulas (TEF) are rare but dangerous complications of disc-battery ingestion. Management approaches include endoscopic or open surgical repair. Unfortunately, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula and significant patient mortality. Thus, several authors have advocated the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. This study describes a patient with spontaneous closure of an acquired TEF following disc-battery ingestion. The late recurrence of the TEF following conservative management, and endoscopic and radiographic evidence of closure, illustrates the importance of long term evaluation before assuming fistula resolution. Practitioners must carefully weigh the risks and benefits before deciding surgical versus conservative management of TEF. An extended follow-up of at least 6 months should be instituted with a high index of suspicion if conservative management is utilized. Transtracheal repair using an imbricated suture technique is a good surgical option when conservative management fails.     

全喉切除术后咽瘘的原因分析与防治措施

目的探讨全喉切除术后咽瘘发生的易感因素、治疗方法及预防措施。方法收集2000年1月～2011年12月行全喉切除术患者114例。对可能影响咽瘘发生的一系列因素包括年龄、术前放疗、颈廓清术范围、肿瘤位置和肿瘤临床分期等进行了回顾性研究。结果术后12例患者发生咽瘘(10.5%),7例咽瘘患者的愈合需要外科治疗干预,其中6例通过咽部黏膜组织的直接缝合而达到治愈,1例行胸大肌皮瓣移植术;另5例通过局部换药、加压包扎等保守方法,瘘口治愈闭合。所有患者均随访2个月以上。结论文献中关于咽瘘发生的相关因素虽存有很多的争议,但研究表明血红蛋白水平,是否有糖尿病,肿瘤位置,肿瘤TNM分级及临床分期与咽瘘发生密切相关。大部分患者的咽瘘通过保守换药治疗,必要时局部直接清创缝合的方法可以达到治愈的效果。     

咽食管括约肌切开术在喉全切除术后发音重建中的作用

目的　探讨咽食管括约肌切开术对减少咽食管括约肌失弛缓对喉全切除术后安装Blom Singer发音管发音重建的影响。方法　喉全切除术后 ,咽食管括约肌收缩或是痉挛都会不同程度地影响食管的气流并阻碍发音。咽食管括约肌的解剖位置是环咽肌以及其上的下咽缩肌的一部分和颈段食管上段的一部分。手术操作是在喉全切除术中、术后于气管造瘘口外上方切除长 5cm ,宽 1cm的咽食管括约肌。结果　 3 3例喉全切除术的患者进行咽食管括约肌切开术后有 3 2例发音成功 ,发音重建的成功率是 97%。其中包括 12例喉全切除术中I期进行环咽肌切开术 ,2 1例是Ⅱ期进行咽食管括约肌切开术的 ,后者又有 9例是安装Blom Singer发音管后发音不能再行咽食管括约肌切开术的。患者 3年存活 2 5例 ,5年存活 18例。同期行喉全切除术和咽食管括约肌切开术的 12例患者 ,Kaplan Meier法统计 3年生存率 81 82 % ,5年生存率 42 86%。结论　咽食管括约肌切开术能提高Blom Singer发音管发音重建的成功率。