Clinical experience with silicon pharyngeal tube for pharyngocutaneous fistula and cervical esophagus stenosis

Total laryngectomy or laryngopharyngectomy are commonly performed for the treatment of laryngeal cancer or hypopharyngeal cancer. However pharyngocutaneous fistula and cervical esophageal stenosis have been reported as postoperative complications of these procedures. We used a silicon pharyngeal tube in cases that developed pharyngocutaneous fistula and cervical esophageal stenosis. The pharyngeal tube was useful for controlling aspiration pneumonia and for starting oral feeding in a case of pharyngocutaneous fistula after a total laryngectomy. It was also helpful for starting oral feeding in a case with cervical esophageal stenosis after total laryngopharyngectomy and free jejunum interposition. This patient was able to maintain a good quality of life until re-operation. Adverse effects from the insertion of the tube included a foreign body sensation and pharyngeal pain that was tolerable with the use of NSAIDs for a short time. Silicon pharyngeal tubes are useful for the treatment of pharyngocutaneous fistula and cervical esophageal stenosis.     

Modified Continuous Mucosal Connell Suture for the Pharyngeal Closure After Total Laryngectomy: Zipper Suture

Objectives

Pharyngocutaneous fistula is a serious complication after total laryngectomy, and there are some risk factors stated in the literature. The surgical suture techniques are not studied so much. The aim of this study is to evaluate the effectiveness of ''modified continuous mucosal Connell suture'' on the incidence of pharyngocutaneous fistula after total laryngectomy.

Methods

This is a retrospective case series study based at a tertiary center with 31 patients who underwent total laryngectomy between July 2011 and December 2013. Pharyngocutaneous fistula formation after total laryngectomy was evaluated with the patients who underwent modified continuous mucosal Connell suture for pharyngeal repair.

Results

Pharyngocutaneous fistula was observed in only one patient (3.2%) who had a history of previous radiotherapy, and it was spontaneously healed within 6 days by conservative treatment.

Conclusion

We defined a new suture technique for the pharyngeal repair after total laryngectomy. This technique is a simple modification of continuous mucosal Connell suture. We named it as zipper suture. It is effective in the prevention of pharyngocutaneous fistula for pharyngeal reconstruction after total laryngectomy.     

Early oral feeding following total laryngectomy

INTRODUCTION: Pharyngocutaneous fistula is one of the most common nonfatal laryngectomy complications (7.6% to 65% of all total patients). Preoperative radiotherapy, advanced tumor stage, poor preoperative medical status, and concomitant pharyngectomy are usually accepted causative factors in fistula formation. Delay of oral feeding is a common practice used by head and neck surgeons to prevent the development of pharyngocutaneous fistula. In this article we analyze our experience with special emphasis given to the early start of postoperative feeding. PATIENTS AND METHODS: The postoperative records of 48 patients who had undergone total laryngectomy or total laryngopharyngectomy were reviewed. All patients were orally fed with water and clear liquids on the first postoperative day. The patients were closely observed at every feeding attempt, and if any sign of fistula was noted, a nasogastric tube was inserted. Preoperative radiotherapy, stage of disease, tumor differentiation, and pharyngectomy with total laryngectomy were statistically analyzed as potential risk factors contributing to fistula formation. The Fisher exact test was used to analyze the data. RESULTS: The overall pharyngocutaneous fistula rate was 12.5% in our series. The only statistically significant factor that increased the rate of fistula formation was resection of pharyngeal mucosa as an extension of total laryngectomy. Other parameters failed to show any statistical significance in development of this complication. CONCLUSION: Evaluation of fistula incidence in our series indicates that initiating oral feeding on the first postoperative day does not contribute to fistula formation. Additionally, the relatively shortened hospital stay and elimination of the psychologic and traumatic side effects of tube feeding are benefits of this approach that should be studied in further prospective quality-of-life studies.     

Prevention of postlaryngectomy pharyngocutaneous fistula: the Memorial University experience

OBJECTIVES: The purpose of this study was to compare the efficacy of a pectoralis major myogenous flap in the prevention of pharyngocutaneous fistula in patients who have undergone total laryngectomy. Our secondary objective was to estimate the economic saving to our health care system. DESIGN: Retrospective clinical study. SETTING: Grace General Hospital, St. Clare's Mercy Hospital, H. Bliss Murphy Cancer and Research Centre, St. John's, Newfoundland. MATERIALS AND METHODS: Two hundred and twenty-three consecutive total laryngectomy procedures performed between June 1978 and December 2001 were reviewed. The fistula rate in laryngectomy patients prior to 1988 without pectoralis major myogenous flaps (group A) was compared with that of patients after June 1988 who had this flap routinely used at primary surgery (group B). Analysis of risk factors within those two groups was essentially similar. RESULTS: In group A, the overall pharyngocutaneous fistula rate was 22.9%. The fistula rate in group B was less than 1%. CONCLUSION: Our study has demonstrated that at our tertiary care head and neck oncology centre, we have dramatically decreased the incidence of postlaryngectomy pharyngocutaneous fistula. By the routine addition of a pectoralis major myogenous flap to cover the pharyngeal defect at surgery, we have substantially and dramatically reduced patient morbidity and mortality and reduced hospital stay, with major financial savings to the health care system.     

Pharyngocutaneous fistula following total laryngectomy: a single institution’s 10-year experience

The etiology of postoperative pharyngocutaneous fistula (PCF) formation following major head and neck surgery is multifactorial and the incidence varies greatly. We reviewed retrospectively the records of 108 consecutive patients who underwent a total laryngectomy during the period from December 1992 to December 2002 at the Helsinki University Central Hospital, Helsinki, Finland. PCF occurred postoperatively in 19 (18%) patients. Two additional patients (2%) developed a PCF later than 30 days after laryngectomy. Nineteen percent of these patients with fistula formation had received previous radiation therapy and laryngectomy was performed for local recurrence. Eighteen (86%) of the all fistulae closed spontaneously and surgical closure of the fistula was performed in three (14%) cases. We conclude that the PCFs in our patient population occurred both in radiated and nonirradiated patients. Although most fistulae close spontaneously without surgical intervention this complication leads to prolonged hospitalization and increased patient morbidity.This paper has been presented at the American Laryngological Association Annual Meeting, Phoenix, Arizona, April 30–May 1, 2004.     

保守治疗咽瘘的临床转归研究

目的:总结全喉切除术后并发咽瘘的临床转归及处理对策。方法:分析21例喉癌下咽癌全喉切除术后咽瘘发生的时间、创面状况和采用的相应治疗措施。结果:咽瘘的转归分为3期:引流清理期(Ⅰ期)、加压包扎期(Ⅱ期)、愈合期(Ⅲ期),不同期进行不同处理。咽瘘经过引流清理期、加压包扎期、愈合期的处理后,14例咽瘘愈合,占66.7%(14/21);其余7例保守治疗无效经手术治愈。结论:咽瘘分别按转归的3期进行处理,取得满意的疗效,咽瘘的转归分期对指导临床治疗有一定参考价值。     

A randomized controlled trial of early oral feeding in laryngectomized patients

OBJECTIVE: To evaluate the safety and efficacy of early oral feeding by comparing it with feeding through primary tracheoesophageal puncture after total laryngectomy with primary pharyngeal closure. STUDY DESIGN: A prospective, randomized, controlled study. METHODS: Patients who underwent total laryngectomy with primary pharyngeal closure and who were candidates for primary voice restoration (an in whose cases primary tracheoesophageal puncture [TEP] was created) were included. After total laryngectomy, patients were randomly assigned to either the oral group (study group) or the TEP group (control group). Patients in the oral group were fed orally with a clear liquid diet on the first postoperative day, then advanced to a regular diet, whereas patients in the TEP group were fed through tracheoesophageal puncture and received nothing orally until the seventh postoperative day; then they were fed orally if fistula had not occurred. Standard criteria for discharge were used for all the patients. RESULTS: During a 3-year period, 67 patients were enrolled in the trial, and complete data were available for 65 patients (32 patients in the oral group, 33 patients in the TEP group). The two groups were similar for factors reported to influence the rate of pharyngocutaneous fistula. In three (9%) patients in the TEP group, fistula occurred on the 5th, 7th, and 14th postoperative days, respectively. Two (6.2%) fistulas occurred in the oral group on the sixth and eighth postoperative days, respectively. In patients without fistula, the mean length of hospital stay was 7.6 days (range, 4-19 d [SD = 3.1 d]) for the oral group and 8.2 days (range, 7-18 d [SD = 2.6 d) for the TEP group. There was no significant difference between two groups for either the incidence of fistula or the length of hospital stay. CONCLUSIONS: Initiation of oral feeding on the first postoperative day in patients undergoing total laryngectomy with primary pharyngeal closure is a safe clinical practice. However, it does not shorten the length of hospital stay for these patients.     

Pharyngocutaneous fistulae following total laryngectomy.

Postoperative pharyngocutaneous fistula formation is a troublesome complication in head and neck surgery and occurred in 8 out of 53 patients following a total laryngectomy (15%). The incidence falls within the lower range of that reported in the literature (6-66%). Different factors which may influence the formation of fistulae were analysed. Factors which seem to increase fistula formation are previous full dose radiotherapy (Co60), residual carcinoma and surgical technique.     

Using a linear stapler for pharyngeal closure in total laryngectomy

This study aimed to evaluate the value of using a linear stapler device in total laryngectomy using a prospective study. Twenty-one total laryngectomies were performed from August 2010 to April 2012, using TA-60 linear stapler for pharyngeal closure. Data collected included age, sex, staging, surgical margins and postoperative course (including complications and swallowing). Patients comprised twenty men and one woman. The mean age was 64 years. Two patients underwent preoperative radiotherapy. Four patients recurred after radiotherapy. Fifteen patients were untreated. Negative surgical margins were achieved in all patients. One patient developed slight pharyngocutaneous fistula. Patients resumed oral intake at 7 days. The mean hospital stay was 10 days. Using a linear stapler to close laryngopharyngeal cavity in total laryngectomy is simple, reliable and practical, avoids pollution of surgical area, saves operation time and decreases the incidence of pharyngocutaneous fistula. It is worthy of clinical application for selected cases. Level of Evidence Case-series     

Pharyngocutaneous fistulae following total laryngectomy

Postoperative pharyngocutaneous fistula formation is a troublesome complication in head and neck surgery and occurred in 8 out of 53 patients following a total laryngectomy (15%). The incidence falls within the lower range of that reported in the literature (6–66%). Different factors which may influence the formation of fistulae were analysed. Factors which seem to increase fistula formation are previous full dose radiotherapy (Co⁶⁰), residual carcinoma and surgical technique.     

Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps

Background: Salvage surgery for laryngeal cancer recurring after radiotherapy is difficult and complications readily occur. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous (PMMC) flap, which has copious blood flow, for preventing post-irradiation pharyngocutaneous fistula.

Aims/objectives: The purpose of this study was to examine the incidence of post-operative complications of salvage total laryngectomy (STL) using the PMMC flap for post-radiotherapy recurrent laryngeal cancer at our institution.

Material and methods: From among 162 patients with laryngeal cancer who had been treated at Tokyo Medical University Hospital between January 2014 and March 2018, we enrolled 11 patients who had undergone STL applying a PMMC flap. We examined patient backgrounds (age, gender, subtype, stage), initial therapy (radiotherapy/chemoradiotherapy), radiation dose, irradiation area, surgery type (with/without neck dissection) and postoperative complications.

Results: No severe systemic complications were encountered. Pharyngocutaneous fistula occurred as a severe local complication in one patient (8.3%) and wound infection as a mild local complication in one patient (8.3%).

Conclusions: Rates of post-operative complications following STL tended to be lower at our institution than those reported for other institutions.

Significance: PIG may be a useful surgical procedure in STL.     

Pharyngocutaneous fistula following total laryngectomy

Pharyngocutaneous fistula (PCF) is the most common complication after total laryngectomy.ObjectivesTo establish the incidence of this complication and to analyze the predisposing factors.MethodThis is a cross-sectional study of a historical cohort including 94 patients who underwent total laryngectomy. The following aspects were correlated to the occurrence of PCF: gender, age, tumor site, TNM staging, type of neck dissection, previous radiation therapy, previous tracheotomy, and use of stapler for pharyngeal closure. The following were considered in PCF cases: the day into postoperative care when the fistula was diagnosed, duration of occurrence, and proposed treatment.ResultsTwenty (21.3%) patients had PCF. The incidence of PCF was statistically higher in T4 tumors when compared to T2 and T3 neoplasms (p = 0.03). The other analyzed correlations were not statistically significant. However, 40.9% of the patients submitted to tracheostomy previously had fistulae, against 21.1% of the patients not submitted to this procedure.ConclusionAdvanced primary tumor staging is correlated with higher incidences of PCF.     

喉切除术后咽瘘的预防和治疗

目的 本文讨论了减少喉切除术后咽瘘发生的外科技巧和围手术期处理。方法 共对365例经由喉全切除术和喉大部分切除术治疗的喉恶性肿瘤病例的临床资料进行分析,其中喉全切除术333例,喉大部分切除术32例。结果 365例喉切除术后28例发生咽瘘,发生率为7.7％;其中喉全切除术后27例发生咽瘘,发生率8.1%;喉大部分切除发音管重建术后1例发生咽瘘,发生率3.1％。结论 采用喉咽食管黏膜分层缝合方式,以及术后颈部持续负压引流对于降低咽瘘发生率关系密切。喉大部分切除发音管重建术的咽瘘发生率低于喉全切除术,可能与喉大部分切除保留一侧梨状窝黏膜,喉咽黏膜缺损较小有关。     

Gastroesophageal reflux prophylaxis decreases the incidence of pharyngocutaneous fistula after total laryngectomy

Pharyngocutaneous fistula is a serious complication after laryngectomy. Gastric fluid is known to cause severe laryngopharyngeal injury and poor mucosal healing. This study was designed to evaluate the effects of a gastroesophageal reflux prophylaxis regimen on the incidence of fistula after laryngectomy. Twenty-one consecutive patients were entered in the study. Patients with positive resection margins were excluded from the overall analysis. All patients had a Connell's two-layer closure of the pharynx with absorbable suture, suction drainage of the neck, postoperative tube feeding, and prophylactic antibiotics. All patients were started on an antireflux regimen postoperatively composed of continuous tube feeds, intravenous ranitidine, and intravenous metoclopramide hydrochloride. Patients were followed postoperatively with Gastrografin swallows and clinically for 8 weeks. The control group consisted of retrospectively studied patients managed identically except for the antireflux prophylaxis. The two groups were well matched for factors reported to influence the rate of pharyngocutaneous fistula formation. The control group had six fistulae (26%) and an average of 16.5 days of hospital stay. The study group had no fistulae and an average of 11.5 days of hospital stay (P = .02). This study suggests that gastroesophageal reflux may predispose to fistula formation after laryngectomy and that mechanical and pharmacological prophylaxsis decreases postoperative morbidity and length of hospital stay.     

Inzidenz von Speichelfisteln in Abhängigkeit vom Zeitpunkt einer oralen Ernährung nach Laryngektomie

Background and objective. A pharyngocutaneous fistula is the most common complication after total laryngectomy. In Germany, a traditional recommendation is to use a nasogastric tube for feeding for 10–14 days postoperatively because many surgeons believe that oral feeding after surgery contributes to fistula development. However, there is no international agreement about when to begin oral feeding after total laryngectomy. Some authors begin oral feeding between the 1st and 4th postoperative day without any nasogastric tube, while others using a nasogastric tube delay oral feedings until 7–14 days after surgery. The aim of the present study was to investigate the relationship between the timing of oral feeding and the development of fistulas after total laryngectomy. Patients/methods. In a prospective trial with 42 consecutive patients who underwent laryngectomy, oral feeding was started on different postoperative days between the 1st and the 10th. Most patients were selected randomly for the different postoperative days. Furthermore, other potential risk factors predisposing to fistula formation were analyzed retrospectively. Results. Five fistulas occurred in the total group (12%). Early postoperative oral feeding does not increase the incidence of fistulas. The fistula rate was only 9% in patients fed orally in the 1st postoperative week. The analysis of further risk factors for fistula formation showed only a significant correlation between type of resection and fistula occurrence (extended laryngectomy with partial pharyngectomy vs standard laryngectomy; p = 0.018). Conclusions. Our results indicate that early oral feeding in the 1st postoperative week does not influence fistula formation after laryngectomy.     

Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy

PurposeTo evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection.Study designRetrospective cohort study.SettingTertiary referral centre.Subject and methodsA Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used.ResultsThere was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used.ConclusionProphylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.     

Staple-assisted laryngectomy for intractable aspiration

Staple-assisted laryngectomy is a unique method previously reported by Lukyanchenko to prevent wound contamination by using a stapling device for suturing pharyngeal defects in total laryngectomy. We have modified his method and applied it to prevent a postoperative pharyngocutaneous fistula in the treatment of intractable aspiration. In contrast to laryngeal cancer patients, a combined use of an intraluminal light to guide the dissection and laryngofissure to pull the epiglottis can be used to facilitate the use of the stapling device. For most patients with intractable aspiration who have significant malnutrition and drug-resistant bacterial colonization of the pharynx, this method offers certain advantages. This report describes our successful experience with this method in the management of patients with intractable aspiration.     

Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy

Objectives/Hypothesis:

The aim of this study was to assess whether the use of the temporoparietal fascia as a free flap for pharyngeal closure reinforcement reduced the incidence of pharyngocutaneous fistula (PCF) in the salvage setting.

Study Design:

Consecutive case series.

Methods:

After research ethics board approval, 12 patients who required salvage laryngectomy, including reinforcement coverag e of the primarily closed pharyngeal defect with temporoparietal fascia as a free tissue transfer, were analyzed.

Results:

One (8%) out of 12 patients experienced pharyngocutaneous fistula that responded with conservative wound packing.

Conclusions:

The PCF rate of 8% is significantly better than in similar salvage cases without flap coverage. Moreover, our PCF rate is comparable to the results shown for the pectoralis major muscle flap. The most obvious benefit of the temporoparietal fascia free flap for pharyngeal coverage in salvage laryngectomy is a reduced PCF rate with diminished donor‐site morbidity, including cosmetic outcome, shoulder girdle function, and chest deformity.     

Acellular dermal graft pharyngeal repair augmentation after laryngectomy

Purpose

Pharyngocutaneous fistula (PCF) after laryngectomy continues to be a serious complication, especially after radiation. Recruitment of non-radiated tissue into the surgical defect may decrease the risk of fistula. These techniques however have significant morbidity and increases operative time. We hypothesized that using acellular dermal graft to reinforce the pharyngeal closure could decrease the risk of fistula, without the added morbidity of a vascularized flap.

Early oral feeding following total laryngectomy

OBJECTIVES: The time to begin oral feeding after total laryngectomy remains a subject of debate among head and neck surgeons. The prevailing assumption is that early initiation of oral feeding may cause pharyngocutaneous fistula; thus, the common practice of initiating oral feeding after a period of 7 to 10 days. The objective of the study was to demonstrate the feasibility and safety of oral feeding 48 hours after total laryngectomy. STUDY DESIGN: Two-part study includes, first, a sequential study and, second, a prospective analysis of our practice. METHODS: Patients undergoing total laryngectomy without partial pharyngectomy or radiation treatment (except irradiation through small ports for a T1 or T2 glottic carcinoma) were included. In the first, sequential part of the study (part I), a group of 18 patients who were fed 7 to 10 days after total laryngectomy (control group) was compared with a group of 20 patients who received oral feeding within 48 hours. To confirm the results of part I, a prospective analysis of this practice was conducted (part II) in which 35 additional patients who met the above criteria were fed within 48 hours after surgery. RESULTS: In part I, pharyngocutaneous fistula occurred in one patient (5%) in the early feeding group and in two patients (11%) in the control group. In part II, pharyngocutaneous fistula occurred in one patient (2.8%). Overall, fistula occurred in two patients in the combined early feeding group (3.6%). This rate of pharyngocutaneous fistula compares favorably with the fistula rate in the control group of 18 patients. Pharyngeal stricture that required dilation occurred in three of our patients in the study group and two in the control group (5.5% vs. 11%, respectively). The length of hospital stay was significantly shortened from 12 to 7 days. CONCLUSION: Our results indicate that in this patient population initiation of oral feeding 48 hours after total laryngectomy is a safe clinical practice.