Surgical Mini-Pharyngostoma: A Safe Technique for … this article: Martin Villares C, Gonzalez...
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Central Annals of Otolaryngology and Rhinology
Cite this article: Martin Villares C, Gonzalez Gimeno MJ, Diez Gonzalez L, San Roman CJ, Dominguez CJ, et al. (2017) Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy Patients. Ann Otolaryngol Rhinol 4(2): 1162.
*Corresponding author
Martin Villares, Department of Otorhinolaryngology, Hospital El Bierzo, Spain, Email:
Submitted: 24 January 2017
Accepted: 20 February 2017
Published: 21 February 2017
ISSN: 2379-948X
Copyright© 2017 Martin et al.
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Keywords•Head and neck cancer•Pharyngocutaneousfistula•Laryngeal neoplasm•Pharyngostoma
Case Report
Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy PatientsMartin Villares C1*, Gonzalez Gimeno MJ2, Diez Gonzalez L1, San Roman Carbajo J1, Dominguez Calvo J1, Valor Garcia C3, Arguello de Tomas M1
1Department of Otorhinolaryngology, Hospital El Bierzo, Spain2Department of Otorhinolaryngology, Universidad Complutense de Madrid, Spain3Department of Otorhinolaryngology, Hospital San Sebastian de los Reyes, Spain
Abstract
From the first laryngectomy performed by Billroth, pharyngocutaneous fistula has not been eradicated. Modern reconstructive techniques can solve almost any surgical problem in laryngectomy patients, but morbidity is still high in critical patients. In a effort to minimize morbilitity in unhealthy patients, we used the surgical pharyngostoma technique as conservative approach for complex postlaryngectomy fistulas in selected patients, in which, aggressive surgical interventions were not safe.
INTRODUCTIONThe laryngectomy technique has been established for dec-
ades and has not changed through out the years, but Pharynx recon-struction after laryngectomy remains controversial [1]. Nowa-days, there is no consensus about the best technique to opti-mize pharynx wound healing, so prevention is better than any treat-ment [2]. Current literature supports aggressive reconstruc-tive techniques in patients with complex pharyngocutaneous fis-tulas [3], but sometimes they are associated with unaccept-able high complication rates [4,5]. In a effort to minimize mor-bilitity, some surgeons still recommend the controlled sub-mental pharyngostoma technique as a simple and safe therapeu-tic approach for these complex postlaryngectomy patients [6-9]. We describe our experience with this conservative concept in five selected laryngectomy patients. The aim of our study is to revise the elective indication of surgical pharyngostoma for spe-cially selected patients with unsafe wounds, in which, aggressive surgical interventions are not safe.
PATIENTS AND METHODS
General description
This is a retrospective study of a cohort of 100 consecu-tive laryngectomy patients. After laryngectomy, the gen-eral technique of pharyngeal closure was the primary su-ture of pharyngeal defects mucosa was sufficient or with a my-ocutaneous flap if the pharyngeal mucosa was not suffi-cient [3]. All the patients had similar postoperative nutri-
tional support and nurse care (nasogastric tube with oral feed-ing on day 7-10, suction drains and antibiotic therapy). We present a case series of five patients underwent a surgical minipharyn-gostoma to assess the results for these specially cases from a rate of 19% of postlaryngectomy fistulas.
Concepts
1. Postlaryngectomy fistula [10]: any anomalous path con-necting the pharynx and the skin.
2. Pharyngostoma [10]: direct and unplanned open-ing from the pharynx to the skin with fre-quent skin necrosis.
3. Surgical controlled pharyngostoma [6]: when the sur-geon creates an artificial and controlled fistu-la between pharynx and skin for protecting su-ture line and skin flaps. These surgical pharyngosto-mas can be:
A) Planned [6,8]: if surgeon plan the artificial fistula preop-eratively, before any fistula formation, as a prophylactic tech-nique
B) Unplanned: when the surgeon create the arti-ficial fistula to solve an unplanned chronic or infect-ed fistula to avoid that infection spreads through all tis-sues planes of the neck [7,9].
Classification of surgical pharyngostomas
We created the surgical pharyngostomas in our laryngecto
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Martin et al. (2017)Email:
Ann Otolaryngol Rhinol 4(2): 1162 (2017) 2/3
my patients in three clinical situations:
a) Intraoperative, after the laryngecto-my, as a Planned Pharyngostoma , before the formation of a un-planned pharyngocutaneous fistula ( prophylactic technique).
b) Along postoperative period, after the forma-tion of a chronic or an infected fistula, as a Controlled Pharyn-gostoma, in order to protect the remaining pharyngeal su-ture and carotid or jugular exposure.
c) When the fistula began to bleed during nursing care be-cause severe wound breakdown. After carotid or jugular sys-tem ligation, we made an Emergent Submental Pharyngostoma.
General principles for management of postlaryngec-tomy fistula
The fundamental principles in the management of fistu-la after larygectomy were described by Stell and Cooney [11]. Planned submental pharyngostoma technique had been well de-scribed in the literature [6-9, 12, 13]. We used in our patients the classical technique, with no personal variations. Guidelines for pharyngostoma closure were well described [3,13]. In our patients, fasciocutaneous flap (deltopectoral flap of Bakamjiam) and pediculated pectoral major flap were used for surgical clo-sure after healing the pharyngostome [14].
CASE PRESENTATIONWe made five surgical submental pharyngostomas in our pa-
tients. One of these surgical pharyngostomes were made intra-operatory, after the laryngectomy and before fistula formation (a pro-phylactic planned pharyngostoma ) and the other four pharyn-gostomas along the postoperatory phase, after unplanned fis-tula formation. We describe each patient who needed a surgi-cal pharyngostoma in our study:
Patient 1
In one patient we created a minipharyngostoma intraopera-tory after a high risk salvage laryngectomy and before fistula formation, as a Planned Prophylactic Pharyngostoma. We could not use pectoral flap the laryngectomy due to a previous non-oncologic surgery in pectoral area. Vascular neck status was very poor because a heavy chemoradiation therapy. After 3 weeks, we closed the pharyngostoma successfully with circular inverted flaps and a submental flap.
Patients 2,3
Along postoperatory phase, two patients presented an un-planned infected fistula without healing after four weeks with in-tensive nursing and nutritional support. We returned to the op-erating room and, after a meticulous surgical wound debri-dement, we created a safe Controlled Submental Pharyngos-tome in each two patient. We closed the two pharyngosto-mas three weeks after with a fasciocutaneous deltopecto-ral flap in one patient and with a pediculated myocutaneous pecto-ral flap in the another patient. The surgery was successful.
Case 4,5
In another two laryngectomy patients, the unplanned fis-tula began to bleed during nursing care in postoperato-ry phase. We had to return immediately to the operation room. Pa-
tient exhibited vessel necrosis (thyroid artery necro-sis in one patient and internal jugular vein rupture in the oth-er patient). Urgent vessels ligation and a wide wound debri-dement were made in the two patients. In the patient with jugu-lar rupture, a myocutaneous pectoral flap was used to cov-er the pharyngeal suture line and to protect the carotid ar-tery. In the two patients, we created a controlled mid-line pharyngostoma for saliva (an Emergency Pharyngos-toma ). The surgery was successful and we closed these pharyn-gostomas four weeks later with a fasciocutaneous deltopecto-ral flap in one patient and with local flaps in the other.
DISCUSSIONIn spite of the high incidence of fistula formation age of chem-
oradiation therapy [1], no consensus exit about the best tech-nique to optimize pharynx wound healing. So, prevention is bet-ter than any treatment [2]. In effort to minimize wound healing complications in high risk laryngectomy patients, some surgeons recommend the conservative concept of intraoperatory prophy-lactic planned pharyngostoma after laryngectomy [6-12]. Krespy [6] suggest to create a pharyngostoma during laryngectomy if we are sure that a complex pharyngostoma will take place dur-ing the postoperatory phase. Sundaram [8], after a rate of 67% of unplanned fistulas after salvage laryngectomy, began to use the controlled pharyngostoma concept in his last 11 salvage larynge-ctomy without regional myocutaneous flaps or free-tissue trans-fers. No fistula formation developed in his patients. We created one surgical pharyngostoma in a salvage-laryngectomy patient with a poor physical health who needed a simple and safe re-construction with low incidence of postoperative complications [5]. The patient had a pervious non-oncologic surgery in pectoral area and microvascular anastomosis was not possible due to the vascular status of neck after chemoradiation [4].
A comprehensive review of literature showed different and controversial results about the management after postlaryngec-tomy fistula formation. Until know, no study proposed a standard clinical guideline or rule for surgical management and closure of these unplanned chronic fistulas. Many surgeons published their techniques to manage the post-laryngectomy fistulas [6-11] but sometimes, modern reconstructive techniques are very aggres-sive operations for a our unhealthy patients [1,4,5]. After unfavo-rable results with a postlaryngectomy fistula with intensive nurs-ing and nutritional support, we managed theses complex pharyn-gostomes with conservative principles, in order to conversion an unsafe wound in a safe wound in a high-risk laryngectomy pa-tient. Aggressive modern reconstructive techniques sometimes are not indicated in these patients [1,4,5 ]. Some authors still recommending considering the creation of a controlled pharyn-gostoma to minimized the risk of major wound complications in high risk patients [6-11]. We present our successfully experience with this conservative approach in two chronic and infected fis-tulas after four weeks of intense nutritional and nurse support. Neumann [7] treats these postlaryngecotmy fistulas the sooner after diagnosis of fistula was archived, with his “early surgical pharyngostoma” concept: the unsafe fistula was modified by an early and safe artificial pharyngostoma. A very complex pharyn-gocutaneous fistula following a large oncologic resection with a gastric transposition was solved by Stew [9] with an easy surgical pharyngostome in a T4 hypopharyngeal carcinoma.
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Ann Otolaryngol Rhinol 4(2): 1162 (2017) 3/3
FINAL CONSIDERATIONSFrom the review the literature and from our limited surgical
experience about five patients, we suggest some possible indica-tions for surgical mini-pharyngostoma in very selected patients as a low-morbidity surgical alternative to aggressive modern re-construction techniques. Further studies and experiences will be required to confirm these surgical indications.
CONFLICT OF INTERESTThis research is part of a communication in accept-proc-
ess at IFOS2017.
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Martin Villares C, Gonzalez Gimeno MJ, Diez Gonzalez L, San Roman CJ, Dominguez CJ, et al. (2017) Surgical Mini-Pharyngostoma: A Safe Technique for Unsafe Laryngectomy Patients. Ann Otolaryngol Rhinol 4(2): 1162.
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