Factors associated with gastrostomy tube dependence following salvage total laryngectomy with microvascular free tissue transfer

Worley, Mitchell L.; Blair, Julie; Momin, Suhael; Day, Terry A.; Hornig, Joshua D.; Skoner, Judith M.; Huang, Andrew T.

doi:10.1002/hed.25367

Cited by 12 publications

(17 citation statements)

References 26 publications

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“…Overall, sufficient oral nutrition was accomplished in more than two-thirds of patients, while permanent G-tube dependence was not commonly required. Symptomatically and function-related stenosis causing dysphagia are frequent sequelae after laryngectomy found in approximately one-third of our patients, which is in accordance to previous reported data [7,[15][16][17]. In particular, stenosis was noticed in more than half of the patients after TLTP, underlining the importance of tumor site and extent of resection.…”

Section: Discussionsupporting

confidence: 92%

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

Grasl

Schmid

Heiduschka

et al. 2021

Cancers

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(1) Objective: To evaluate long-term functional outcome in patients who underwent primary or salvage total laryngectomy (TL), TL with partial (TLPP), or total pharyngectomy (TLTP), and to establish a new scoring system to predict complication rate and long-term functional outcome; (2) Material and Methods: Between 1993 and 2019, 258 patients underwent TL (n = 85), TLPP (n = 101), or TLTP (n = 72). Based on the extent of tumor resection, all patients were stratified to (i) localization I: TL; II: TLPP; III: TLTP and (ii) surgical treatment (A: primary resection; B: salvage surgery). Type and rate of complication and functional outcome, including oral nutrition, G-tube dependence, pharyngeal stenosis, and voice rehabilitation were evaluated in 163 patients with a follow-up ≥ 12 months and absence of recurrent disease; (3) Results: We found 61 IA, 24 IB, 63 IIA, 38 IIB, 37 IIIA, and 35 IIIA patients. Complications and subsequently revision surgeries occurred most frequently in IIIB cases but rarely in IA patients (57.1% vs. 18%; p = 0.001 and 51.4% vs. 14.8%; p = 0.002), respectively. Pharyngocutaneous fistula (PCF) was the most common complication (33%), although it did not significantly differ among cohorts (p = 0.345). Pharyngeal stenosis was found in 27% of cases, with the highest incidence in IIIA (45.5%) and IIIB (72.7%) patients (p < 0.001). Most (91.1%) IA patients achieved complete oral nutrition compared to only 41.7% in class IIIB patients (p < 0.001). Absence of PCF (odds ratio (OR) 3.29; p = 0.003), presence of complications (OR 3.47; p = 0.004), and no need for pharyngeal reconstruction (OR 4.44; p = 0.042) represented independent favorable factors for oral nutrition. Verbal communication was achieved in 69.3% of patients and was accomplished by the insertion of voice prosthesis in 37.4%. Acquisition of esophageal speech was reached in 31.9% of cases. Based on these data, we stratified patients regarding the extent of surgery and previous treatment into subgroups reflecting risk profiles and expectable functional outcome; (4) Conclusions: The extent of resection accompanied by the need for reconstruction and salvage surgery both carry a higher risk of complications and subsequently worse functional outcome. Both factors are reflected in our classification system that can be helpful to better predict patients’ functional outcome.

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Section: Discussionsupporting

confidence: 92%

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

Grasl

Schmid

Heiduschka

et al. 2021

Cancers

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“…However, tumor stage was not identified as a confounding factor in our analysis for dysphagia outcomes, and both reconstruction type and type of salvage operation (TL vs. TL with partial pharyngectomy) were independent prognosticators on multivariable analysis, with dysphagia being 2.66 times more likely in patients treated with TL and partial pharyngectomy compared to those who only underwent a TL without pharyngectomy. A recent study by Worley et al also observed a progressive increase in stricture rate and resulting dysphagia with increasing extent of pharyngectomy ( 51 ). In the total patient group (both TL patients and patients with TL and partial pharyngectomy), reconstruction with a muscle onlay PM flap proved independently associated with more dysphagia when compared to inset myocutaneous PM flap and to primary closure without tissue transfer.…”

Section: Discussionmentioning

confidence: 92%

Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

et al. 2020

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Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

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“…It should be noted that the SLC patients did have a higher need for adjuvant re‐irradiation (40%) compared to the MLFU group (17%) ( P = .01). Although the administration of re‐irradiation had no bearing on PCF formation because fistula rates were reported within the 30‐day postoperative window and prior to initiation of re‐irradiation, the deleterious effects of re‐irradiation may have further compromised these patients’ already limited functional pharyngeal structures 15 . Overall, G‐tube dependence within the STL population reconstructed with MVFTT remains a significant issue that underscores the rehabilitation challenges that these patients face.…”

Section: Discussionmentioning

confidence: 99%

“…After approval from the institutional review boards of Baylor College of Medicine (Houston, TX) and Medical University of South Carolina (Charleston, SC), the medical records of adult patients who underwent STL with MVFTT after primary radiation with or without chemotherapy from January 2010 to April 2019 for oncologic or palliative purposes were reviewed. Our institutions maintain de‐identified patient databases of MVFTT outcomes with results published in the literature on elderly, laryngectomy, and oral cavity reconstruction swallowing outcomes 14–17 . Only patients who underwent patched or tubed MVFTT reconstruction of the pharyngoesophagus were included, excluding those who had primary pharyngeal closure with muscle overlay MVFTT.…”

Section: Methodsmentioning

confidence: 99%

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

et al. 2020

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Objective To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. Methods Retrospective review. Results Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety‐six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)‐tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G‐tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). Conclusion Despite MVFTT reconstruction after STL, G‐tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. Level of Evidence 4 Laryngoscope, 131:E875–E881, 2021

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Factors associated with gastrostomy tube dependence following salvage total laryngectomy with microvascular free tissue transfer

Cited by 12 publications

References 26 publications

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

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