The anatomy and complications of “t” versus vertical closure of the hypopharynx after laryngectomy

Abstract

The early postoperative hypopharyngeal anatomy of 37 consecutive patients undergoing total laryngectomy at the Boston Veteran's Administration Hospital between July 1977 and April 1980 was studied by barium swallow radiographs and correlated with the technique of closure. The "pseudoepiglottis," a structure radiographically resembling a normal epiglottis, was seen arising from the anterior hypopharynx near the base of the tongue in 21 of 28 evaluable patients. It occurred in all patients with vertical closures vs. 67% of patients with a "T" shaped closure. The average length in the "T" closure group was 9.6 mm (range 0-35) vs. 18.4 mm (6-40) in the vertical group, a statistically significant difference (p less than 0.05). Radiologic strictures occurred in 39% of all patients, dysphagia in 29%, fistulae in 18%, and sinus tracts in 14%. All complications occurred more frequently in the vertical closure group. Patients who received preoperative cis-platinum bleomycin chemotherapy and postoperative irradiation had 50% dysphagia and 67% stricture rates. The average ratio of the width of the retropharyngeal space to that of C4 was 0.48 in stricture patients vs. 0.29 in non-stricture patients (statistically significant at the p less than 0.01 level). This ratio taken in the early postoperative period may help predict which patients will develop strictures.

Laser treatment of symptomatic anterior pharyngeal pouches after laryngectomy

“…Several studies mention percentages of 35% up to 100%. [1][2][3][4] In 1962, Kirchner and Scatliff 1 reported on anterior pharyngeal pouches and suggested the term ''pseudo-diverticulum.'' Hartley et al 5 used the term ''pseudo-epiglottis'' because of the resemblance of the posterior wall of the anterior pharyngeal pouch to the epiglottis on a barium swallow.…”

“…According to the literature, their occurence varies from 35% to 100%. [1][2][3][4] Anterior pharyngeal pouches can cause a prolonged mealtime, regurgitation, accumulation of food and a foreign body sensation, finally leading to a decreased enjoyment in eating. Whether or not these symptoms are related to the anterior pharyngeal pouch or should be seen as a ''normal'' postlaryngectomy effect is still a matter of debate.…”

Transoral Robotic Surgery Total Laryngectomy

“…The ideal pharyngotomy closure has been a subject of debate. In order to reduce the development of pharyngeal shelf and associated neopharyngeal diverticula [6], Davis et al [7] advocated the T-shaped pharyngotomy closure to improve postlaryngectomy swallowing function. Currently, pharyngotomy closure is routinely performed in a vertical, linear fashion, to minimize technical error as well as reduce blood supply at the corners of the T-shaped suture line, as postulated.…”

“…Currently, pharyngotomy closure is routinely performed in a vertical, linear fashion, to minimize technical error as well as reduce blood supply at the corners of the T-shaped suture line, as postulated. However, common practice leaves the concerns of Davis et al [7] unresolved. The mucosal-sparing TORS incision allows for a substantial improvement in pharyngeal defect size.…”

Transoral Robotic Surgery Total Laryngectomy: Evaluation of Functional and Survival Outcomes in a Retrospective Case Series at a Single Institution

“…This is a technically less demanding closure than previously described T-shaped closure techniques [14] and theoretically reduces the risks of pharyngeal shelf and neopharyngeal diverticula formation with associated poor swallowing outcomes [15]. All senior authors reporting on TORS-TL close the pharyngotomy in a horizontal orientation, with Lawson et al [9] also applying fibrin glue over the incision for watertight closure.…”