Keywords
complications - CO
2 laser - larynx - carcinoma
Introduction
During the seventies, Strong and Jako proposed the use of endoscopic laser surgery
in the treatment of laryngeal lesions.[1]
[2] Since then, the transoral laser microsurgery (TLM) has been gaining ground in the
world of laryngeal oncology, establishing itself as an effective option in the management
of malignant tumors of the glottis, supraglottis, and hypopharynx.
The treatment's advantages, such as magnification generated by the microscope, allows
us to make limited resections to differentiate healthy tissue from that which has
been affected, thus, preserving adjacent disease-free areas. In turn, it has allowed
a decrease in the number of tracheotomies and in the use of nasogastric tubes.[3]
[4]
[5] Moreover, it is possible to achieve oncological benefits similar to those obtained
through open surgery in patients with early and properly selected tumor stages.[5] The results reported in the literature show all patients that underwent this treatment
presented relatively low rates of complications.
However TLM is not a harmless technique. Therefore, the aim of this study is to describe
the complications that occurred in a group of patients treated for glottic and supraglottic
carcinomas in all stages by TLM in a tertiary hospital.
Methods
A retrospective analysis of the patients diagnosed with squamous cell carcinoma (SCC)
of the glottis and supraglottic for all stages (T1, T2, T3, T4), N −/+, M −/+ was
performed according to the criteria of the Union Internationale Contre le Cancer (UICC)
and the American Joint Committee on Cancer (AJCC) in a tertiary hospital. We included
in the study patients treated with TLM between January 2009 and March 2012. We identified
cases by searching the medical records of our department using the codes from the
International Classification of Diseases (ICD) −9. The Ethics Committee of our institution
approved this study.
By reviewing medical records we obtained demographic data (age, gender), medical history,
tumor stage, diagnostic tests information, histological findings, complications, and
type of surgery. In the final analysis, only complications strictly associated with
the surgical technique were included. We excluded complications associated with anesthesia
or exacerbation of chronic diseases that were not possible to associate with the use
of this technique. The type of complications were classified according to the stage
of presentation: intra-operatively or post-operatively and immediate or delayed.
Before the surgery, an interdisciplinary committee specialized in head and neck tumors
discussed each case. Patients with lesions suspicious for malignancy were scheduled
for laryngeal microsurgery with biopsy; those that were positive underwent glottic
or supraglottic CO2 laser resection. After surgery, the committee reviewed pTNM and assessed the need
for reoperation or additional treatment with radiotherapy (RT).
For the surgical procedure, all of the patients received general anesthesia with orotraqueal
intubation with special tubes for laser surgery (Covidien - Mallinckrodt, Dublin,
Ireland). The anesthetist reduced their O2 level using narcotic gases, and protected the balloon tube in its distal portion
with cotton sponges moistened with saline. The resection was performed using a Lumenis
CO2 laser device (Yokneam, Israel), with a power setting of 4–8 W, used in superpulsed
mode and continuous setting, varying in size and shape of the spot according to the
moment of the surgery by using the micro- manipulator Acublade (Lumenis). The type
of cordectomy was classified according to the European Laryngological Society (ELSOC)
proposal for glottic[6] and supraglottic endoscopic resection.[7] In the case of small tumors (T1a, T1b), whenever possible, en bloc resection was
attempted. After resection, the piece was pinned and oriented on a corkboard. In bulky
tumors (T2, T3, or T4), most cases required piecemeal resections. Laser vestibulectomy
was performed when the lateral or anterior portion of the tumor was hidden by a ventricular
fold. In all cases, the surgeons tried to achieve a margin of healthy tissue of 2–3mm,
trying to preserve the functions without affecting the oncological radicality of the
procedure.
In our Department, patients treated for head and neck malignant tumors are followed
for at least five years at the Department of Head and Neck Oncology. For this study,
however, we considered a group of patients that had been followed for a minimum of
36 months.
We conducted statistical analysis using SPSS for Windows, version 20.0 (SPSS, Inc.,
Illinois, U.S.A.). Quantitative variables in the study were expressed as mean ± standard
deviation. We applied the chi-square test to study differences in hospital stay, the
need to place SNG, or dysphagia, depending on T stage. We analyzed the correlations
between variables using the Spearman test.
Results
From a total of 131 interventions (98 primary, 33 reoperations), 98 patients met the
inclusion criteria. Ninety-four (95.9%) patients were men and 4 (4.1%) patients were
women. The mean age of the study group was 64.2 years (± 10.7 years = Min 45 / Max
88). Of these, 22 (22.4%) were diabetic, 40 (40.8%) were hypertensive, 93 (94.9%)
were smokers, and 41 (41.8%) consumed alcoholic beverages. Regarding to tumoral stage,
45 (45.9%) patients were classified as pT1, 32 (32.7%) as pT2, 15 (15.3%) as pT3,
and 6 (6.1%) as pT4 ([Table 1]). Eighty-seven (88.8%) patients were classified as N0, 6 (6.1%) as N1, 4 (4%) as
N2a, and 1 (1%) as N2b. In the sample of patients included in the study, there were
no cases of distant metastases. The mean follow-up was 40.1 months (± 14 = Min 5 /
Max 72). As for most frequent type of cordectomy, in glottis tumors, Type 4 was performed
in 28 (28.6%) patients, whereas, for supraglottic tumors, Type IVb was performed in
12 patients (12.2%) ([Table 2]). The results will be presented in subgroups as glottis (GTG), supraglottic (STG),
and transglottic tumors (TTG). The mean hospital stay was 3.6 days (± 8.3 = Min 1
/ Max 66) for glottic carcinoma, 13.2 days (± 25.5 = Min 2 / Max 149) for STG group,
and 38 days (± 54.8 = Min 2 / Max 116) for TTG group, being statistically significant
when comparing the periods for different locations (p < 0.0001).
Table 1
Pathological tumoral stage, regional lymph nodes, and distant metastases
|
N0
|
N1
|
N2
|
M
|
Total
|
|
pT1
|
44
|
1
|
0
|
0
|
45
|
|
pT2
|
28
|
2
|
2
|
0
|
32
|
|
pT3
|
9
|
3
|
3
|
0
|
15
|
|
pT4
|
6
|
0
|
0
|
0
|
6
|
|
Total
|
87
|
6
|
5
|
0
|
98
|
Abbreviations: M, distant metastases; N, regional lymph node patient groups; pT, pathological
tumoral stage.
Table 2
Glottic and supraglottic cordectomy practiced as rated by the ELSOC
|
Type of cordectomy
|
pT1
|
pT2
|
pT3
|
pT4
|
Total (%)
|
|
GLS Type III
|
2
|
0
|
0
|
0
|
2 (2.04%)
|
|
GLG Type IV
|
27
|
1
|
0
|
0
|
28 (28.57%)
|
|
GLS Type Va
|
14
|
8
|
0
|
0
|
22 (22.44%)
|
|
GLS Type Vb
|
0
|
3
|
3
|
1
|
7 (7.14%)
|
|
GLS Type Vc
|
0
|
5
|
1
|
2
|
8 (8.16%)
|
|
GLS Type Vd
|
0
|
1
|
0
|
1
|
2 (2.04%)
|
|
SGL Type IIa
|
1
|
2
|
0
|
0
|
3 (3.06%)
|
|
SGL Type IIb
|
0
|
1
|
1
|
0
|
2 (2.04%)
|
|
SGL Type IIIa
|
0
|
5
|
0
|
1
|
6 (6.12%)
|
|
SGL Type IIIb
|
0
|
1
|
3
|
0
|
4 (4.08%)
|
|
SGL Type IVa
|
0
|
3
|
2
|
0
|
5 (5.10%)
|
|
SGL Type IVb
|
1
|
2
|
8
|
1
|
12 (12.2%)
|
|
Total
|
45
|
18
|
4
|
4
|
98 (100%)
|
Abbreviations: ELSOC, European Laryngological Society; GLS, glottic laser surgery;
pT, pathological tumoral stage; SGL, supraglottic laser surgery.
In the group that had intraoperative complications, one patient with a transglottic
tumor (pTIVa) suffered ignition of the airway, which the surgical team was able to
control without vital impact for the patient, while another lost a tooth after surgery
(2/98 = 2.04%). There were no skin burns or eye injuries in any of the patients nor
laser injuries on operating room personnel. Immediate post-surgical complications
occurred in 6 patients (6/98 = 6.1%), five of them presented post-surgical bleeding
and required clipping of the superior laryngeal pedicle. Two patients in the STG (1pT3,
1 pTIVa), two patients in the GTG (1 pTIVa pT3), and another patient from the TTG
(pTIVa), a total of five patients, required urgent tracheotomy postoperatively. Another
patient from the STG (1pT2) needed urgent tracheostomy due to acute dyspnea secondary
to airway edema ([Table 3]).
Table 3
Intraoperative, immediate, and delayed postoperative complications associated with
laser surgery
|
Complications
|
N
|
%
|
Type
|
|
Intraoperative
|
2
|
2.04%
|
One patient lost a tooth and another suffered ignition of the airway.
|
|
Immediate postoperative
|
6
|
6.1%
|
5 episodes of post-surgical bleeding and 1 episode of dyspnea secondary to airway
edema.
|
|
Delayed postoperative
|
13
|
13.2%
|
8 patients suffered aspiration pneumonia. 2 patients had cervical abscess (one of
them complicated with mediastinitis). 2 patients had stenosis of the laryngeal vestibule.
1 patient had thyroid cartilage chondritis.
|
|
Total
|
19
|
19.38%
|
−
|
Abbreviations: Min, minimum; Max, maximum.
Moreover, 42 (42.9%) patients required the use of a nasogastric feeding tube (NFT)
in the immediate postoperative period, 13 (20.6%) in the GTG (pT1 2, 4 pT2, 4pT3,
and 3 pT4a), 25 (80.6%) in the group of STG (1 pT1, 10 pT2, pT3 13, pTIVa 1), and
4 (100%) in the group of TTG (1 pTIVa pT2 and 3) (p < 0.0001). The mean duration of NFT was 0.9 days (± 2.2 days = Min 0 / Max 13) in
the group of patients treated for glottic tumors, 6 days (± 5.7 days = Min 0 / Max
29) in the group with supraglottic tumors, and 15.5 days (± 19.2 days = Min 2 / Max
44) in the group of patients treated for transglottic tumors. Thus, the difference
between the mean duration of the NFT in patients treated for supraglottic and transglottic
tumors regarding patients by glottic tumors was statistically significant (p < 0.0001) ([Table 4]).
Table 4
Mean hospital stay, percentage of placement, and duration of NFT according to tumor
location
|
Glottic
(Mean = Min / Max)
|
Supraglottic
(Mean = Min / Max)
|
Transglottic
(Mean = Min / Max)
|
p
|
|
Mean hospital stay
|
3.6 days
( ± 8.3 = 1 / 66)
|
13.2 days
( ± 25.5 = 2 / 149)
|
38 days
( ± 54.8 = 2 / 116)
|
< 0.0001
|
|
NFT
|
20.6%
|
80.6%
|
100%
|
< 0.0001
|
|
NFT mean duration
|
0.9 days
( ± 2.2 days = 0 / 13)
|
6 days
( ± 5.7 days = 0 / 29)
|
15.5 days
( ± 19.2 days = 2 / 44
|
< 0.0001
|
Abbreviations: Min, minimum; Max, maximum; NFT, nasogastric feeding tube.
During post-surgical follow-up, 13 (13/98 = 13.2%) patients had some type of late
complication. Eight (8.1%) patients had aspiration pneumonia after surgery, 7 patients
in the STG (2 pT2 and 5 pT3) and one in the GTG (pTIVa). Two (2.04%) patients had
a cervical abscess, both in the STG (pT2 and pT3), and one of them complicated by
mediastinitis. Two (2.04%) patients from the STG group (pT3) suffered laryngeal stenosis
after treatment with TLM, and up to 3 interventions were required to achieve local
control for both. One (1%) patient on whom the surgeon had to expose the thyroid cartilage
during tumor resection required accurate hospitalization for medical treatment due
to chondritis (Ca. glottis pT4a). Fourteen (14.2%) patients required TL: 6 (6.1%)
of them secondary to aspiration pneumonia, 4 in the STG (3 pT3, 1 pT4a), and 2 in
TTG (2pT4a). For the rest of TL, the surgical team had to achieve local control of
the disease, which they were not able to achieve by TLM. Post-surgical delayed complications
were more frequent in the TTG group, affecting 50% (2/4) of patients, and in the STG
group, affecting 41% (13/31) of patients (p < 0.001). Furthermore, complications were statistically more frequent in larger tumors
for all locations (p < 0.001) ([Table 3]).
During follow-up, 40 (40.8%) patients had some degree of postoperative dysphagia.
Twelve (20.04%) from the GTG group (3pT1, 3 pT2, pT3, and pT4a 2), 25 (80.64%) from
the STG group (2 pT1 10 pT10 12 pT3 1 pT4a), and 4 (100%) in the TTG had some type
of dysphagia, most of them improving after recovery from surgical site and through
swallowing rehabilitation. Nonetheless, it is important to note that we do not have
a standardized swallowing rehabilitation protocol in patients treated with partial
laryngeal surgery. In 6 (6.1%) patients, catheterization percutaneous gastrostomy
(PEG) was necessary (4 pT3 supraglottic, 1 pT4a glottis, and 1 Ca. transglottic pT4a).
Regarding comorbidities, alcohol consumption and snuff consumption were statistically
related to the occurrence of complications (p < 0.001); however, we found no statistical correlation between diabetes (p = 0.863) and the occurrence of complications. In this study, no patient died from
complications of TLM.
Discussion
Authors have previously classified complications from laser surgery as intraoperative
and postoperative (immediate or delayed), also being divided into minor and major,
minor referring to complications that resolve spontaneously or can be treated in the
office under local anesthesia without major consequences for the patient, while major
complications are those requiring intensive medical treatment and even revision surgery.[3]
In this retrospective study, we analyzed the results of a group of 98 patients and
131 CO2 laser interventions (98 primary, 33 reoperations) due to laryngeal tumors (pT1, pT2,
pT3, and pT4) treated by primary intervention by TLM. We found that incidence of intraoperative
complications was low, affecting only 2% of patients; whereas immediate postoperative
complications occurred in 6.1% and delayed in up to 13.2% of patients. None of them
were fatal.
Among the various types of complications that can affect patients, post-surgical bleeding
is the most feared. In our series, this complication represents 5.1% of the immediate
post-surgical complications, affecting 6.4% of patients in the STG, 3.2% of GTG, and
25% of TTG (¼). Vilaseca et al[3] reported 8% of bleeding in a series of 275 patients, of which 6.9% were in the group
with supraglottic tumors and 2.9% had glottic tumors. Similarly, Steiner and Ambrosch[8] reported bleeding rate of 7% in supraglottic tumors and 0% in glottic tumors; whereas
authors like Peretti et al,[9] Remacle et al,[10] and Canis et al[11] reported 4, 4.4, and 9% of episodes of post-surgical bleeding from treatment of
supraglottic tumors. In our series, no late bleedings were evident; however, we believe
these complications should be considered, as they are even more dangerous because
the patient is at home and, thus, the possibility of a fatal outcome is higher.[12] For this reason, some authors recommend performing prophylactic electrocoagulation
of blood vessels in the laryngeal pedicle. As for associating TLM with neck dissection,
some authors suggest ligation of the laryngeal branches of the external carotid artery.[12] Moreover, Ellies and Steiner, in a study that included 1,528 patients treated for
TLM, showed 4.7% (72 patients) incidence of post-surgical bleeding. External carotid
ligation was required on 7 of such cases.[13]
In our study, 8.1% of patients suffered aspiration pneumonia after surgery. Our finding
was lower than that described by Roh et al,[14] who reported an incidence of 11.5% of aspiration pneumonia after TLM and higher
than that described by Vilaseca et al,[3] who reported a rate of 6.1% of pneumonia in the treatment of glottic, supraglottic,
and hypopharyngeal tumors, and 2% described by Canis et al[11] after treatment with TLM of supraglottic tumors. Six (6.1%) patients included in
our study, all of them over 65 years old, had to undergo TL due to recurrent episodes
of aspiration pneumonia; 4 of them received treatment for extended supraglottic tumors,
confirming the limited indication of these cases.
Regarding cervical complications, 2 (2%) patients had cervical abscess formation,
one complicated by mediastinitis. No case of emphysema or cervical fistula was evident.
However, Vilaseca et al[3] reported development of cervical emphysema in 3 patients and cervical fistula in
one patient in their study, while Peretti et al[9] describe two other cases of persistent cervical fistula after performing temporary
tracheotomy in their patients. Another 2% of our patients had stenosis of the laryngeal
vestibule after extensive laser resection of supraglottic tumor, a higher incidence
compared with 0.4% stenosis found in Canis et al[11] Only one (1%) patient included in the study required treatment for chondritis in
the thyroid cartilage. These findings corroborate those described by Vilaseca et al,[3] showing 0.72% of cases of thyroid cartilage chondritis after TLM.
In our study, 42% of patients required NFT; 20.6% of these were from the GTG group,
80.6% from the STG, and 100% of those patients treated in the TTG. It is important
to note that, in most cases, the placement of NFT follows a security principle due
to the width of resection. During admission, swallowing was evaluated and the NFT
was removed after achieving adequate swallowing; hence, the difference in duration
between the various groups. In 6.1% of patients, on the other hand, PEG placement
was necessary due to deglutition complications. Bernal-Sprekelsen et al,[15] in a study in of 210 patients treated for tumors of the larynx and hypopharynx in
stage T2 to T4, report an average use of NFT of 23.2% in patients with small tumors
and 63% in advanced tumors. Of these patients, 6.2% required gastrostomy and another
3.8% required tracheostomy due to deglutition difficulties. Moreover, Canis et al[11] reported NFT averaging 74% during the first 14 days after surgery, requiring that
the NFT be kept during 30 days in 18% of cases, of which 6% would require keeping
it between 31 and 90 days. It is important to remember Canis et al. conducted their
study in patients with supraglottic tumors and that most of these patients had advanced
tumoral stages (III and IV). Finally, of all patients in the study by Canis et al,[11] 8 (3%) required additional measures due to swallowing failure, 5 patients would
require gastrostomy, and 3 other total laryngectomy.
In our sample, air ignition was evident in one case, which we were able to treat immediately
without conditioning further consequences for the patient. This occurred despite using
special orotracheal tube for laser surgery and relying on the invaluable collaboration
from anaesthetists to reduce levels of O2, and taking surgical precautions such as
placing cottonoid sponge with saline. Nonetheless, it is clear that the risk of ignition
is always present, even if every precaution is taken.
Finally, it is important to highlight that the complication rate for glottic, supraglottic,
and hypopharyngeal tumors, at all stages, that have been operated on by experienced
surgeons ranges between 3% and 19%.[3]
[12]
[16]
[17] This hypothesis may be confirmed by comparing tumor size, tumor location, and level
of surgeon experience with the occurrence of complications.[3] Moreover, we must emphasize the limitations of our study. Given that it is a retrospective
study, there is a possible risk of bias in our results, as it relies on the number
of incidents reported by the surgeon in the surgical protocol and the rate of complication
reported in the medical reports during follow-up.
Conclusion
Previous studies have compared the use of TLM showing good oncologic results and low
complication rates, compared with traditional open surgery during the intervention,
in the immediate and delayed postoperative period and in the long term, with respect
to RT.[11]
[18] However, it is important to consider that life-threatening complications such as
bleeding, dyspnea, or ignition of the air[19] may appear in this type of surgery, requiring immediate attention and close post-surgical
follow-up due to the effects on these patients. In the long term, follow-up is also
important to assess the occurrence of recurrent pneumonia and swallowing disorders
among such patients, as thee are complications that will put the patient's life at
risk or reduce their quality of life.
