Keywords
total laryngectomy - laryngeal cancer - pharyngocutaneous fistula
Introduction
Laryngeal cancer represents 4.5% of all malignancies and is one of the most common
cancers of the upper aerodigestive tract.[1]
The main modalities of surgical treatment include transoral laser microsurgery (TLM),
open preservation surgery (especially supracricoid laryngectomy), and total laryngectomy
(TL). In the recent years, we have performed an increasing number of open preservation
surgery, even in elderly patients,[2] which can be attributed to the improvement of diagnostic approaches and to the improvement
in the preoperative staging,[3] but also to better living conditions for the elderly. However, until today, we have
observed many patients with the advanced stage of the disease who needed a demolitive
treatment. Also, simultaneously, there has been an increase in the average age of
the patients who underwent a TL. This phenomenon is due to the increase of survival
and, therefore, to the aging of the population. In the elderly, due to the presence
of comorbidities, the surgical approach more appropriate in many cases remains a TL.
In 1971, for the first time, Lukyanchenko et al[4] reported the use of a stapler for the closure of the esophagus to reduce surgical
times and postoperative complications, such as pharyngocutaneous fistula (PCF).
Over time, the type of esophageal closure technique with a stapler has changed from
the initial open technique to the semiclosed and closed techniques. However, the experiences
reported in the literature are still scarce and nonunique, especially in relation
to the appearance of PCF.
A PCF is a postoperative complication that increases the length of hospital stay and
delays oral feeding. It may be a condition that severely compromises the health of
the patient, especially when they are elderly with comorbidities.
In the present study, we report our experience with mechanical closure of pharyngoesophagectomy
performing, for the first time with a stapler, a horizontal suture instead of a vertical
suture. We perform the closure of the pharyngoesophagectomy with a horizontal suture,
as reported by Shah et al[5] because, in the semiclosed technique, a pharyngoesophagectomy that corresponds to
the horizontal portion of the T-shaped manual suture of the traditional TL remains.
Materials and Methods
The present nonrandomized study was performed on consecutive patients with pathologically
proven squamous cell endolaryngeal carcinoma.
The inclusion criteria for the patients were: endolaryngeal carcinoma with no extension
to the suprahyoid epiglottis, to the pyriform sinus, and to the postcricoid extension,
patients not eligible for transoral laser surgery or organ preservation surgery.
All of the patients were informed of the benefit, of the risks, and of the complications
of this surgical technique and of its alternatives (radiotherapy or chemoradiotherapy)
before they gave their informed consent.
The protocol was approved by the Institutional Review Board (IRB). All of the patients
were preoperatively submitted to a computed tomography (CT) scan and to a microlaryngoscopy
to confirm the extent of involvement of the tumor and to exclude laryngopharyngeal
invading. The tumors were staged according to the 7th edition of the tumor node and
metastasis (TNM) classification[6] established by the American Joint Committee on Cancer. The TL was performed using
a mechanical linear stapler for the pharyngoesophageal suture with the semiclosed
technique. The neck dissection was performed according to the side and extension of
the primary tumor and the Lymph nodal (N) clinical classification.
The demographics and clinical data of the patients, along with comorbidities, histopathology
of the resection margins, nasogastric tube (NGT) removal time, length of hospitalization,
and postoperative complications were collected.
Surgical Technique
One day prior to the surgery, a laryngoscopy was performed preoperatively in the office
setting with a distal-chip flexible nasopharyngoscope Exera II (Olympus, Tokyo, Japan).
A traditional laryngectomy was performed in the initial steps. When the larynx was
connected to the hypopharynx with the remaining thin mucosa-submucosa ([Fig. 1]) layer, a small pharyngoesophagectomy (∼5 mm) was performed along the median line
at the level of suprahyoid region, and the free border of the epiglottis was pulled
down using Allis pincers 20 cm (NGS Instruments) to avoid trapping part of the epiglottis
between the jaws of the stapler. At this time, the larynx, hooking his tracheal termination,
has been pulled upward and a mild tension on the hypopharynx mucosa was performed
by an assistant and the stapler was inserted ([Fig. 2]).
Fig. 1 Complete dissection of the larynx from the anterior wall of the esophagus.
Fig. 2 Insertion of the linear stapler oriented with its open jaws horizontally (perpendicularly
to the esophagus)
We have used for the present study the Proximate PLC-Linear Cutter reusable stapler
(Ethicon Inc., Somerville, NJ, USA), which affixes two double staggered rows of stitching
in titanium, simultaneously passing a scalpel in the middle of the two rows. It was
oriented with its open jaws horizontally (perpendicularly to the esophagus), then
it was activated and 4-fold rows of horizontal sutures line were performed ([Fig. 3]). The larynx was removed and specimens were taken from the surgical margins to be
evaluated extemporaneously. As traditionally, an intramuscular second suture layer
was made and a NGT feeding tube was introduced when the TL was completed.
Fig. 3 Pharyngoesophageal closure realized with horizontal suture by the mechanical semiclosed
technique.
Statistical Analysis
Statistical analysis was performed with the MedCalc software (MedCalc Software, Ostend,
Belgium) using the chi-squared test and the Fisher exact test. The Mann-Whitney test
and the independent sample t-test were used to compare age, NGT feeding tube removal
time, and length of hospitalization. All p-values are two-tailed, and p < 0.05 was considered significant.
Results
A total of 33 TLs were performed between 2014 and 2017 at the Otolaryngology Unit,
Azienda Ospedaliera Cannizzaro, Catania, Italy, using the linear stapler for pharyngoesophageal
closure.
Out of the total sample, 31 patients were male, and 2 were female. Their age ranged
from 48 to 84 years old (mean ± standard deviation [SD]: 69.3 ± 9.4; median = 72.8).
According to the TNM classification, 6 cases were classified as T1bN0, 6 as T2N0,
1 as T2N1, 8 as T3N0, 4 as T3N1, 1 as T3N2, 3 as T4N0, 3 as T4N1, and 1 as T4N2. Out
of the total 33 patients, 13 (39.3%) underwent selective or modified neck dissection,
5 underwent ipsilateral selective neck dissection, 5 underwent bilateral selective
neck dissection, 3 underwent modified neck dissection and contralateral selective
neck dissection, and 7 of the 33 patients were not submitted to neck dissection. A
total of 5 patients presented with metastatic lymph nodes and were treated with radiotherapy.
A total of 15 patients (45.4%) were ≤ 70 years old, and 18 were > 70 years old. Analyzing
the results in relation to age (
[Table 1]), 3 (20%) of the 15 patients ≤ 70 years old, and 10 (55.5%) of those aged > 70 years
old presented with tumors at an early stage (T1-T2) (p = 0.07), All of the T1-T2 classified tumors were previously treated. In the group
of younger patients, 4 had been previously treated with radiation therapy (1 case)
or with TLM (3 cases), while in the group of older patients, 9 had been previously
treated with radiation therapy (6 cases) or with TLM (3 cases). Comorbidities were
present in 4 of the 15 younger patients (3 hypertension, 1 psychiatric illness), and
in 13 of 18 elderly patients (3 hypertension, 4 diabetes, 1 renal infarction, 1 pulmonary
emphysema, 2 hepatopathy, and 2 hypertension and diabetes). The elderly group had
more comorbidities, which was statistically significant (p = 0.014). We found complications in 2 of the younger patients; one of them had comorbidities.
In older patients, a complication occurred in 4 of the 13 with comorbidities. In the
group of younger patients, the complications were postsurgically related (1 postsurgical
bleeding and 1 PCT); while, in the elderly, 2 out of 4 were surgery-related, while
2 were systemic complications (1 intestinal infarction, 1 postsurgical bleeding, 1
renal failure, 1 PCF). The occurrence of surgery-related complications was not significantly
different in the two groups ([Table 2]). The removal time of the NGT tube was of 6.8 ± 0.4 and of 7.8 ± 0.6 days in the
younger and older patients, respectively (p = 0.086). The time of hospitalization was higher in the group of elderly patients
(8.4 ± 0.5 versus 9.9 ± 1.6 days, p = 0.052), mainly due to comorbidities.
Table 1
Comparison of data between patients ≤ 70 and >70 years old
|
Data of the Patients
|
≤ 70 years old (n = 15)
|
> 70 years old (n = 18)
|
p-value
|
|
Age
|
|
|
< 0.001
|
|
mean ± SD (years old)
|
58.7 ± 5.6
|
77.2 ± 4.4
|
|
T status
|
|
|
0.007
|
|
T1-T2
|
3 (23%)
|
10 (77%)
|
|
T3-T4
|
12 (60%)
|
8 (40%)
|
|
N status
|
|
|
0.12
|
|
N0
|
8 (34.8%)
|
15 (65.2%)
|
|
N+
|
7 (70%)
|
3 (30%)
|
|
Neck dissection
|
|
|
0.16
|
|
No
|
7 (35%)
|
13 (65%)
|
|
Yes
|
8 (61.5%)
|
5 (38.5%)
|
|
Comorbidities
|
|
|
0.014
|
|
No
|
11 (68.8%)
|
5 (31.2%)
|
|
Yes
|
4 (23.5%)
|
13 (76.5%)
|
|
Complications
|
|
|
0.66
|
|
No
|
13 (48.1%)
|
14 (51.9%)
|
|
Yes
|
2 (33.3%)
|
4 (66.7%)
|
|
NGFTR time
Mean ± SD (days)
|
6.8 ± 0.5
|
7.8 ± 0.6
|
0.086
|
|
Length of hospitalization mean ± SD (days)
|
8.6 ± 0.5
|
9.7 ± 1.6
|
0.052
|
Abbreviation: NGFTR, Naso-gastric-feeding Tube removal; N, Node; SD, standard deviation;
T, Tumor.
Table 2
Correlation between comorbidities and postsurgical complications in the two groups
|
Patients
|
PSC
n (%)
|
No PSC
n (%)
|
|
≤ 70 years old
n = 15
|
1 (25%)
|
3 (75%)
|
|
> 70 years old
n
= 18
|
2 (15.4%)
|
11 (84.6%)
|
|
p-value
[*]
|
1.00
|
Abbreviation: PSC, postsurgical complications.
* Fisher exact test.
Discussion
The use of staplers in head and neck surgery was introduced late in relation to in
thoracic, abdominal, and gynecological surgery. However, although it has already been
introduced for 40 years for the closure of pharyngoesophagectomy in patients undergoing
TL, it has not yet had a wide acceptance. Studies published during these years are
still few and heterogeneous regarding the type of staplers used, the pharyngoesophagectomy
closing techniques, and the indication for TL (primary or salvage after radiotherapy).
Our study, like other studies,[7]
[8] include patients in the early tumor stages; however, in the early tumor stage, most
of these our patients were elderly patients were elderly. This difference can be attributed
to the fact that we prefer to treat early laryngeal cancers and local recurrence with
conservative treatments (endoscopic surgery or open surgery), and reserve TL or radiotherapy
only for cases that cannot benefit from further conservative treatment (TLM) or organ
preservation surgery, as supracricoid laryngectomy. It is known that older subjects
are less eligible for organ preservation surgery because of the greater difficulties
they present in postsurgical rehabilitation. A greater number of older patients in
our experience had comorbidities (p = 0.014). However, we did not encounter a significant difference in terms of the
appearance of postsurgical complications in the two groups of patients. The appearance
of PCT represents the most frequent postsurgical complication after TL. Therefore,
it constitutes one of the most used parameters for the evaluation of the effectiveness
of the use of the stapler. According to some authors, the appearance of PCF after
TL with stapler ranges from 0 to14%,[9]
[10]
[11]
[12]
[13]
[14] while other authors reported incidences of 26.7% and of 30%.[7]
[8]
[15] A PCF appeared in 6% of the total 33 patients in our sample. The highest percentage
of PCFs observed by Dedivitis et al[7] and by Babu et al,[8] compared with ours, may be due to the fact that in 75%[7] and in 70%[8] of these cases, the laryngectomies were of salvage after radiotherapy, while in
our study only 22% of the patients had previously been treated with radiotherapy.
An important aspect of postsurgical outcome after TL is the average time of removal
of the NGT tube, that is, the time elapsed until returning the patients to their normal
oral feeding from the day of surgery. The removal time of the NGT tube after TL with
mechanical suture is reported by few authors.[11]
[15] In our experience, we have found a median time of removal of NGT tube similar to
those reported by Altissimi et al[11] and by Zhang et al.[16]
The average length of hospitalization depends mainly on the occurrence of postoperative
complications (PCF, surgical wound infections, systemic complications). The mean duration
of hospitalization after TL with a stapler is reported only by Paddle et al[17] (median time: 6 days). We have analyzed our results considering the age of the patients
and found no statistically significant differences with regard to the removal time
of the NGT tube and hospitalization time, despite a difference in the presence of
comorbidities.
An increase in the duration of surgery exposes patients to more intra- and postoperative
complications in relation to the increase of the duration of the anesthesia, especially
in the elderly. Turrentine et al[18] showed that an increase in 30 minutes in the duration of the surgery increases the
odds of death by 17% in patients aged > 80 years old.[17] The closure of pharyngoesophagectomy with stapler takes ∼ 5 minutes, while manual
closing takes much longer, and its duration is relative to the experience of the surgeon.
According to some authors,[15]
[19] the stapler reduces the duration of the surgery in ∼ between 45 and 80 minutes.
All of the previous studies, excluding the one by Dedivitis et al,[7] despite their lack of homogeneity, reported a benefit in reducing the appearance
of PCF in patients who underwent TL with the closure of the pharyngoesophagectomy
with a stapler. The appearance of postsurgical complications can put at risk the survival
of the patient, mainly in the elderly. The delay of the beginning of an adequate oral
feeding, and the need to prolong the antibiotic therapy due to the risk of the PCF,
may irreversibly impair the health condition of the patient.
The closure of pharyngotomy with horizontal mechanical suture avoids the weakest critical
point of the vertical suture represented by the trifurcation point. With this technique,
no opening of the esophagus occurs because the larynx is unglued posteriorly, saving
the anterior wall of the esophagus. Furthermore, it reduces the contact surface between
the NGT tube and the suture.
Conditions, which would reduce the risk of postsurgical complications and a faster
recovery. However, the technique has some limitations represented by the fact that
it can be used in a restricted number of patients with endolaryngeal cancer.
Conclusions
The use of the stapler for the horizontal closure of the pharyngotomy in patients
subjected to TL proved to be useful and safe even when used in elderly patients not
eligible for further conservative treatment.
