Postoperative complications of salvage total laryngectomy

Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Cancer (Impact Factor: 4.9). 05/2005; 103(10):2073-81. DOI: 10.1002/cncr.20974
Source: PubMed

ABSTRACT The objectives of the current study were to report the incidence of postoperative complications for salvage total laryngectomy (STL) compared with primary total laryngectomy (PTL) and to identify patient and tumor-related factors predictive of postoperative complications.
A sample of 183 patients who had received a total laryngectomy were identified from an existing database of 662 patients treated for squamous cell carcinoma of the larynx. PTL and STL were performed in 113 and 70 patients, respectively. Initial therapy in the patients who required salvage surgery included radiotherapy (RT) in 32 (46%) and chemoradiotherapy (CTRT) in 38 (54%). Postoperative complications were recorded for each group and categorized into local, swallowing, airway, and systemic complications. Postoperative complication rates for STL after RT and CTRT were compared with those after PTL by univariate analysis. Patient and tumor-related predictors of complications were identified by univariate and multivariate analyses.
The overall mortality rate was 0.5%. Forty percent of all patients developed a postoperative complication after total laryngectomy. Local complications, which were the most frequent, occurred in 52 (28%) patients. Pharyngocutaneous fistula occurred in 31 (17%) patients. Statistical analysis showed that there was a greater number of patients with local wound (45% vs. 25%, P = 0.02) and fistula complications (32% vs. 12%, P = 0.012) in the STL-CTRT group compared with the primary laryngectomy group. Multivariate analysis showed that primary CTRT was an independent predictor of local complications and pharyngocutaneous fistula.
Salvage laryngectomy was more frequently associated with postoperative complications after CTRT compared with PTL. Problems related to local wound healing, especially the development of pharyngocutaneous fistula, constituted the most common postoperative complication in these patients. Multivariate analysis showed that primary CTRT was an independent predictor of local wound complications and pharyngocutaneous fistula.

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    ABSTRACT: In the last decade the primary treatment of laryngeal and hypopharyngeal cancer was shifted towards organ preservation, i.e. preservation of the larynx. The treatment of laryngeal cancer was changed from standard radiotherapy towards hyperfractionated radiotherapy. Hypopharyngeal cancer is nowadays mostly treated with a combination of chemotherapy and radiotherapy instead of primary surgery. Therefore, the greatest shift in treatment protocols found was for hypopharyngeal cancer. The goal of this thesis was in the first place to find out whether recurrent laryngeal cancer can be treated with preservation of the larynx and the consequences of organ preservation for the function of the “new” organ. The second goal of this thesis was to find out which treatment protocols are used in the Netherlands for hypopharyngeal cancer. Also, to find the consequences of chemoradiation protocols for surgical treatment of recurrent hypopharyngeal cancer. Chapter I is a general introduction of laryngeal and hypopharyngeal cancer. The incidences of laryngeal and hypopharyngeal cancer are mentioned. Furthermore, the biggest risk factors, being smoking and alcohol, are described. Especially, the effect of tobacco smoke on the development of laryngeal and hypopharyngeal cancer is described. Tobacco smoke contains several substances, which can cause mutations in genes. The mutations deregulate several enzyme systems and cell regulation systems, which cause degeneration of squamous cell epithelium. An overview of the other chapters of this thesis is given. In Chapter II two partial laryngectomy techniques are described. The oncological and functional results of the endoscopic CO2 laser and the frontolateral partial laryngectomy for the treatment of the recurrent glottic laryngeal cancer are described. The indications of both techniques are mentioned. Both techniques have good oncological results and less functional problems were found. With the CO2 laser 44-58% of the patients are cured with preservation of the larynx; with the frontolateral partial laryngectomy 71% was cured. It is important to realize that in case of a new recurrence, a total laryngectomy can be performed without an extra risk of failure for therapy. Both partial laryngectomy techniques, CO2 laser and frontolateral partial laryngectomy, are good treatment modalities for recurrent glottic laryngeal cancer. However, the indications for the different techniques are important and should be followed strictly. In chapter III the functional and oncological results of the third partial laryngectomy technique, cricohyoidoepiglottopexy (CHEP), is described. With the CHEP 79% of the patients are cured with preservation of the larynx. In eight patients a Flexible Endoscopic Evaluation of Swallowing (FEES) was performed to objectify problems swallowing. In none of the patients aspiration was found. Before and after the operation the voice was recorded and judged. After the operation the voice is worst. However, most patients are satisfied with there voice. The CHEP appears oncologically safe and functional for the treatment of recurrent glottic laryngeal cancer in selected patients. In chapter IV was investigated whether the quality of life is different after a partial laryngectomy versus a total laryngectomy for recurrent laryngeal carcinomas after radiotherapy. Also the voice of both groups of patients was judged. The quality of life was investigated with the EORTC Quality of Life Questionnaire (QLQ) – C30 Dutch version 3.0 and the EORTC – H & N 35 questionnaire. The only difference found was smell and taste related. The voice was judged with the Voice Handicap Index. No differences between the two groups were found. There are no big differences in quality of life after treatment with a partial or a total laryngectomy. This is mainly caused by the unexpected good quality of life after a total laryngectomy. In chapter V the treatment of hypopharyngeal cancer in the Netherlands is described. The treatment of hypopharyngeal cancer in the period 1985 – 1994 was investigated. The biggest group of patients was treated with radiotherapy alone or with combined radiotherapy and surgery. The overall 5-year disease-free survival after treatment with curative intention was 32%. The disease-free survival is better after combined surgery and radiotherapy. In chapter VI, the complications after salvage surgery in patients prior treated with radiotherapy alone or chemoradiation is described. The post-operative complication rate is significantly higher (92% vs. 50%) in the chemoradiation group. The most frequent complication found was a pharygocutaneous fistula. The quality of life, after a longer post-operative period, showed a significant difference in social functioning in disadvantage of the chemoradiation group. In the general discussion (chapter VII) the found results are discussed. The most important conclusion is that there is place for organ preservation therapy, but we must remain critical of indications and side effects of organ preservation protocols while we should realize that quality of life after total laryngectomy are not as poor as we might sometimes think.
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    ABSTRACT: This chapter discusses the unique challenges in the diagnosis, workup, treatment and follow-up of patients who may have, or have failed chemoradiation protocols. The role of various imaging modalities, particularly PET scanning, is reviewed. Surgical salvage in this population is emphasized, addressing the extent of resection both at the primary site and the neck, and the surgical complications encountered in this population. Options for surgical reconstruction are discussed, including free tissue transfer. While surgical salvage is the main focus of this chapter, other salvage modalities available to patients who have been previously chemoirradiated are examined. These include ­re-irradiation with or without chemotherapy, brachytherapy and photodynamic therapy. Finally, the treatment outcomes with respect to morbidity and mortality in this population are reviewed.
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    ABSTRACT: Die vorliegende Aufarbeitung der klinischen Daten von Patienten, die wegen eines histologisch gesicherten lokoregionären Rezidives eines fortgeschrittenen Karzinoms des Larynx oder Hypopharynx nach abgeschlossener Induktionschemotherapie mit Paclitaxel und Cisplastin sowie primärer Radiotherapie einer sogenannten Rettungschirurgie (‚Salvage Chirurgie’) unterzogen wurden, ergab ein ungünstiges onkologisches Ergebnis. Bei 16 von 20 Patienten mit histologisch gesicherten lokalen oder regionären Metastasen konnte keine lokoregionäre Tumorkontrolle erzielt werden. Nur zwei von 20 Patienten waren zum Zeitpunkt der Datenerhebung tumorfrei und am Leben. Dieses Ergebnis widerspricht einigen in der Literatur angegebenen positiveren Resultaten von Rettungschirurgie wegen Rezidiven von Kehlkopftumoren, wobei sich diese in der Regel auf weniger fortgeschrittene initiale Tumorstadien beziehen, die bei einem primären Eingriff eine Laryngektomie nicht erforderlich gemacht hätten. Die durchgeführten Salvage Laryngektomien zeichneten sich durch eine hohe Morbidität aus, wobei die therapieresistente pharyngokutane Fistel mit 73,3% Inzidenz im Vordergrund stand. Diese hat neben der erheblichen Beeinträchtigung des Patienten auch zu einer erheblichen Verlängerung der Aufenthaltsdauer und Kosten im Vergleich mit denen einer primären Laryngektomie ohne Vorbehandlung geführt. Wir haben zurzeit keine Lösung für dieses Problem, zu dem in der Literatur ebenfalls unterschiedliche Angaben in sehr unterschiedlichen Patientenkollektiven gemacht werden. Eine ausgedehnte elektive Neck dissection im Rahmen der Laryngektomie bei initial (vor Radiochemotherapie) unauffälligen Lymphknoten ist insofern zu diskutieren, als dass sich ähnlich wie in vergleichbaren Studien auch bei uns histologisch keine Metastasen in der endgültigen histologischen Aufarbeitung nachweisen ließen. Eine Ausräumung der Halslymphknoten wegen persistierender zervikaler Raumforderungen ohne lokale Tumormanifestation kann wegen der geringen Komplikationsrate trotz des relevanten Anteils histologisch tumorfreier Resektate großzügiger indiziert werden. Allerdings zeigte sich bei Vorliegen von histologisch nachgewiesenen Restmetastasen ähnlich wie bei den lokalen Rezidiven ein ungünstiger onkologischer Verlauf. Die Patienten sollten aus unserer Sicht über diese Situation informiert werden, bevor sie sich hinsichtlich des initialen Therapieansatzes (primäre Laryngektomie versus Radiochemotherapie) entschließen. Die Möglichkeit einer Rettungschirurgie mag für die Patienten dabei psychologisch beruhigend wirken, da fälschlicherweise angenommen werden könnte, dass die chirurgische Behandlung durch einen vorangegangenen konservativen Therapieansatz nicht beeinträchtigt würde. Dies kann für unseren Behandlungsansatz allerdings nicht bestätigt werden. Salvage surgery for local recurrences is of high morbidity and poor oncological and functional outcome also for this organ-sparing strategy as it is for others. Neck dissection for disease after radiochemotherapy risks to be an over-treatment and is burdened with a high risk of recurrences and distant metastases in presence of histologically confirmed persistent lymph node metastases. This must be considered when informing the patient about different therapeutic options.