Pharyngocutaneous Fistula Research Articles

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

Simple SummaryEvaluation of the long-term functional outcome after primary or salvage laryngopharyngectomy. Long term functional outcome mainly depends on extent of pharyngectomy and salvage situation, which is reflected by our new classification system. (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.

Influence of Preoperative Radiation Therapy on the Occurrence of Pharyngocutaneous Fistula After Total Laryngectomy.

IntroductionChemo-radiotherapy (CRT) has increasingly been employed for the treatment of laryngeal cancer at T3 or higher rather than total laryngectomy (TL), in order to preserve the larynx. However, TL is still frequently performed in patients with advanced laryngeal cancer, especially T4 disease. When CRT is performed for advanced cancer, there is a certain rate of residual disease or relapse, and TL is conducted as salvage surgery for those patients, but TL following CRT is associated with a high incidence of postoperative complications.ObjectiveThe purpose of this study was to investigate the influence of preoperative radiation therapy on the occurrence of postoperative complications of TL, particularly pharyngocutaneous fistula (PCF).MethodsWe retrospectively investigated 142 patients who underwent TL for laryngeal cancer whether postoperative complications were related to a history of radiation therapy or neck dissection. Detailed investigation of the 32 patients who underwent radiation therapy was also conducted.ResultsPCF was significantly higher after radiation therapy. Neck dissection was not related. As the time from radiation therapy to TL decreased, the incidence rate of postoperative PCF increased and the time to closure became significantly longer. Preoperative laboratory tests did not show a significant difference in Hb and Alb, but the lymphocyte count was significantly lower in patients with PCF.

Surgical Outcome of Pharyngocutaneous Fistula After Total Laryngectomy: A Retrospective Study.

The management of pharyngocutaneous fistula is challenging. We typically treat postlaryngectomy pharyngocutaneous fistulas with a pedicled pectoralis major flap transfer. This study analyzed the outcomes of our surgical treatments for pharyngocutaneous fistula to propose considerations for surgical strategies. This retrospective review included all patients who underwent surgical repair of a postlaryngectomy pharyngocutaneous fistula at the National Cancer Center Hospital East in Kashiwa, Japan, from January 2005 to December 2019. The final analysis included 33 cases (median age, 71 years). Twenty-two cases had a history of radiotherapy to the head and neck region. Wound closures were performed with a pedicled pectoralis major musculocutaneous flap (n = 26) or pedicled pectoralis major muscle flap (n = 7). In 1 case, a deltopectoral flap was combined with the pectoralis major musculocutaneous flap. The median total operation time was 236 minutes, the median blood loss during surgery was 144 mL, and the median hospital stay after the reconstructive surgery was 39 days. Minor leakage occurred in 19 cases, and major leakage occurred in 2 cases. The fistula was finally cured successfully in 31 cases. We compared the outcomes in patients with leakage after surgical repair to those in patients without leakage after surgical repair to determine the risk factors for leakage after surgical repair of a pharyngocutaneous fistula. Five patients in the nonleakage group and 17 in the leakage group had a history of preoperative radiation (P = 0.052). The median preoperative blood values in the nonleakage and leakage groups were as follows: albumin, 3.6 and 3.2 g/dL (P = 0.061), and C-reactive protein, 2.36 and 6.77 mg/dL (P = 0.031), respectively. The time between the occurrence of the fistula and reconstructive surgery was 32 and 9 days in the nonleakage and leakage groups, respectively (P = 0.009). Our surgical treatment for postlaryngectomy pharyngocutaneous fistula succeeded in 31 of 33 cases (94%). This study demonstrated that pedicled pectoralis major flap transfer is useful for the treatment of postlaryngectomy pharyngocutaneous fistula.

Surgical emphysema as an early sign for pharyngocutaneous fistula following total laryngectomy: a case report

BackgroundPharyngocutaneous fistula is the most common and troublesome complication after total laryngectomy. Many factors may be used in laryngectomy patients for the early diagnosis of pharyngocutaneous fistulae such as skin flap edema, neck erythema, salivary leak, postoperative barium swallow, and wound amylase level. Its diagnosis is mainly standing on a clinical basis.Case presentationThis report described two cases of laryngeal carcinoma, which presented with a history of persistent hoarseness of voice and mild stridor and were diagnosed with a battery of clinical investigations and managed successfully with total laryngectomy and lateral neck dissection. Both patients suffered from postoperative surgical emphysema before developing pharyngocutaneous fistula.ConclusionSurgical emphysema can precede the occurrence of pharyngocutaneous fistula after total laryngectomy. Further studies are needed to confirm this finding.

Early versus late oral feeding following total (pharyngo)laryngectomy: Systematic review and meta-analysis.

Timing of oral feeding following total laryngectomy is a contentious issue with highly varied practices. Multiple database search was performed to identify studies comparing outcomes of early (≤5 days) versus late (>5 days) oral feeding. Bias assessment was carried out using Cochrane bias tool. Random-effects meta-analysis was used. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The rate of pharyngocutaneous fistula (PCF) in randomized control trials (RCTs) in early versus late feeding was 15.2% versus 11.7% (RR 1.35, 95%CI [0.68-2.7], p = 0.40). The rate of PCF in the cohort studies was 14.1% versus 20.5% (RR 1.0, 95%CI [0.76-1.3], p = 0.98). The length of hospital stay was significantly shorter in the early feeding group (mean difference (days) -4.68 (-6.2 to -3.1, p < 0.0001). Early oral feeding appears to be safe and is associated with shorter hospital stay. However, the quality of evidence is low and the patient characteristics are not representative of current practices.

Comparación de pacientes con laringectomía total primaria y de rescate

Introduction and objectivesTotal laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival. MethodsThe study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death. ResultsThe mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P=.000) and between fistula and infection (P=.000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P=.038), T4 (P=.026), lymphovascular invasion (P=.019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P=.005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P=.026). ConclusionsAlthough organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Platelet-Rich Fibrin Enhances Surgical Wound Healing in Total Laryngectomy.

Autologous growth factor (AGF) is a cytokine that has gained medical research interest because it helps improve and accelerate the wound healing process. Platelet-rich fibrin (PRF) is the latest generation of platelet concentrate that can be obtained through a simple procedure known as AGF referencing. One of the most common complications of total laryngectomy (TL) is pharyngocutaneous fistula. To prevent this complication, health care providers must closely monitor the postoperative wound healing process.This study aimed to investigate the effectiveness of PRF application in enhancing wound healing after TL. A randomized controlled trial was conducted in the Department of Otorhinolaryngology - Head and Neck Surgery, Faculty of Medicine, Dr. Cipto Mangunkusumo Hospital Universitas Indonesia, Jakarta, Indonesia, from June 2019 to December 2019. We included 20 patients who underwent TL for laryngeal squamous cell carcinoma. They were divided into two groups (10 patients who received applied autologous PRF around the esophageal stoma during TL and another 10 patients as the control). These patients were observed for 2 weeks postoperatively. In the bivariate analysis performed using the chi-square test, the pain threshold and edema of postoperative wounds in the PRF-treated group demonstrated significant differences compared with those in the control group. PRF application in TL enhanced the postoperative wound healing process, especially with regard to edema and pain.

Prophylactic Glycopyrrolate Administration to Aid Otolaryngology Residents in Prevention of Post-laryngectomy Pharyngocutaneous Fistula.

Pharyngocutaneous fistula (PCF) after laryngectomy occurs when there is a failure in the pharyngeal repair resulting in a salivary leak (Dedivitis et al. in Acta Otorhinolaryngol Ital 27(1):2-5, 2007). In the post-operative period this complication is not only a challenge to the surgeon but also distressing to the patient and his family. We conducted a retrospective cum prospective study, to research the effect of starting prophylactic glycopyrrolate intravenous injection in total laryngectomy. Fifty patients underwent total laryngectomy with modified radical neck dissection over a period of 5years by the trainee otolaryngologists. Of these 25 patients were started on glycopyrrolate for 7 post-operative days. And 25 control patients, who were not given glycopyrrolate. All the patients were observed for evidence of PCF. Of the total 50 patients, only 1 patient in study group and 12 patients in the control group developed PCF. This was statistically significant (p value 0.0039). Tumor stage, site, and gender were found to have no statistically significant correlation with development of PCF. The prophylactic administration of glycopyrrolate was found to reduce the odds of development of PCF in total laryngectomy cases. There was associated blurring of vision and constipation amongst the cases subjects, which was only transient with complete recovery on cessation of drug.

Woody hardness classification impact on salvage laryngectomy functional outcomes

PurposePost-radiation therapy salvage surgeries are challenging for surgeons due to tissue fibrosis. The woody hardness classification is valuable in differentiating the degree of neck stiffness, but its clinical utility has not been evaluated. We applied it to patients undergoing salvage laryngectomy to study the impact of woody hardness on postoperative outcomes. Materials and methodsA retrospective observational study was performed on patients undergoing salvage laryngectomy between 2014 and 2019. Patients were assigned into the A (extremely woody hard), B (moderately woody hard), or C (mildly woody hard) woody hardness class. The primary outcome was pharyngoesophageal stricture development. Secondary outcomes included time to pharyngoesophageal stricture, pharyngocutaneous fistula development, time to pharyngocutaneous fistula, development of post-operative complications, and tracheoesophageal puncture complications. ResultsFifty-one patients were included in the study: Class A 1 patient, Class B 30 patients, and Class C 20 patients. The single Class A patient was grouped with the Class B patients. The development of a pharyngoesophageal stricture shows consistent negative association with woody hardness despite most analyses not reaching statistical significance. These associations are robust to a number of confounding variables in multivariate logistic and time to event analyses. Furthermore, the time to event analysis controlling for squamous cell carcinoma diagnosis led to a statistically significant association between woody hardness (i.e., A/B higher risk) and time to stricture (HR=5, p=0.02). ConclusionsThis study suggests that this classification may be useful in predicting pharyngoesophageal stricture formation in salvage laryngectomy patients and could be used to implement stricture preventive measures.

A Prospective Study on Local Complications of Primary Total Laryngectomy/Laryngopharyngectomy for Laryngeal and Hypopharyngeal Malignancies

Background: Carcinoma larynx is one among the most common head and neck malignancy which accounts for 2% of all cancers whereas hypopharyngeal cancer is one of the most aggressive tumor with poorer prognosis. Total laryngectomy/laryngopharyngectomy (TL/TLP) is the treatment of choice for locally advanced laryngeal and hypopharyngeal cancers. Objectives: To study the complications associated with primary TL/TLP along with the sociodemographic profile and clinicopathologic features of laryngeal and hypopharyngeal cancers. We also aimed to assess the risk factors associated with complications. Methods: All stage III or IVA laryngeal and hypopharyngeal malignancy cases as per American Joint Committee on Cancer (AJCC) 8^th edition staging, who underwent primary total laryngectomy/total laryngopharyngectomy during the year 2018-2019 in our institute, KIMS Hubli, have been studied. Sociodemographic profile and clinicopathological features were noted. These patients were followed up for 6 months for any local complications. Results: Mean age of the study population was 58 years with male predominance. Primary glottic carcinoma was most common. Most common presenting symptom was change in voice and most common anatomical site involved was true cords. Overall complication rate was 32%. Most common complication encountered was wound infection and pharyngocutaneous fistula (8% each). As complications set in length of hospital stay increases. We found significant association with PCF and length of hospital stay. Conclusion: With proper case selection, and regular wound care, complications can be avoided in case of TL/TLP. Once complications set in, it increases hospital stay and the expenditure, hence is traumatizing to the patient and hence should be avoided.

Study of pharyngocutaneous fistula after total laryngectomy

Study of pharyngocutaneous fistula after total laryngectomy

Role of Nutritional Support in Head and Neck Cancer Patients

Malnutrition could occur in patients with head and neck cancer due to the disease itself and the side effects of treatment. The consequences of malnutrition lead to the discontinuity of treatment and the deterioration of quality of life and prognosis. Nowadays, there are available tools for nutrition screening and assessment which could early identify the patient at risk malnutrition and give them the prompt nutritional interventions. Nutritional anagements, including nutrition counseling, modification of the diet, the supplement of oral nutritional supplement, enteral nutrition, and parenteral nutrition, have roles from the beginning to the end of head and neck cancer treatment and the proper nutritional interventions were associated with the better results. Nutrition interventions were an essential part in prevention and treatment of the postoperative complications such as chyle leakage and pharyngocutaneous fistula. The research involving in immunonutrients showed the efficacy in improvement of the clinical outcome of patients undergoing treatment for head and neck cancer. Therefore, appropriate nutrition interventions were important and required the multidisciplinary team approach.&#x0D;

Internal jugular vein rupture after oncologic resections in the head and neck

BackgroundInternal jugular vein (IJV) blowout after major oncologic resections in the head and neck is a rare fatal yet preventable complication. The condition is unregistered sufficiently in the literature.ResultsThe records of patients who underwent oncologic neck surgery were retrospectively reviewed. The study included records between January 2014 and November 2019 at Kasr Al Ainy Educational Hospital. 275 patients underwent cervical ablative procedures. Ten patients developed IJV blowout. Six patients were saved. Four patients had diabetes mellitus with postoperative wound infection and dehiscence. Three patients were given primary radiotherapy; two of them developed flap necrosis. Eight patients acquired pharyngocutaneous fistula (PCF). Regional flap coverage was done in three patients. Sentinel hemorrhage occurred in all patients.ConclusionsIJV blowout is a rare potentially life-threatening complication usually preceded by sentinel hemorrhage. The condition is essentially preventable by the prompt and structured response.

The Use of Indocyanine Green Angiography for Cosmetic and Reconstructive Assessment in the Head and Neck.

Reconstructive procedures in the head and neck can be a surgical challenge owing to the complex anatomical and physiological structure. Different locoregional and microvascular flaps are used for various defects to improve both function and cosmesis. Subjective clinical findings have been the mainstay for perfusion monitoring; however, areas of borderline perfusion are much more difficult to assess clinically. Multiple technologies that offer objective perfusion assessment have been developed to improve surgical outcomes. Indocyanine green (ICG) angiography has gained popularity owing to its minimal invasiveness and increased sensitivity and specificity in assessing flap perfusion particularly in the head and neck. It has been extensively used in free flaps, pedicled flaps (including nasal reconstruction), facelift procedures, random flaps, skull base reconstruction, and pharyngocutaneous fistula prediction. Its perioperative use has provided valuable qualitative and quantitative data that aid our understanding of flap hemodynamics. Clinically, this impacted decision-making in flap design, harvest, inset, and precocious salvage interventions. Though increased cost and intraoperative time could be limitations, cost-effectiveness studies have supported its use, particularly in high-risk individuals. Limitations include the lack of standardized dosing and consistent methodology agreement for data analysis. Future studies should involve larger cohorts and multi-institute studies to overcome such limitations.

Montgomery Salivary Bypass Tube in Head and Neck Cancer: The Experience of Our Otolaryngology Clinic.

One of the most common complications in the immediate and late postoperative period following total laryngectomy or pharyngolaryngectomy is pharyngocutaneous fistulae (PCF) formation and pharyngoesophageal stenosis (PES), causing significant mortality and morbidity. Since 1978, Montgomery salivary bypass tube (MSBT) has been used to reduce the incidence of PCF and PES. The aim of this retrospective study was to analyze the outcomes of using MSBT both as a tool to prevent PCF and PES and to treat these complications in the postoperative period. Between January 2013 and December 2019, we inserted 109 MSBT in 87 patients with laryngeal/hypopharyngeal cancer treated in the Unit of Otolaryngology of our University Hospital. Sixty (86.9%) patients healed from complications with primary and secondary placement of MSBT. Seven patients presented a persistence of PCF and 2 presented a recurrence of PES. Secondary placement of MSBT allowed treating successfully 15 (83%) of 18 patients. Only 3 of them presented a PCF at the end of the follow-up period. According to our experience, the MSBT is an affordable, easy to apply and well-tolerated tool. Although it is generally used for PCF treatment, it can also be used intraoperatively for PCF and PES prevention.

Bipedicled submental musculofascial “hammock” flap for salvage laryngectomy closure reinforcement

The aim of the study was to describe a novel technique for reinforcement of salvage laryngectomy closure using a bipedicled musculofascial submental flap. A retrospective cohort study design identified patients who underwent salvage laryngectomy reinforcement with a bipedicled submental hammock flap between January 2008 and December 2016 were compared to salvage laryngectomy patients treated with primary closure of the neopharynx during the same time period. Pharyngocutaneous fistula rates were compared between groups. Pharyngocutaneous fistula rate in the submental hammock group (2/31, 6.5%) was significantly lower compared to the primary closure group (14/45, 31%, P < .05). The bipedicled musculofascial submental hammock flap is a viable method for reinforcement of salvage laryngectomy defects. It has a favorable pharyngocutaneous fistula rate compared to primary closure alone and has unique advantages over conventional methods of reinforcement.

A Novel Laryngoscope-assisted Method for Sealing Pharyngocutaneous Fistula.

Pharyngocutaneous fistula (PCF) is one of the most common but stranded complications for salvage laryngectomy. As for localized fistula, there is no convincing standard and method to cure. This paper described a patient who was submitted to extensive resection of mass in right lingual root, total laryngectomy, and pharyngoesophageal reconstruction with an anterolateral thigh flap (ALTF), because of recurred carcinoma of right lingual root which invaded bilateral epiglottis. 2 weeks after surgery, subsequent pharyngocutaneous fistula developed at the junction of the tracheostomy, and maintained over 2 months under conservative treatment. With the assistance of laryngoscope, inner and outer orificiums of fistula were found and sealed by bundled iodoform strip. 9 days after sealing, fistula had been already filled with fresh granulation tissue. During 2 years after surgery, the fistula area dose not recur. This technique provides a safe and effective way for sealing the inner and outer orificiums of fistula.

Platelet-rich fibrin: an autologous biomaterial for healing assistance of pharyngeal repair in total laryngectomy.

The aim of this study was to evaluate the potential role of platelet-rich fibrin (PRF) application on the pharyngeal repair on decreasing the incidence of pharyngocutaneous fistula (PCF) after total laryngectomy. This randomized controlled clinical trial was conducted on 67 patients with advanced laryngeal carcinoma who underwent total laryngectomy, over 2years in the Otorhinolaryngology Department, Mansoura University Hospitals, Egypt. Patients were randomly assigned into two groups: PRF group (n = 35) and control group (n = 32). Risk factors for development of PCF as well as the incidence of PCF were studied in both groups. There was no statistically significant difference between groups regarding demographic data, medical comorbidities, basal hemoglobin and albumin levels, data related to the tumor (location, grade and TNM staging) and surgical details (preoperative tracheotomy and neck dissection). However, regarding the incidence of PCF, there was a statistically significant difference between groups as shown in Table 2. PCF was detected in 2/35 patients (5.7%) in the PRF group and in 10/32 patients (31.3%) in the control group (p = 0.004). PRF application on the pharyngeal repair after total laryngectomy enhances the healing process and consequently decreases the incidence of PCF.

Meta-analysis on the rate of pharyngocutaneous fistula in early oral feeding in laryngectomy patients.

Laryngectomy remains a common operation in head and neck units. The operation holds significant risk of post-operative morbidity including swallowing dysfunction. The most significant post-operative concern is the formation of a pharyngocutaneous fistula [PCF], the reported incidence of which is between 3% and 65%. The purpose of this systematic review and meta-analysis was to assess the safety of initiating early oral feeding following laryngectomy and the risk of PCF formation. A literature search was conducted through online databases: MEDLINE, EMBASE and PubMed. Eligible studies were included which contained cohorts of patients who had undergone laryngectomy, with early oral feeding commencing within seven days compared to late oral feeding. The primary outcome assessed was the incidence of PCF. Studies were excluded if cohorts had not included laryngectomy or if no comment was made on PCF formation. Meta-analysis was used to examine associations between oral feeding and PCF formation using Fixed Effect models. Twelve studies and 1883 patients were included after systematic review. Six studies were non-interventional whereas the remaining were randomized clinical trials. Exposure included those with early oral feeding (before seven days) or late feeding oral feeding (after seven days) and the outcome assessed was the risk of PCF formation. Results from observational studies showed a higher risk of PCF formation for early feeders compared to late feeders [RR=1.56, 95% CI: 1.15, 2.11]. Higher risk was also observed for RCT but was not significant [RR=1.40, 95% CI: 0.85, 2.30]. Overall, there was a 50% greater risk of PCF formation for early oral feeding compared to late oral feeding [RR=1.51, 95% CI: 1.17, 1.96]. While early oral feeding can reduce post-laryngectomy patients' hospital stay and improve psychological wellbeing, there is a significant relative risk of PCF development within this group. However, this must be taken in context of the significant heterogeneity that exists within the literature.

Free flap head and neck microsurgery with VITOMⓇ 3D: Surgical outcomes and surgeon's perspective

ObjectiveTo report on the application of the 3D exoscopic system to microsurgery in a cohort of head and neck cancer patients; to analyse the performance of microvascular anastomoses, flap harvesting and insetting under exoscopic view and to evaluate the surgeon's feedback after procedures. MethodsAn observational study was performed on 10 consecutive patients undergoing exoscopic microsurgical free flap reconstruction. The VITOMⓇ 3D system was applied to all procedures for microsurgical anastomoses, flap harvesting and insetting. Data about the type of resection and reconstruction, intraoperative and post-operative complications were recorded. Surgeon's feedback on exoscopic experience was collected through a questionnaire. ResultsReconstruction after oncologic demolition was performed by radial forearm flap in 3 cases (30%), antero-lateral thigh flap in 4 cases (40%), composite fibula flap in 2 cases (20%) and chimeric scapula flap in 1 case (10%). The mean surgical time for the microsurgical anastomoses (1 vein and 1 artery) was 34 min (range: 32–38). No intraoperative complications occurred and only two patients experienced pharyngo-cutaneous fistula in the post-operative time. There were neither cases of loss of flap, nor need of surgical revision. None of the cases had to be converted to OM technique. The surgeon never experienced back/neck pain, headache and nausea/vertigo. Occasionally, he felt tired and stressed and he reported eyestrain after one procedure only. ConclusionsVITOMⓇ 3D is easy to apply in the field of head and neck microsurgery and provides optimal stereoscopic view and anatomical details. Further studies are needed to validate indications and advantages of 3D exoscope as compared to OM.