Postoperative Pharyngocutaneous Fistula Research Articles

Iatrogenic pharyngo-esophageal diverticulum post-anterior cervical discectomy and fusion: A case report and review of literature.

The purpose of this study is to report a case of iatrogenic pharyngoesophageal diverticulum post-anterior cervical discectomy and fusion (ACDF) surgery, its management and management of postoperative complications. We also did a thorough review of literature about iatrogenic pharyngoesophageal diverticulum which is a rarely encountered complication occurring after a commonly performed surgery; ACDF. Here we describe a case of iatrogenic pharyngoesophageal diverticulum post-ACDF surgery. In this paper we also make comparisons to the 23 cases reported in the literature in terms of: presentations, clinical findings, management courses, and complications. This study was approved by the Institution Review Board of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. (Ref. no.: IRB-2023-01-473). The reported subject provided written informed consent before initiation of this study. Our case is a 45-year-old male with a history of ACDF surgery 8 years ago. He presented with dysphagia and regurgitations which started 1 year after ACDF. He was labeled as a case of Zenker's diverticulum and underwent multiple failed open and endoscopic surgeries prior to presenting to us. Upon presenting to our center, barium swallow showed the pharyngoesophageal diverticulum. Patient definitive diagnosis of iatrogenic rather than Zenker's diverticulum was established intra-operatively with esophagoscopy which revealed exposed hardware inside the diverticulum. He underwent open diverticulectomy and diverticulopexy. Postoperatively he developed pharyngocutanous fistula and right vocal fold palsy, both successfully managed conservatively. Iatrogenic Pharyngoesophageal diverticulum is a rare complication following ACDF, however prolonged dysphagia shall warrant further investigation by contrast studies. Open diverticulectomy with muscle reinforcement is a good management modality. Due to the complicated anatomy secondary to previous operations, we recommend conservative management for patients with postoperative pharyngocutaneous fistula.

Risk factors and healing factors for pharyngocutaneous fistula after total laryngectomy for laryngeal cancer: An epidemiological study.

To analyse the risk factors and healing factors of pharyngocutaneous fistula (PCF) in patients with laryngeal cancer after total laryngectomy, and to explore the relevant epidemiology. A retrospective analysis was conducted on laryngeal cancer patients who underwent total laryngectomy in our hospital from January 2010 to December 2022. The 349 patients included in the study were divided into a PCF group of 79 and a non-PCF group of 270. Perform one-way analysis of variance and multivariate logistic analysis on various data of patients included in the statistics, and analyse the risk factors and healing factors of PCF. Smoking, history of radiation therapy for laryngeal cancer, history of chemotherapy for laryngeal cancer, tumour location (larynx, pharynx, oesophagus), preoperative albumin, postoperative proteinaemia, <99 haemoglobin, postoperative haemoglobin, postoperative C-reactive protein (CRP) level are the risk factors for PCF. Also, radiation therapy and postoperative proteinaemia were the main reasons for preventing PCF healing. Smoking history, laryngeal cancer, radiation therapy, albumin, haemoglobin and CRP are risk factors for postoperative PCF after total laryngectomy, while radiation therapy and postoperative hypoalbuminaemia are key factors affecting PCF healing.

Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration

Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive. To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration. This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023. Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL. The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula. The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.

Impact of stapler versus manual closure techniques on pharyngocutaneous fistula development post-total laryngectomy: A systematic review and meta-analysis.

Pharyngocutaneous fistula (PCF) is a major complication after total laryngectomy, with significant morbidity and mortality. Whether mechanical stapler closure of the pharynx reduces fistula rates compared to hand-sewn techniques remains unclear. We conducted an updated systematic review and meta-analysis to clarify this question. Five databases were systematically searched from inception through November 2023 for studies comparing stapler versus suture closure for fistula outcomes after laryngectomy. Odds ratios (OR) were pooled using random-effects models and fixed-effects models. Subgroup and sensitivity analyses were performed. Risk of bias was appraised using NHLBI tools. Nine studies with 803 patients were included. Mechanical closure significantly reduced fistula incidence versus suture closure (OR = 0.57, 95% CI 0.34-0.95, p = 0.03). Subgroup analysis found that stapling's protective effect varied by patient age, country/region, linear stapler size and female percentage. Stapling reduced fistula odds by 80% in the Turkey subgroup (OR = 0.20, 95% CI 0.09-0.50) but showed no benefit in other regions. Patients <60 years showed an 84% fistula reduction with stapling (OR = 0.17, 95% CI 0.06-0.45), whereas older subgroups did not. Linear stapler size of 60 mm significantly reduced fistula occurrence while 75 mm did not. There was no evidence that low female percentage mitigated stapling benefits. Mechanical stapler closure after total laryngectomy meaningfully reduces the likelihood of postoperative PCF formation compared to hand-sewn closure, especially for patients younger than 60 years old. The absolute risk reduction supports its utility to prevent this complication.

Procalcitonin for Early Detection of Pharyngocutaneous Fistula after Total Laryngectomy: A Pilot Study.

The aim of this prospective study was to investigate the role of procalcitonin as an early diagnostic marker of pharyngocutaneous fistula (PCF) in a cohort of head and neck patients treated with total laryngectomy for squamous cell carcinoma. This prospective study was conducted on a sample of patients enrolled from January 2019 to March 2022. All patients were subjected to a "protocol" of blood chemistry investigations, scheduled as follows: complete blood count with formula, ESR dosage, CPR, and PCT. PCT was also dosed by salivary sampling and a pharyngo-cutaneous swab in patients who presented with PCF. The dosage scheme was systematically repeated: the day before the intervention (t0); the 5th day postoperative (t1); the 20th day postoperative (t2); and at time X, the day of the eventual appearance of the pharyngocutaneous fistula. A total of 36 patients met the inclusion criteria. The patients enrolled in the study were subsequently divided into two groups: 27 patients underwent total laryngectomy (TL) for laryngeal cancer without postoperative complications, and 9 patients were undergoing TL with postoperative PCF. Using the Cochran's Q test, statistical significance was found for PCT among T0, T1, Tx, and T2 (p-value < 0.001) between the PCF and non-PCF groups. The Z test demonstrated that there is a difference in PCT levels at T1 and T2 and that this difference is statistically significant (p < 0.001). PCT could be considered an early marker of complications in open laryngeal surgery. According to our results, it could be useful in the precocious detection of pharyngocutaneous fistulas and in the management of antibiotic therapy.

Novel techniques for prevention of post-operative pharyngocutaneous fistula in locally advanced laryngeal and hypopharyngeal cancers.

Pharyngocutaneous fistula is one of the most common complications following total laryngectomy. It increases hospital stay and the financial burden on patients, and prolongs nasogastric feeding. This paper presents novel techniques for prevention of pharyngocutaneous fistula. A retrospective study was conducted at a tertiary referral centre to assess the effectiveness of continuous extramucosal pharyngeal suturing and the hydrogen peroxide leak test in prevention of pharyngocutaneous fistula in 59 patients who had undergone total laryngectomy with or without partial pharyngectomy for locally advanced cancers of the larynx and hypopharynx. The incidence of pharyngocutaneous fistula in our study was 6.8 per cent, which is considerably lower than the incidence reported in various previous studies. The continuous extramucosal suturing technique provides watertight closure of the neopharynx and can be recommended as a reliable method for neopharyngeal closure post total laryngectomy to reduce the occurrence of pharyngocutaneous fistula.

Current Treatment of Postoperative Head and Neck Fistulas Utilizing Negative Pressure Wound Therapy

Postoperative pharyngocutaneous fistula after head and neck surgery is a devasting complication that increases hospitalization time and delays the initiation of oral intake and postoperative adjuvant therapy. Although it is commonly experienced, the treatment strategy differs greatly according to the size and site of the fistula and the preference of the surgeon, and a standard therapy remains to be established.Since it was first reported in 1997, negative pressure wound therapy (NPWT) has been widely applied in the treatment of complicated intractable wounds all around the body. However, its use in the treatment of head and neck fistulas has been less frequent because of the numerous undulations of the skin on the surface of the head and neck, which make an airtight seal difficult to achieve. In addition, salivary contamination and possible air leakage from the fistula are major obstacles in applying NPWT to head and neck fistulas.We have actively applied NPWT in the management of head and neck fistulas and have successfully treated these complicated wounds. Thorough wound bed preparation and the application of hydrocolloid materials around the wound edge have enabled the continuation of NPWT without leakage and infection. Incisional drainage performed a small distance from the location of the fistula was helpful for avoiding leakage during NPWT.In this article, we present our current treatment strategy utilizing NPWT for head and neck fistulas and delineate the tips for avoiding leakage during NPWT.

Salivary bypass tube in total laryngectomy: Systematic review and meta-analysis.

The aim of this study is to determine whether the preventive positioning of a salivary bypass tube (SBT) after total laryngectomy (TL) reduces the incidence of postoperative pharyngocutaneous fistula (PCF) and pharyngeal stenosis (PS). This study was conducted in conformity with the PRISMA statement. 1960 patients with a median age of 62.0 years were included. A SBT was placed in 980 (50%) patients (SBT group). The cumulative PCF incidence in the SBT group was 15.8% (95% CI: 9.3-23.6). The measured pooled OR comparing PCF incidence in patients with SBT compared to those without was 0.40 (95% CI: 0.24-0.65). The pooled PS incidence in the SBT group was 12.3% (95% CI: 5.4-21.6). The measured pooled OR comparing PS incidence in patients with SBT compared to those without was 0.43 (95% CI: 0.24-0.65). PCF and PS could be prevented by the intra-operative placement of a SBT.

術後咽頭皮膚瘻に対するパウチ法を用いた管理の有用性

術後咽頭皮膚瘻に対するパウチ法を用いた管理の有用性

Preemptive Utilization of Anterior Belly of the Digastric Muscle Flaps in Transoral Robotic Radical Tonsillectomy.

ObjectiveTo demonstrate the use of an anterior belly of the digastric muscle flap (ABDMF) during transoral robotic radical tonsillectomy (TORRT) with concomitant neck dissection with the intent of preventing the formation of postoperative pharyngocutaneous fistulas.Study DesignRetrospective study.SettingSingle academic tertiary care center.MethodsIn this study, all patients were included who underwent TORRT plus limited pharyngectomy with concomitant neck dissection and ABDMF for the treatment of oropharyngeal squamous cell carcinoma between September 2012 and September 2020. The rate of fistula formation was assessed in patients with preemptive utilization of ABDMF.ResultsA total of 43 patients underwent TORRT with neck dissection and ABDMF. No patients developed a fistula in the postoperative period or associated morbidity with the use of this flap.ConclusionPreemptive use of ABDMF in TORRT with concomitant neck dissection represents a reconstructive option that may help prevent the formation of pharyngocutaneous fistula by reinforcing the posteroinferior boundary of the parapharyngeal space.

Technique of neo-pharynx reconstruction with supra-clavicular artery island flap in a case of pharyngeal stricture

&lt;p class="abstract"&gt;Pharyngeal stenosis frequently occurs after laryngectomy or laryngo-pharyngectomy, more commonly in patients complicated with a post-operative pharyngo-cutaneous fistula. Oral feeding becomes challenging, restricted to liquids. In such cases, dilatations can be futile if there is a complete stricture necessiating surgery. We present a case of 72 -year-old man who underwent total laryngectomy with partial pharyngectomy with pectoral major myocutaneous flap reconstruction for second primary of hypopharyngeal T3N0M0, after primary laryngeal T1N0M0 treated with RT presented with nearly 4 cm pharyngeal stricture causing him absolute dysphagia. Multiple dilations failed to create adequate passage, pharyngeal stricture was then excised, and a neopharynx was constructed with supraclavicular artery island flap. The outcome was uneventful with restoration of normal pharyngeal permeability and swallowing by 12&lt;sup&gt;th&lt;/sup&gt; post-operative day. Post-operative follow-up after 8 months remained satisfactory. Resection of limited height pharyngeal stenosis can be successfully performed as end-to-end anastomosis whereas reconstruction of a long segment pharyngeal stricture utilizing a loco-regional flap gives satisfactory outcome.&lt;/p&gt;

Oncological and Functional Outcomes of Primary and Salvage Total Laryngectomy.

To evaluate and compare the oncological and functional outcomes of total laryngectomies (TL) performed as first line treatment or for salvage after failure of conservative approaches for treating advanced laryngeal carcinoma (LSCC). A retrospective cohort study. A cohort of 217 patients who underwent TL was divided according to whether the procedure was for primary treatment of their LSCC (101 patients) or for recurrences after conservative surgery or chemo-radiotherapy (116 patients). The overall survival rate and disease-specific survival rate were significantly higher in the primary TL group than in the salvage TL group (P = .04 and P = .01, respectively). The recurrence rate was significantly higher and the disease-free survival (in months) was shorter for patients who had salvage TL than for those who had primary TL (P = .00 and P = .01, respectively). The salvage TL group also included significantly more cases of postoperative pharyngo-cutaneous fistula needing salivary stent positioning, and experienced significantly longer hospital stays than the primary TL group (P = .04 and P = .03, respectively). Oncological and functional outcomes of primary TL were significantly better than after salvage TL. If salvage TL was performed after conservative surgery had failed, the oncological and functional results were better than after the failure of organ-preserving protocols. This could justify a first attempt at conservative surgery for intermediate-advanced LSCC in selected cases, reserving chemo-radiotherapy only for patients unsuitable for surgery. 4 Laryngoscope, 131:E569-E575, 2021.

Prevention of fistulas after salvage laryngectomy using temporoparietal fascia free flap.

SUMMARYWe conducted a retrospective review to assess the role of the temporoparietalis fascia flap (TPFF), comparing rates of postoperative pharyngocutaneous fistula (PCF) and functional outcomes with those of pectoralis major myocutaneous flap (PMMF) and primary closure of the pharynx, in a population of patients treated with salvage total laryngectomy (STL). Patients were divided in three groups depending on the pharynx reconstruction technique after primary closure: no vascularised tissue augmentation (group 1), PMMF patch (group 2), or TPFF patch (group 3). The main outcomes analysed were overall fistula rate, fistula requiring reoperation and speech and swallowing function at 6 months. Factors influencing the incidence of fistulas were also evaluated. 39 patients respected inclusion criteria: 14, 11 and 14 patients in the three groups, respectively. Nine patients of 39 (23.1%) experienced a PCF. No statistically significant differences were noted between the three groups, except for a longer surgical operation time and a trend for better functional results in group 3. None of the factors analysed significantly influenced the overall rate of fistula. TPFF patch thus represents a reliable alternative to PMMF in preventing PCF in the setting of STL, with minor donor-site morbidity and good functional outcomes.

Elective neck dissection for the node-negative neck during salvage laryngectomy: an analysis of survival outcomes and complication rates.

This study aimed to evaluate the effect of neck dissection on survival and complication rates in patients with no clinical or radiological evidence of cervical nodal disease (N0) undergoing salvage laryngectomy. A retrospective study was conducted of patients with squamous cell carcinoma of the larynx following primary radiotherapy that required salvage laryngectomy. Disease-free and overall survival rates were compared over three years using Kaplan-Meier analysis. Pharyngocutaneous fistula rate, hospitalisation length and the requirement for further surgical intervention were also compared across cohorts. Twenty-three cases met the inclusion criteria (17 neck dissections, 6 undissected). No significant differences in survival outcomes were identified. One patient who underwent neck dissection for advanced, recurrent transglottic squamous cell carcinoma showed evidence of occult lymph node metastases. Fistula rates did not differ significantly between dissected and non-dissected groups; however, two patients required surgical repair of post-operative pharyngocutaneous fistula following neck dissection. In this study, elective neck dissection did not appear to alter survival outcomes or complication rates during salvage laryngectomy. Given the small but significant risk of occult neck metastases, its true value remains unclear.

Bradykinin Receptor B1 and C-Reactive Protein as Prognostic Factors for Pharyngocutaneous Fistula Development After Laryngectomy

Pharyngocutaneous fistulae (PCF) are one of the most common complications after laryngectomy. Predisposing risk factors have been studied, yet knowledge to determine which patients are prone to developing a fistula remains scarce. This study aims to establish prognostic parameters to identify individual patients at risk for PCF development. As PCF and inflammation seem to be interwoven, this work focuses on markers able to detect an inflammatory response. We retrospectively analyzed all patients who had undergone a laryngectomy at our clinic in the years 2007 to 2017 (n = 182). Immunohistochemical expression of bradykinin type 1 and 2 receptor and vascular endothelial growth factor receptor 2 was studied in all available tumor samples. Additionally, the clinical inflammation parameters ‘body temperature’, ‘pain’, ‘c-reactive protein (CRP)’, and ‘leucocytes’ were postoperatively tracked in all patients. The times between fistula diagnosis, therapeutic approach, and hospital discharge were recorded. We found a strong correlation between inflammation and the formation of a fistula. High bradykinin 1 receptor expression in the tumor samples correlated with postoperative PCF development. Persistently elevated CRP and leukocyte levels beyond the 6th postoperative day were also risk factors. A decreased time lapse between PCF diagnosis and surgical revision clearly correlated with a shorter hospital stay. In this study, we identified a bradykinin 1 receptor positive patient group at high risk for development of PCF. We recommend close monitoring for fistula formation in these patients to ensure timely intervention.

Patterns of cervical node positivity, regional failure rates, and fistula rates for HPV+ oropharyngeal squamous cell carcinoma treated with transoral robotic surgery (TORS)

Objectives(1) Report the patterns of cervical node positivity for HPV + oropharyngeal squamous cell carcinoma (OPSCC) treated with transoral robotic surgery (TORS) and a unilateral level II–IV node dissection. (2) Investigate the regional failure rate following this operation. (3) Report the rate of pharyngocutaneous fistula (PCF) formation intraoperatively and postoperatively following TORS/neck dissection. MethodsRetrospective case series of 88 patients with HPV+ OPSCC treated with TORS and simultaneous neck dissection levels II–IV at the University of Washington from 2010 to 2016. Primary endpoints were PCF, regional recurrence, disease-free survival (DFS), and overall survival (OS). ResultsThe overall frequency of cervical node positivity was 93%, with 84% in level IIa, 7% in IIb, 23% in III, and 13% in IV. Two patients developed PCF intraoperatively, repaired with a local digastric flap, and no postoperative PCF occurred. Sixteen patients (18%) received surgery alone, 49 patients (56%) received adjuvant radiation, and 23 patients (26%) underwent adjuvant chemoradiation. DFS at 2 years was 95% and OS at 2 years was 100%. No concerning level Ib nodes were identified preoperatively or during surgery, and no regional failures occurred in this location. ConclusionOur data suggests, in TORS for HPV+ OPSCC, neck dissection of levels II–IV accurately stages the neck pathologically and prevents regional recurrences, with adjuvant therapy when indicated, and survival outcomes are excellent. Single-staged operations did not result in any postoperative PCF. Avoiding dissection of level Ib with TORS oropharyngectomy limits morbidity to the marginal mandibular nerve and salivary function, and resulted in no postoperative fistulas with minimal reconstruction interventions.

The Hybrid Transoral-Pharyngotomy Approach to Oropharyngeal Carcinoma: Technique and Outcome.

The indications, techniques, and outcomes for a minimally invasive surgical approach in oropharyngeal squamous cell carcinoma (OPSCC) unsuitable for transoral resection are not well-described. A retrospective case series was performed using a prospectively assembled database of transoral surgery-treated OPSCC patients who also underwent a "hybrid" approach of combined transoral and limited pharyngotomy for tumor resection. Disease and functional outcomes were evaluated. Twenty patients underwent complete tumor resection using the hybrid approach. Median follow-up was 48 months. No postoperative pharyngocutaneous fistula occurred. One patient (5%) had a local recurrence. Kaplan-Meier estimates for disease-specific survival at 2 and 5 years were 94.4% (95% CI, 84%-100%) and 87% (95% CI, 70%-100%). All but 1 patient (due to chemoradiotherapy-related chondroradionecrosis) were decannulated, and 2 required long-term gastrostomy. In the absence of a favorable transoral access, the "hybrid" approach of combined transoral and limited pharyngotomy can accomplish margin-negative primary tumor resection, with a high degree of disease control and functional recovery in selected OPSCC patients.

The application of free anterolateral thigh flap with a reporter skin paddle in the reconstruction of circumferential hypopharyngeal defects

To study the short-term results and technological improvement of free anterolateral thigh (ALT) flaps in the reconstruction of circumferential hypopharyngeal defects. The free ALT flap with a reporter skin paddle was used in 22 cases with circumferential hypopharyngeal defects. The short-term results of reconstructive surgeries and key points, advantages and complications of this technique were summarized. The length of circumferential hypopharyngeal defects ranged from 7 to 9 cm. ALT flap with an area of (8-9) cm × (11-18) cm was harvested. A reporter skin island with the skin area of (2.0-3.0) cm × (2.5-4.0) cm was designed. 91% (20/22) of ALT flaps survived. Two cases with flap necrosis underwent second reconstruction with a pedicled pectoralis major flap. All the patients had patent anastomotic lumen. Good postoperative subjective swallowing evaluation was obtained in 59% (13/22) of patients; 41% (9/22) of patients had acceptable swallowing results. Three patients (14%) presented with postoperative pharyngocutaneous fistula. One case recovered spontaneously in short-term and other two cases received the second reconstructive surgery. The application of free ALT flap with a reporter skin paddle in the reconstruction of circumferential hypopharyngeal defect is technologically easy and reliable, with satisfying swallowing function and limited trauma.

再発下咽頭癌に対する救済手術後に生じた難治性瘻孔に対してフィブリン糊の瘻孔内充填が有効であった1例

再発下咽頭癌に対する救済手術後に生じた難治性瘻孔に対してフィブリン糊の瘻孔内充填が有効であった1例

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer?

To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer. A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005. Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive). Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer.