Salivary Bypass Tube Research Articles

The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy.

Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial. We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF. Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status. PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube.

There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

Pharyngocutaneous Fistula after Laryngectomy: An Umbrella Systematic Review to Uncover Lacunae in Meta-Analyses

Objective—The objective of this study was to systematically assess meta-analyses to determine the lacunae in the literature for PCF following laryngectomy. Methods—Bibliometric analysis were carried out on meta-analyses on PCF after total laryngectomy for laryngeal cancer in the PubMed database. Results—Twenty-four meta-analyses were considered eligible and chosen for analysis. Six meta-analyses (25%) focused on the risk factors for PCF in TL. Four meta-analyses (16.6%) focused on the role of the onlay flap. Four meta-analyses (16.6%) focused on the timing of feed initiation. Three meta-analyses (12.5%) focused on using a stapler for pharyngeal closure. Two meta-analyses focused on types of pharyngeal reconstruction. Other meta-analyses analyzed the use of salivary bypass tubes, the method of pharyngeal closure, organ preservation protocols on PCF, primary and secondary TEP, and the effect of non-surgical treatment on PCF. Conclusion—Despite plenty of published meta-analyses, there is a lack of scrutiny on certain critical aspects of PCF.

Salivary bypass tube in managing persistent and large pharyngocutaneous and tracheoesophageal fistulas: a series of seven cases

BackgroundA salivary bypass tube (SBT) is a silicone tube that directs oral content from the mouth to the esophagus. We studied a series of seven cases of persistent and large neck fistulas of different aetiologies to assess the beneficial use of SBTs in each case.Case presentationA total of seven patients underwent SBT insertion, six cases were post-total laryngectomy with underlying laryngeal malignancy, and one case was poor wound healing of a neck abscess after extensive drainage. Five cases have pharyngocutaneous fistula (PCF) and two cases have tracheoesophageal fistula (TEF), and all of the cases have failed conservative and multiple surgical management for fistula closure, with some concurrently having neopharynx stenosis. Post-insertion, all patients were able to eat orally after day 2 to 1-week. The duration of tube usage was one month in the three cases of persistent PCF post-operatively, and in two cases, the fistula was healed and the tube was removed without fistula recurrence. The other four cases (three post-radiotherapy fistulas and one stoma recurrence) were planned for lifelong use, with the duration of usage ranging from 4 months to 3 years. The outcome is their fistula is dry, and they tolerate the tube well. There were no intraoperative or immediate postoperative complications, and no complications were observed in the temporary usage cases. Among the patients who had to use the tube for a longer term, one had localised pressure necrosis of regional soft tissue that resolved after tube adjustment, and another had a loose-fitting tube that displaced distally into the oesophagus and resolved with a larger tube.ConclusionsSBT is safe, easy-to-apply, reduces morbidity, improves mental health, reduces inpatient stay, and overall improves the patient's quality of life in the management of persistent and large TEF and PCF for temporary or long-term usage.

Management of Locally Advanced Laryngeal Cancer—From Risk Factors to Treatment, the Experience of a Tertiary Hospital from Eastern Europe

Laryngeal cancer is an important oncological entity in which prognosis depends on the establishment of appropriate preventive and diagnostic measures, especially in high-risk populations. We present a retrospective two-year study (January 2021 to December 2022) with 152 patients diagnosed with laryngeal cancer from a tertiary hospital in Romania. The average age of the patients was 62 years old for both sexes, with a range from 44 to 83 years. The most frequent symptom was dysphonia with or without dyspnea in 142 cases (93.42%), followed by dyspnea alone in nine patients (5.92%) and dysphagia in one case (0.66%). Surgical treatment in this study consisted of partial laryngectomy (CO2 laser transoral tumor ablation, supraglottic horizontal laryngectomy or hemilaryngectomy), or total laryngectomy. The main treatment was total laryngectomy (63%). For the eight patients with initial organ preservation treatment, the average time of recurrence was about two-and-a-half years. For the four patients who underwent a total circular pharyngo-laryngectomy, the upper digestive tract needed to be rebuilt with a salivary bypass tube or with a tubed myocutaneous flap from the major pectoralis muscle. One strong point is characteristic of the study group in gathering patients with advanced stages of laryngeal carcinoma candidates for salvage surgery and extended reconstruction methods. The development of new prevention protocols is mandatory in Eastern European countries.

A Novel Endoscopic Technique for Positioning Salivary Bypass Tubes.

A Novel Endoscopic Technique for Positioning Salivary Bypass Tubes.

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.

The use of salivary bypass tube reduces the risk of pharyngo-cutaneous fistulas after salvage total laryngectomy.

Background: The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL).

S2062 Sudden Dysphagia After Total Laryngopharyngectomy

Introduction: Total laryngopharyngectomy is done for extensive laryngeal and hypopharyngeal cancers, including squamous cell carcinoma and advanced thyroid cancer. The surgery’s aim is to remove cancer, and restore continuity of the oral cavity and esophagus. Most commonly a skin flap is used to recreate a neopharynx connecting the mouth to the esophagus. A favored method is to use the anterior thigh flap. Common sequelae of this surgery include fistula formations and strictures. We present a case of food impaction in the post surgical period of an anterolateral thigh flap reconstruction after squamous cell carcinoma of the larynx. Case Description/Methods: A 58 y male with a history of squamous cell carcinoma of the larynx complicated by tumor invasion of the cervical esophagus and epiglottis status post total laryngopharyngectomy, tracheostomy, G tube, and cricothyroidotomy presented to the ED with discomfort after eating lasagna. His post surgical course had been complicated by recurrent fistula formation and was therefore recommended NPO status and a salivary bypass tube was placed. Following his meal he felt a foreign body sensation, dysphagia, and vomited. On physical exam he was noted to be uncomfortable but was able to tolerate his oral secretions. An esophagram revealed occlusion of the proximal salivary bypass tubing and an EGD was subsequently performed. Using a pediatric scope the salivary bypass tubing was entered and retained food was seen. Using gentle suctioning, water, and forceps, the food was pushed into the native esophagus. The patient's symptoms resolved following the procedure and he was discharged on tube feeds. Discussion: Pharyngoesophageal reconstruction with an anterolateral thigh flap reconstruction is a favored surgical technique after total laryngectomy. To prevent or treat a post surgical fistula or stricture, a salivary bypass tube may be placed. While studies show that the majority of patients are eventually able to tolerate nutrition by mouth, gastroenterologists should be aware of the risk of food bolus given the narrow diameter and lack of distensibility and motility of the bypass tubing.Figure 1.: Endoscopy image showing. Red arrow: Inlet patch Blue arrow: melanocytosis.

The effect of salivary bypass tube use on the prevention of pharyngo-cutaneous fistulas after total laryngectomy.

The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL). A consecutive series of 133 patients who underwent total laryngectomy between 1997 and 2019 was reviewed. The incidence of PCF was compared between patients who did not receive SBT (nSBT group; n = 55) and those preventively receiving SBT (SBT group; n = 78) in both primary and salvage TL. Risk factors for PCF were evaluated in a univariate and multivariate analyses. The overall PCF rate was 30%. Preoperative characteristics were similar between the nSBT and SBT groups, except for older age (p = 0.016), lower preoperative hemoglobin (p = 0.043), and lesser neoadjuvant chemotherapy (p = 0.015) in the SBT group. The rate of PCF the nSBT group, was 41.5%, compared to 21.8% in the SBT group (p = 0.020). In multivariate analysis, only the use of SBT was associated with lower risk of PCF (OR = 0.41 (95% CI 0.19-0.89), p = 0.026). This effect was verified only in the subgroup of patient operated for salvage TL (OR = 0.225; 95% CI 0.09-0.7; p = 0.008). The use of SBT in our series in salvage TL, appears to be associated with a decreased risk of PCF.

"Fistula Zero" Project After Total Laryngectomy: The Candiolo Cancer Institute Experience.

ObjectivesPharyngocutaneous fistula (PCF) is a troublesome complication after total laryngectomy. The “Fistula zero” project aims to reduce the number of PCF by following a detailed protocol based on three fundamental key points.Materials and MethodsThe Fistula zero project included 77 patients who underwent total laryngectomy in the period from January 2019 to December 2020. The protocol consisted of three main aspects: the systematic placement of a Har-El salivary bypass tube, the continuous horizontal watertight pharyngeal suture using a barbed suture, onlay insetting of a pedicled flap in pre-treated patients.ResultsOne case of PCF (1.3%) and three small blind fistulas (3.9%) were observed in this series. The mean length of hospitalization was 18 days.ConclusionPharyngocutaneous fistula (PCF) prolongs hospitalization and delays adjuvant treatments. Thanks to a strict adherence to the protocol, it was possible to reduce PCF rates, avoiding lengthy hospitalization and additional surgical procedures.

Do Salivary Bypass Tubes Reduce the Risk of Pharyngocutaneous Fistula after Laryngopharyngectomy-A Systematic Review and Meta-Analysis.

To evaluate the effect of salivary bypass tube (SBT) usage on the occurrence of pharyngocutaneous fistula (PCF) in patients after a laryngopharyngectomy, a total of 20 studies, published between 1988 and 2021, were identified including 2946 patients. We performed a meta-analysis assessing the risk of PCF occurrence in patients after SBT application compared to those without. PCF occurred in 26.8% of cases (669/2496) and SBT was applied in 33.0% of patients (820/2483). There was an overall trend towards lower PCF rates when using SBTs (22.2% vs. 35.3%; p = 0.057). We further selected five studies, comprising 580 patients who underwent laryngopharyngectomies, for meta-analysis showing that application of SBT reduced the risk of PCF formation (OR 0.46; 95% CI 0.18-1.18; p = 0.11). The meta-analysis demonstrates a beneficial effect of SBT insertion on PCF formation in patients after laryngopharyngectomy.

A New Montgomery® Salivary Bypass Tube Placement Technique: Report of Procedures Performed on Patients With Tracheoesophageal Fistula or Pharyngoesophageal Stenosis.

Salivary Bypass Tube is an important tool to prevent or treat some complications of laryngeal and hypopharyngeal surgery and its placement may prove difficult. In this article, we propose a new technique to simplify its management by using an Oral/Nasal Tracheal Tube Cuffed-Reinforced that allowed us to reduce operating times, complications related to prolonged general anesthesia, and the traumas on the tissues incurred during the forced positioning of the device with standard techniques.

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.

Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy.

To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection. Retrospective cohort study. Tertiary referral centre. A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used. There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used. Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.

Bacterial colonization of Montgomery salivary bypass tubes after hypopharyngeal reconstruction in head and neck cancer patients

BackgroundHypopharyngeal reconstruction after salvage pharyngolaryngectomy results in high postoperative morbidity. The use of salivary bypass tubes can reduce pharyngocutaneous fistula (PCF) formation. The influence of bacterial colonization has not been described in literature.MethodsBacterial swipes from 26 consecutive patients reconstructed after laryngopharyngectomy in combination with Montgomery salivary bypass tubes (MSBT) were analyzed in regards to PCF formation.ResultsPCF occurred in 2 untreated primary and in 9 salvage laryngopharyngectomies, respectively. Bacterial colonization showed high rates of gram-negative pathogens and drug resistance to standard Ampicillin treatment. Type of bacteria was not associated with fistula formation. Antibiotic resistance was found in 6 out 11 patients (54%) with PCF.ConclusionsWe identified high rates of antibiotic-resistant Gram-negative pathogens on MSBT. Although not statistically significant, PCF were found more frequently in drug-resistant patients. Bacterial colonization of hypopharyngeal reconstructions should therefore be taken into account for perioperative prophylaxis.

The use of standardized order sets to improve adherence to evidence-based postoperative management in major head and neck surgery

BackgroundStandardized order sets (SOSs) are clinical tools derived from clinical care pathways that have shown improved patient-recovery and economic benefits. The primary objective was to examine the effect of SOSs on adherence to evidence-based postoperative guidelines for laryngectomy patients. MethodsA retrospective chart review comparing handwritten and SOS-based postoperative physician orders was conducted for consecutive laryngectomies performed (n=70) within a 3-year time period. Orders were analyzed for errors and deviations from evidence-based guidelines. Secondary outcome included complications such as thromboembolic disease, return to operating room, fistula formation, salivary bypass tube, length of hospital stay and death. ResultsApproximately 81% of cases utilizing handwritten orders had at least one error (n=36) compared to 38% in the group that used an SOS (n=34) (P<0.0001). Subgroup analyses demonstrated that errors in mechanical deep vein thrombosis prophylaxis (P<0.0001) and antibiotic prophylaxis (P=0.0173) orders were significantly reduced in the SOS group compared to the handwritten group. No significant differences were observed between the two groups for measured postoperative complications (P>0.05) and length of hospital stay (18.6 days in both SOS and handwritten orders groups). ConclusionsSOSs are associated with reduced errors in postoperative orders. They are important tools to improve adherence to standardized guidelines for surgeries requiring complex postoperative management. Clinical care pathways and Enhanced Recovery After Surgery protocols can use SOSs to ensure appropriate orders are being made.

Routine use of salivary bypass tubes in laryngectomy patients: systematic review.

Pharyngocutaneous fistula is a cause of significant morbidity following laryngectomy. Routine use of salivary bypass tubes during laryngectomy has been proposed to reduce the incidence of fistulae and neopharyngeal strictures. Following a systematic search of Embase, Medline and Cochrane databases (1946 - current), included articles were assessed for bias according to the Cochrane Handbook for Systematic Reviews of Interventions. Three case-control trials showed reduced pharyngocutaneous fistula rates with the use of salivary bypass tubes; six case series reported widely varied fistula rates. With regards to stricture rates, the largest case-control trial found no improvement with salivary bypass tube use. No fatal adverse events were observed among the 204 patients who received a salivary bypass tube. Low-level evidence suggests salivary bypass tubes may reduce the incidence of fistula in high-risk patient groups. A robust randomised controlled trial, or large, multicentre cohort studies, are needed to further examine this intervention.

Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

Laryngopharyngeal Repair in Salvage Laryngectomy

Although associated with significant morbidity including fistula, stricture, poor voice rehabilitation, and even death, salvage laryngectomy and laryngopharyngectomy will remain as important surgical procedures as long as transoral surgery and chemoradiation therapy continue to be employed primarily in the treatment of laryngeal malignancy. Multi-institutional retrospective analyses indicate that onlay pectoralis myofascial flaps may reduce the incidence of post-operative fistula to 10–15 % compared to 30 % associated with primary closure alone. Regional and distant fasciocutaneous flaps have limited morbidity and their use may minimize the rates of stricture. Employment of salivary bypass tubes appears to reduce the incidence of fistula to less than 10 %. Voice rehabilitation outcomes with tracheoesophageal puncture are equivalent between fasciocutaneous flaps and primary closure, and better than the voice quality attained with enteric flaps or pectoralis flaps. Pectoralis onlay flaps are a viable option in select patients undergoing primary closure who are aware of the associated morbidity and voice outcomes. Free tissue transfer, in particular the anterolateral thigh flap, used in conjunction with salivary bypass tubes offers an ideal balance of donor site morbidity, post-operative fistula, and voice rehabilitation, and should be considered for appropriate patients.