Total Laryngopharyngectomy Research Articles

Laminin-5 immunohistochemical mapping for analysis of local extension in hypopharyngeal cancer: A preliminary report

Laminin-5 γ2 chain (LNγ2) plays an important role in cancer differentiation and migration. Using a novel immunohistochemical mapping technique to investigate whole mucosal strips of total laryngopharyngectomy specimens using iodine, H-E, and LNγ2 stainings, we investigated the locoregional behavior of hypopharyngeal cancer. Surgical specimens from two patients with pyriform sinus cancer were investigated. Three percent iodine was applied to the tumor-bearing laryngopharynx during surgery and photographed. Stainabilities of H-E and LNγ2 on pathologic sections from all mucosal strips were scored and coordinated with the laryngopharyngeal photograph to illustrate the immunohistochemical map. In both patients, the main tumor of invasive squamous cell carcinoma was circumferentially surrounded by a superficial lesion characterized by high grade intraepithelial neoplasia that remained unstained by iodine. On LNγ2 immunohistochemical mapping, the main tumor was demonstrated by Score 2 staining and the superficial lesion by a stronger Score 3 staining. The finding of neoplastic cells at the periphery demonstrating a higher potential than the cancer cells at the tumor center is suggestive of impending progression from neoplasia to carcinoma. The current preliminary report suggested morphological evidence of intraepithelial infiltration and lateral invasion in hypopharyngeal cancer.

Thyroid gland invasion in laryngopharyngeal squamous cell carcinoma: Prevalence, endoscopic and CT predictors

The authors studied the prevalence of histological thyroid gland invasion in laryngopharyngeal cancer and the preoperative endoscopic and CT signs predictive of this invasion. Retrospective study of patients with laryngopharyngeal squamous cell carcinoma (T3 and T4) treated by total laryngectomy or total laryngopharyngectomy associated with concomitant total thyroidectomy or ipsilateral lobectomy and isthmectomy. Eighty-seven patients were included. Eleven patients (12.6%) presented thyroid gland invasion. Subglottic tumour extension greater than or equal to 10mm (P=0.008) and cricoid cartilage destruction on CT (P=0.001) were statistically correlated with histological thyroid gland invasion. An intact appearance of the laryngeal cartilages on CT was associated with a low probability of thyroid gland invasion. Thyroid gland invasion must not be underestimated in patients with advanced laryngopharyngeal cancer. Preoperative CT is an essential part of the preoperative work-up. Thyroidectomy must not be performed systematically.

Reconstruction of the jejunoesophageal anastomosis with a circular mechanical stapler in total laryngopharyngectomy defects

The aim of this study was to demonstrate the technical feasibility and potential benefits of using a circular mechanical stapler with free jejunal transfer for jejunoesophageal anastomosis in total laryngopharyngectomy reconstruction while comparing the rates of fistula and stricture. This study was a retrospective review of 12 free jejunal flaps completed with circular mechanical stapler for the jejunoesophageal anastomosis with comparison to 17 jejunal free flaps where all anastomoses were hand sewn. In all, 29 patients underwent free jejunal transfer: 12 had jejunal free flap with circular mechanical stapler for jejunoesophageal anastomosis, whereas 17 patients had hand-sewn anastomosis. Corresponding rates of fistula and stricture were 0/12 fistulas and 3/12 strictures in the stapler cohort and 2/17 fistulas with 0/17 strictures in the hand-sewn cohort. No statistically significant difference in rate of fistula was observed between each cohort, whereas a trend toward increased rate of stricture (p = .06) was observed in the stapled anastomosis cohort. Use of circular mechanical stapler appears to be a safe and effective technique at the jejunoesophageal anastomosis for total laryngopharyngeal defects with comparable fistula and stricture rates to grafts that are hand sewn.

Sequential Second Free Flap for Head and Neck Reconstruction in a Patient with Fanconi Anemia and Metachronous Squamous Cell Carcinoma

Sir: Fanconi anemia is a rare genetic disease characterized by chromosomal instability, bone marrow failure, congenital malformations, and increased susceptibility to both solid and leukemic malignancies. The incidence of solid malignancies approaches 28 percent by 40 years of age, with a high proportion of these being head and neck tumors.1 In a series of 754 patients with Fanconi anemia, Kutler et al. reported that 3 percent developed head and neck squamous cell carcinoma, with a 50 percent relapse rate by the age of 40.2 Although Fanconi anemia patients may develop multiple tumors over a lifetime, repeated operations/ reconstructions are rarely seen because of their shortened life expectancies. Furthermore, surgeons may be hesitant to treat patients with Fanconi anemia because of an increased risk of complications, particularly if treatment involves extensive resection or possible free tissue transfer. We have previously described a successful mandibular reconstruction with a free fibula free flap in a patient with Fanconi anemia and squamous cell carcinoma of the mandible.3 Unfortunately, the patient developed squamous cell carcinoma of the pharynx 18 months later. We now report subsequent pharyngeal reconstruction with a metachronous free flap. Initially, a 43-year-old woman with Fanconi anemia was referred to our institution with an erosive floor-of-mouth mass ultimately diagnosed as squamous cell carcinoma. She underwent hemimandibulectomy and bilateral neck dissection followed by immediate reconstruction with a right fibular osteomyocutaneous flap. The patient recovered from surgery without complications and underwent adjuvant radiation therapy. Her postoperative result was satisfactory. Eighteen months later, she was found to have squamous cell carcinoma of the hypopharynx. She then underwent total laryngopharyngectomy and construction of a neopharynx using a tubed anterolateral thigh flap. The soft tissues of the right neck were resurfaced with a separate skin paddle based off of a second perforator; the left lateral neck received a split-thickness skin graft. The patient recovered without any hematologic complications but did suffer partial skin graft loss and a small pharyngocutaneous fistula. A modified barium swallow performed 6 weeks postoperatively demonstrated a small leak that resolved 1 month later, resulting in satisfactory cosmetic and functional outcomes. As recommended by our hematologists, during both hospitalizations, the patient's perioperative hemoglobin level and platelet count were maintained above 7 g/dl and 50,000 cells/ml, respectively, by means of hematopoiesis-stimulating agents and blood product transfusions. A total of 42 units of single-donor platelets and 13 units of packed red blood cells were administered while the patient was hospitalized after the second free flap. In conclusion, patients with Fanconi anemia are at increased risk for perioperative hematologic complications. There are two published reports that describe successful free tissue transfer in Fanconi anemia patients.3,4 To our knowledge, this is the first reported case of a patient with Fanconi anemia to undergo a second sequential free flap operation for metachronous head and neck cancer reconstruction. As this case demonstrates, such large-scale reconstructions can be successfully undertaken with careful perioperative management of patients with this disease. Karly A. Kaplan, M.D. Alyssa J. Reiffel, M.D. David I. Kutler, M.D. Christine H. Rohde, M.D. Jason A. Spector, M.D.

Closure of laryngectomy defects in the age of chemoradiation therapy

The use of chemoradiation therapy in laryngeal cancer has resulted in significant reconstructive challenges. Although reconstruction of salvage laryngectomy defects remains controversial, current literature supports aggressive management of these defects with vascularized tissue, even when there is sufficient pharyngeal tissue present for primary closure. Significant advancement in reconstructive techniques has permitted improved outcomes in patients with advanced disease who require total laryngopharyngectomy or total laryngoglossectomy. Use of enteric and fasciocutaneous flaps result in good patient outcomes. Finally, wound complication rates after salvage surgery approach 60% depending on comorbid conditions such as cardiac insufficiency, hypothyroidism, or extent of previous treatment. Neck dehiscence, great vessel exposure, fistula formation, or cervical skin necrosis results in complex wounds that can often be treated initially with negative pressure dressings followed by definitive reconstruction. The timing of repair and approach to the vessel-depleted neck also present challenges in this patient population. Currently, there is significant institutional bias in the management of the patient with postchemoradiation salvage laryngectomy. Future prospective multi-institutional studies are certainly needed to more clearly define optimal treatment of these difficult patients.

Reconstruction of hypopharyngeal and cervical esophageal defect after resection of hypopharyngeal carcinoma: a new technique based on the use of bilateral platysma myocutaneous flaps

Commonly used procedures for reconstructing hypopharyngeal and cervical esophageal defects resulting from total laryngopharyngectomy (TL) are the gastric conduit or colon transposition as well as microvascularized free flaps. Herein we designed an alternative procedure utilizing bilateral platysma myocutaneous flaps (PMCFs) for the reconstruction of hypopharyngeal and cervical esophageal defects. This report summarizes the technical description of this procedure. TL and cervical esophagectomy were performed and bilateral PMCFs were harvested for reconstruction of hypopharyngeal and cervical esophageal defects in 25 patients aged between 46 and 73 years (mean 58.7 ± 16.2 years). All these patients had advanced-stage (IV) cancer with involvement of the cervical esophagus. Operative time ranged from 176 to 382 minutes (average 243 ± 91 minutes) and the mean intraoperative blood loss was 294 ± 119mL. There were six cases of anastomotic leak (24.0%) and two of them (8.0%) developed anastomotic stricture. Neither flap necrosis nor postoperative death was observed. The majority of our patients (68.0%) were restored to a normal unrestricted oral diet after surgery. The 3-year and 5-year actuarial survival rates were approximately 54.7% and 26.1%, respectively. We conclude that reconstruction of the cervical esophagus with bilateral PMCFs is a valuable method for treating advanced hypopharyngeal carcinoma.

Primary TEP Placement in Patients with Laryngopharyngeal Free Tissue Reconstruction and Salivary Bypass Tube Placement

The authors examined the feasibility and advantages of primary tracheoesophageal puncture (TEP) with intraoperative placement of the voice prosthesis for patients undergoing laryngopharyngectomy requiring free tissue reconstruction and salivary bypass tube placement. Six patients were identified; 4 underwent total laryngopharyngectomy, and 2 underwent total laryngectomy with partial pharyngectomy. All 6 required free tissue reconstruction, and a salivary bypass tube was placed in all cases. All patients had a 20F Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, California) placed. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. At 6 months, 4 patients available for evaluation had successful voice outcomes, and 3 were disease free. This study demonstrates the effectiveness of voice prosthesis placement at the time of primary TEP associated with free tissue reconstruction of a laryngopharyngeal defect with salivary bypass tube placement.

Reconstruction of the jejunoesophageal anastomosis with a circular mechanical stapler in total laryngopharyngectomy defects.

Background. The aim of this study was to demonstrate the technical feasibility and potential benefits of using a circular mechanical stapler with free jejunal transfer for jejunoesophageal anastomosis in total laryngopharyngectomy reconstruction while comparing the rates of fistula and stricture. Methods. This study was a retrospective review of 12 free jejunal flaps completed with circular mechanical stapler for the jejunoesophageal anastomosis with comparison to 17 jejunal free flaps where all anastomoses were hand sewn. Results. In all, 29 patients underwent free jejunal transfer: 12 had jejunal free flap with circular mechanical stapler for jejunoesophageal anastomosis, whereas 17 patients had handsewn anastomosis. Corresponding rates of fistula and stricture were 0/12 fistulas and 3/12 strictures in the stapler cohort and 2/17 fistulas with 0/17 strictures in the hand-sewn cohort. No statistically significant difference in rate of fistula was observed between each cohort, whereas a trend toward increased rate of stricture (p 1⁄4 .06) was observed in the stapled anastomosis

下咽頭混合型小細胞癌と考えられた１例

Combined small cell carcinoma (CSCC) involves small cell carcinomas and nonsmall cell carcinomas including squamous cell carcinoma (SCC). CSCC of the hypopharynx is extremely rare, with just 5 cases described to date in English literature. A 75-year-old man with CSCC of the hypopharynx seen for abnormal upper gastrointestinal endoscopic findings was found in video hypopharyngoscopy to have a right pyriform sinus tumor. Pathological biopsy findings showed SCC in situ (cTisN0M0). Radiotherapy with 70 Gy brought complete remission. A relapse three months later thought to be recurrent SCC (rT2N2cM0) at the tumor site necessitated total laryngopharyngectomy and bilateral neck dissection and free rectus abdominis flap reconstruction. Pathological findings showed small cell carcinoma. Most radiation-induced cancer arises 10 years later. We think the primary tumor was likely CSCC with SCC. After undergoing two chemotherapy courses (CBDCA+VP-16) for small cell carcinoma, the man died 4 months after surgery. We review the literature and discuss clinical features and management of this rare tumor.

Current trends in initial management of hypopharyngeal cancer: The declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

Radical Resection or Chemoradiotherapy for Cervical Esophageal Cancer?

The prognosis and quality of life (QOL) for those with cervical esophageal cancer is extremely poor, and chemoradiotherapy remains the mainstay treatment. During the past few years, our surgical teams has implemented a more aggressive and radical resection: total laryngopharyngectomy with neck dissection, total esophagectomy, and reconstruction with stomach. This study compares the results of chemoradiotherapy and that of the aforementioned surgical approach. This is a retrospective study of 15 patients who underwent radical resection and 14 patients who received chemoradiation. Their age, sex, tumor stage and grade, pre- and posttreatment dysphagia scores, operating time, blood loss, length of intensive care and postoperative stay, days to resume oral intake, complications, Eastern Cooperative Oncology Group (ECOG) status, QOL score, and disease-specific survival were recorded and compared. There were no significant differences in age, sex, pretreatment dysphagia score, cancer stage and grade, ECOG status (posttreatment), associate diseases, preoperative QOL, or follow-up period between the two groups. However, the posttreatment dysphagia score was significantly better for the operative group (P < 0.001). QOL improved in both groups, and the operative group seemed better although the difference was not significant. In addition, the survival between the two groups was statistically insignificant (P = 0.97, log-rank test). Our experience showed that radical surgery that includes total laryngopharyngectomy with neck dissection, total esophagectomy, and reconstruction with stomach for cervical esophageal cancer is beneficial to patients in terms of better eating.

Early and long-term morbidity after total laryngopharyngectomy

To determine the early and long-term morbidity of patients treated with a total laryngopharyngectomy and reconstruction using a jejunum interposition or gastric pull-up procedure. It is a retrospective study; and it is conducted in tertiairy referral center. Sixty-three patients were included in whom 70 reconstructions were performed (51 jejunum interpositions and 19 gastric pull-up procedures) between 1990 and 2007. The studied parameters were success rate of the reconstruction, early and long-term complication rate, and functional outcome including quality of life. Subjective quality of life analysis was determined by two questionnaires: the EORTC Quality of Life Questionnaire (QLQ)-C30 Dutch version 3.0, and the EORTC-Head and Neck (H & N 35). The success rates were 84 and 74%, respectively. The procedures were associated with a high complication rate (63% after jejunum interposition and 89% after gastric pull-up), and a lengthy rehabilitation. Surviving patients were found to have a good long-term quality of life. Complete oral intake was achieved in 97%, and speech rehabilitation in 95%. These procedures are associated with significant morbidity, high complication rates, lengthy rehabilitation, but a good long-term quality of life.

Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy

: Pharyngoesophageal defects traditionally have been reconstructed using a jejunal or radial forearm flap. In 2002, the authors began using the anterolateral thigh flap for pharyngoesophageal reconstruction, and it has become our preferred method. The purpose of this study was to analyze the clinical and functional outcomes achieved using this technique. : The medical records of 91 male and 23 female patients who underwent pharyngoesophageal reconstruction using an anterolateral thigh flap were retrospectively reviewed. Outcomes analyzed included length of hospital and intensive care unit stay, fistula and anastomotic stricture formation and other complications, swallowing and tracheoesophageal speech function, and survival. Most patients had primary (27%) or recurrent (42%) squamous cell carcinoma. Before reconstruction, 71% of patients had undergone surgery, radiotherapy, or both. There were 67 circumferential and 47 near-circumferential defects. : Mean intensive care unit stay was 1.9 +/- 2.2 days, and mean hospital stay was 9.0 +/- 4.7 days. Two patients experienced total flap loss, and 1 patient had partial flap necrosis. Pharyngocutaneous fistulas and strictures occurred in 9% and 6% of patients, respectively. Ninety-one percent of patients tolerated an oral diet without the need for tube feeding. Tracheoesophageal puncture was performed for speech rehabilitation in 51 patients. Eight-one percent of patients with a secondary tracheoesophageal puncture achieved fluent speech versus 41% of patients with a primary tracheoesophageal puncture. : This series demonstrates that excellent clinical and functional outcomes, with minimal donor site morbidity and quick recovery, are possible with pharyngoesophageal reconstruction using an anterolateral thigh flap. Cancer 2010. (c) 2010 American Cancer Society.

Dysphagia after an L-shaped reconstruction technique of the free jejunum graft

The free jejunum graft is a well-established reconstruction technique after total laryngopharyngectomy. However, besides necrosis of the jejunum graft, the two most important complications are pharyngocutaneous fistula formation and dysphagia due to stricture formation. This study aims to develop an L-shaped reconstruction technique of the free jejunum graft to decrease pharyngocutaneous fistula formation and long-term stricture formation after total laryngopharyngectomy. An L-shaped side-to-end anastomosis was performed at the proximal end of the jejunum graft in six patients treated for piriform sinus carcinoma. Patient and operation characteristics and follow-up were recorded. A successful jejunum transfer was performed in all six patients. No pharyngocutaneous fistula or stricture formation occurred during a median follow-up of 23 months (range: 18-30 months). Swallowing rehabilitation started at the median 12th postoperative day (range: 5-150 days). Four patients developed dysphagia at a median of 2 months (range: 1-6 months) after oral intake was started. X-barium swallow revealed a redundant pouch of the transferred jejunum graft, which resulted in compression on the jejunum interposition during swallowing. In three patients, an operation was required to resolve these problems. After the revision operation, no dysphagia occurred during a median follow-up of 12 months (range: 7-13 months). Because of dysphagia complaints in the majority of our patients, we cannot recommend the described technique and should find other means to improve direct postoperative results and long-term quality of life in this difficult-to-treat group of patients.

Reconstruction of Total Laryngopharyngectomy Defects with Deep Inferior Epigastric Perforator Flaps

Laryngopharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh, radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. We present a novel approach for total laryngopharyngectomy reconstruction using deep inferior epigastric perforator (DIEP) flaps. A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006 to 2007 was performed. Those undergoing DIEP flaps were identified; management and postoperative course were analyzed. Two patients underwent successful reconstruction of total laryngopharyngectomy defects using DIEP flaps. Flaps up to 10 x 30 cm were harvested. Average donor vessel diameters were 2.5 cm and 3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent reexplorations. There were no postoperative bulges or hernias, and no leaks were detected on postoperative swallow evaluation. The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngopharyngectomy defects. Pedicle length is abundant, and donor vessel caliber is excellent. Large surface-area flaps can be harvested; excess flap can be deepithelialized or utilized for external skin. Primary closure of the donor site can be routinely achieved, negating the need for skin grafts.

National laryngopharyngectomy and reconstructive surgery survey

To understand the various methods available to reconstruct total laryngopharyngectomy defects and to understand which, and to what degree, various factors influence the surgeon in choosing a particular reconstructive method. Otolaryngologists and plastic surgeons who perform head and neck reconstruction were surveyed regarding preference of laryngopharyngectomy reconstruction. Numerical and rank-order data was analyzed using T statistics and Fisher exact test. Two hundred surveys were mailed and 72 physicians (36% response rate) provided data, with otolaryngologists comprising 54% of the respondents. Otolaryngologists were more likely to consider voice (P = .003) and swallowing (P = .02) outcomes compared to plastic surgeons. In contrast, plastic surgeons more often included cosmesis (P = .05) among those factors influencing their reconstructive choice. However, rank-order analysis demonstrated no statistical difference between plastic surgeons and otolaryngologists with respect to each factor. Our study sought to examine what motivates surgeons from several specialties to choose one reconstructive method over another for laryngopharyngeal defects. Otolaryngologists were more likely to consider voice and swallowing function in contrast to plastic surgeons, who more frequently included cosmesis as a factor. However, when physicians were asked to rank the importance of each of the eight factors from most to least important in influencing their reconstructive option, there was no statistical difference between plastic surgeons and otolaryngologists with respect to each factor. Further research is necessary to provide an evidence base for which reconstructive method offers the optimal functional restoration.

Pathology Quiz Case 1

A 66-YEAR-OLD WOMAN PRESENTED FROM AN outside institution 1 week after undergoing an aborted thyroidectomy for locally aggressive cancer of the thyroid gland. Intraoperative findings were notable for extrathyroid extension involving the right cricotracheal complex and encasement of the right recurrent laryngeal nerve, which was sacrificed. She did report childhood exposure to radiation, presumably for treatment of acne. There was no palpable residual thyroid or lateral neck disease on physical examination. Flexible fiberoptic laryngoscopy demonstrated a paretic right true vocal cord. A finecut computed tomogram of the neck demonstrated softtissue density fullness of the subglottic larynx, which was consistent with either tumor invasion of the airway or postoperative edema (Figure 1). In the operating room, a firm submucosal soft-tissue fullness was identified on endoscopy. Findings from a biopsy confirmed malignancy, showing cribriform and glandular architecture composed of squamoid, mucous, and intermediate cell types beneath an unremarkable respiratory epithelium. The patient underwent a total laryngopharyngectomy withacompletionthyroidectomy,bilateralparatrachealnode dissection,andacomprehensiverightneckdissection.Gross examination of the surgical specimen showed an infiltrative tumorarisingwithin the thyroidgland,withextension to the larynx, esophagus, and anterior strap muscles. The tumor demonstrated a complex histologic picture, with a gradual transition of 2 distinct types of cancer: a low-grade carcinomawithcribriformarchitectureandacarcinomaof papillary architecture and follicles containing brightly eosinophilic colloid material. The cribriform component of the tumor infiltrated ossified thyroid cartilage (Figure2) andanterior strapmusculature.Both thecribriformandthe papillary components showed mildly enlarged nuclei with irregular nuclear contours, nuclear grooves (Figure 3), and scattered intranuclear cytoplasmic pseudoinclusions. Metastatic foci of each tumor were present within numerous cervical lymph nodes. Immunohistochemical staining was positive for thyroid transcription factor 1 and thyroglobulin in both components of the tumor, although only amicroscopicfocusstainedpositively inthecribriformareas (Figure 3, inset). Staining showed strong positivity for p63 inthecribriformportion.StainingforKi-67andp53revealed a low degree of nuclear positivity ( 5%), consistent with a low-grade tumor. What is your diagnosis? Figure 1.

Modified ileocolic free flap: Viable choice for reconstruction of total laryngopharyngectomy with total glossectomy

Reconstruction following total laryngopharyngectomy and total glossectomy is quite challenging. Many free flaps are not options for reconstruction of this particular defect because of the large area that requires reconstruction and the size discrepancies of the oral and esophageal stomas. We propose a modified ileocolic free flap for reconstruction of these defects. We conducted a retrospective chart review. Two patients underwent a modified ileocolic free flap following total laryngopharyngectomy and total glossectomy. One of these patients was able to tolerate thin liquids by mouth, and 1 patient developed severe trismus limiting oral intake. There were no significant flap-related complications aside from fistula in 3 patients that healed with conservative management. The modified ileocolic free flap is a viable option for reconstruction following total laryngopharyngectomy and total glossectomy.

Functional Outcomes and Reevaluation of Esophageal Speech After Free Jejunal Transfer in Two Hundred Thirty-Six Cases

Swallowing and communication are occasionally impaired after free jejunal transfer. Here, the relationship between surgical procedure and functional outcome was analyzed in 236 patients undergoing free jejunal transfer after total laryngopharyngectomy from 1992 through 2003. Swallowing and communication functions were also investigated with a questionnaire in 40 long-surviving patients. Although oral feeding could be resumed after surgery in most patients, anastomotic stricture and nasal regurgitation occurred in 12.7% and 29.7% of patients, respectively. Use of our standardized procedure, the tensed jejunal method, significantly reduced the incidence of stricture (P < 0.01) but increased the rate of nasal regurgitation; however, in most cases regurgitation gradually resolved. Of the 40 long-surviving patients, 17 attended a speech rehabilitation program at which 12 learned to perform esophageal speech without voice restoration procedures (11 of the 12 had received a tensed jejunal graft). Our standardized procedure helps prevent strictures and encourages esophageal speech.

Novel STSG Donor Site for Forearm Flaps: Radial Skin Paddle

Objective Split thickness skin grafts (STSG) harvested from the thigh are often utilized to provide coverage for radial forearm donor sites. To eliminate the morbidity of the thigh STSG donor site, we assessed the feasibility of harvesting the STSG from the radial. Methods Prospective data was collected from patients undergoing forearm free flap reconstruction at a tertiary medical center in a 6-month period. The radial forearm free flap (RFFF) harvesting procedure was modified to incorporate STSG harvest from the paddle site as the first step after arm tourniquet activation. Results There were 27 patients in this cohort, with mean age of 68.2. There were 24 fasciocutaneous RFFF, 2 osteocutaneous RFFF, and 1 ulnar flap. The indications for free tissue transfer were as follows: intraoral defects (n=13), pharyngeal patch repair (n=8), total laryngopharyngectomy (n=1), external skin coverage (n=5). The mean forearm defect was 41.2 cm2 (24–77 cm2). 22 out of 27 skin grafts were non-meshed. Harvesting from the forearm skin paddle was successful in 25 patients (93%). Two patients required a thigh STSG; both patients were octagenerians with frail skin. All the forearm donor sites healed well, except one patient required a later revision procedure for exposed tendon. Conclusions Based on this study, the thigh STSG donor site can be eliminated in 9 out of 10 patients undergoing radial forearm free flaps. This translates to decreased risk of pain, infection, and wound oozing. Older patients with frail skin and atrophied forearm muscles were likely to require a thigh donor site.