Abstract
After laryngectomy or lateral pharyngotomy for treatment of laryngeal or hypopharyngeal cancer the occurrence of a pharyngo-cutaneous fistula is a challenging complication. Especially after previous radiotherapy and expanded surgical resections of mucosa the management is demanding. Besides the prolonged hospital stay, increased treatment costs and reduced quality of life, a delayed adjuvant treatment follows the development of a fistula. Treatment strategies range from conservative procedures comprising parenteral nutrition, antibiotics and local wound care to primary surgical closure or reconstructive tissue transfer. We report three cases of using the fibrin/thrombin-coated collagen patch TachoSil ® as a solitary or adjuvant strategy in surgical treatment. In one patient primary closure of the fistula was achieved by transoral application of the collagen patch. In the other cases a not tension free primary suture was strengthened by the adjuvant use of TachoSil ® . The healing process was rapid and straightforward in all patients. The use of TachoSil ® may be indicated in between conservative treatment strategies and reconstructive surgery. After occurrence of a fistula the healing process is intended to be accelerated by primary closure with TachoSil ® or by sealing of a primary suture.
1
Introduction
Advanced primary or recurrent laryngeal- and hypopharyngeal carcinomas have to be treated in a multimodal concept. In many cases a total laryngectomy or resection by lateral pharyngotomy is the only surgical treatment option with curative intent. However, pharyngo-cutaneous fistulas (PCF) might occur even if best practice techniques have been applied. The risk for complications is significantly increased in cases with extensive mucosa resection or previous radiotherapy. In literature the incidence varies between 3% and 65 % , whereas retrospective publications including a sufficient number of patients state 13% to 21% .
Pharngocutaneous fistulas present with local symptoms like local erythema, edema of the skin and tenderness on palpation. Additionally, slight fever and increased parameters of inflammation can indicate the development of a fistula. In advanced stages, percutaneous leakage can be observed as wound dehiscence and necrosis of skin and soft tissue occurs . Besides these clinical signs the diagnosis of an insufficient pharyngeal closure following surgery can be confirmed by a Gastrografin swallow.
Early treatment can prevent the development of large fistulas with hard to manage complications and substance defects. Treatment strategies depend on the size of the fistula and the accompanying complications like wound dehiscence and tissue necrosis. At early stages oral nutrition has to be stopped and alimentation maintained via nasogastric feeding tube. Moreover, systemic antibiotics based on the performed susceptibility screening are indicated. In addition resection of necrotic tissue, management with antimicrobiotic wound dressings (e.g. Cutimed Sorbact ® ) as well as daily renewing of a circular bandage are recommended. By intensive wound care, especially in not-radiated tissue, small fistulas can be successfully treated in many cases . In case of pharyngo-cutaneous fistulas that cannot be controlled by a conservative approach an operative revision is indicated. Successful closure of small defects can be achieved by a multilayer closure with slowly resolving suture material. For larger defects a pharyngeal reconstruction by regional or microvascular flaps is promising . As a further treatment strategy we report 3 cases where closure was achieved by a Fibrin/thrombin-coated collagen patch (TachoSil ® , Takeda). This can be accomplished solitarily or in addition to the before mentioned approaches.
TachoSil ® is a sponge like patch made of equine collagen that is depleted by immunogenic epitopes. On its active surface the human coagulation factors thrombin and fibrinogen ( Fig. 1 ) are applied. In diverse surgical specialties, TachoSil ® has a broad range of indications for intraoperative tissue sealing, support of haemostasis and strengthening of sutures. During surgery, TachoSil ® is applied with its active surface on the surgical wound that is intended to be closed. Blood or extravasating liquids dissolve the dry coating followed by the release of coagulation factors. In cases of a poor amount of endogenous liquids the patch can be moistened with saline before application. After dissolving, the released thrombin converts the additionally released fibrinogen to fibrin monomers that spontaneously polymerise. Endogeneous factor XIII catalyses the cross-linking to a mechanically stable network.
In head and neck surgery the fibrinogen/thrombin-coated collagen patches are used mainly for the closure of cerebrospinal fluid leakages . For the first time we report on the use of TachoSil ® for sealing of pharyngo-cutaneous fistulas in previously radiated tissue of 3 patients that underwent total laryngectomy or lateral pharyngotomy for carcinoma resection.
1.1
Case presentation
1.1.1
Patient 1
The patient presented in our outpatient clinic with hoarseness and dyspnoea for more than four weeks. Endoscopy and CT-scan revealed a cT4 transglottic laryngeal tumour. Consecutively, a Panendoscopy with biopsy of the suspicious tissue was performed and revealed a squamous cell carcinoma of the larynx with infiltration of the thyroid cartilage and the hypopharynx.
A laryngectomy and bilateral neck dissection in four levels were performed with curative intent. Due to the infiltration of the hypopharynx more than a third of the pharyngeal circumference had to be resected, making the primary closure of the pharynx difficult. Nevertheless, a tension free suture was possible without reconstructive surgery. Unfortunately, in the caudal part of the pharynx a pharyngo-cutaneous fistula developed postoperatively. Conservative treatment with granulation promoting management, circular wound bandages and systemic antibiotics were not successful. Therefore, a surgical revision was indicated and revealed a pharyngeal fistula with a cranio-caudal diameter of 1.5 cm ( Fig. 2 arrow). After refreshing the mucosal margins the fistula was sutured in a multilayer approach. Due to inflammation and the marked substance loss of mucosal tissue a tension free adaption was not possible in the caudal part of the hypopharynx. Since the patient refused any reconstructive approaches such as free microvascular or local tissue transfer an additional coverage by TachoSil ® was performed. Three stripes of TachoSil ® fleece were placed with its biologically active side on the suture of the hypopharyngeal tube and were adapted by slight pressure. An overlay of approx. 1 cm of the wound and the single patches was considered in particular ( Fig. 2 right).
The following postoperative route was free of further complications, especially with regard to further leakage. Moreover the Gastrografin swallow x-ray revealed no persistent or recurrent fistula 10 days after revision surgery was performed.
1.1.2
Patient 2
A laryngectomy with bilateral neck dissection (4 regions) was performed with curative intent in a patient with rcT4 recurrent laryngeal carcinoma with extension into the hypopharynx. Despite resection of hypopharyngeal mucosa a primary closure was possible by tension free sutures. However, the Gastrografin swallow 10 days postoperatively showed a paraesophageal fistula of 0.5 × 1.5 cm. For further evaluation a hypopharyngoscopy was performed under general anaesthetic revealing a slit-shaped perforation of the pharynx of 0.5 × 0.1 cm ( Fig. 3 arrow). As an alternative to a transcervical exploration with reconstructive covering of the fistula a transoral sealing by TachoSil ® was conducted. For this aim a collagen patch of 1.5 × 1 cm was placed on the orifice through a closed laryngoscope ( Fig. 3 middle). Due to the moisture of the mucosa the coagulation factors were released and the patch stuck tight on the surface ( Fig. 3 bottom). Postoperatively no complications occurred and ten days after surgery the Gastrografin swallow revealed no persistent or recurrent fistula formation.
