Complications after Total Laryngectomy, Pharyngolaryngectomy, and Conservative Laryngeal Surgery
Some complications are unpredictable, some are unpreventable and some are incurable. They may be further aggravated by a failure in conscientious reporting. There is a natural disposition to avoid emotional confrontation with all types of disappointment and emphasize the positive aspect of these encounters. This should never supersede the necessity of the open and frank study of all complications so that their full impact is comprehended on the personal and scientific levels. This scholarly and humanizing experience will make medicine a noble profession.
John J. Conley
According to the National Comprehensive Cancer Network Practice Guide in Oncology v.2.2010, “in tumors of the larynx, the decision to perform either total laryngectomy or conservation laryngeal surgery (i.e., laser resection, hemilaryngectomy, supraglottic laryngectomy, etc.) will be decided by the surgeon but should adhere to the principle of complete tumor extirpation with curative intent”.1 There are multiple treatments and different options and consequences, and the most appropriate one should be the decision of a multidisciplinary team, considering patient preferences, tumor characteristics, experience and facilities available.2–4
Surgery for laryngeal or hypopharyngeal carcinomas can be indicated either as initial treatment or as a salvage procedure. When properly indicated and performed, surgery achieves 90% local control.2,5,6 Total laryngectomy is mostly employed for recurrent disease after failure of previous treatment, although it is a good option for advanced tumors that are not suitable for organ preservation because of oncologic criteria, patient status, or health system resources.7 Conservative laryngeal surgery, when properly indicated, avoids the permanent undesirable sequelae of total laryngectomy, namely permanent tracheostoma and alaryngeal speech, allowing the patient to swallow without aspiration.4–7 Salvage surgery after failure of radiotherapy or chemoradiotherapy increases the risk of short-term and long-term complications,8 and reduces the chances for partial surgery options.9–12
Complications after surgery of the laryngopharynx result in prolonged hospitalization, increased morbidity related to local infections, tissue necrosis and vascular rupture, resource utilization, and patient anxiety. Rehabilitation and additional postoperative treatments may be delayed beyond the recommended time.
The incidence of complications ranges from 7% to 41%, with pharyngocutaneous fistula being the most frequent.13,14 After partial surgery, every effort is made to avoid aspiration, so the selection procedure should include a thorough investigation of the patient′s capacity to tolerate pulmonary complications.5–8
A major challenge for the surgeon is the identification of patients and surgical scenarios with a higher risk of complications, and attempting to prevent their occurrence while favoring early detection of symptoms.
Total Laryngectomy and Pharyngolaryngectomy
Total laryngectomy is a dreadful intervention in which the surgeon admits late diagnosis and the inability for conservative surgery, but it should not be avoided at all costs because life is more important than voice;15 a lung-powered voice can also be achieved through a tracheoesophageal fistula. A good quality of life can be maintained after total laryngectomy.16 Although conservation surgery is possible after radiotherapy failure, only around 30% of patients are suitable.17
According to the National Clinic Guide for surgical prophylaxis from the Scottish Intercollegiate Guidelines Network, for head and neck surgery (contaminated/clean-contaminated), there is consistent evidence that a single dose of an antibiotic with a half-life long enough to achieve activity throughout the operation is adequate.18 There is evidence from several studies of antibiotic prophylaxis during surgery that dosages with longer duration have no increased benefit over a short course. A single standard therapeutic dose of antibiotic is sufficient for prophylaxis under most circumstances. Intravenous prophylactic antibiotics should be given up to 30 minutes before incision.
Local policy makers have the experience and information required to make recommendations about specific drug regimens based on an assessment of evidence, local information about resistance and drug costs. Narrow-spectrum, less expensive antibiotics should be the first choice for prophylaxis.
The best way to avoid complications after total laryngectomy is through careful and meticulous technique, with minimum mucosal damage and accomplishing a water-tight pharyngeal mucosa closure without tension. If possible, tracheotomy should be avoided before definitive surgery because of the higher incidence of local infection; the tissue around a previous tracheotomy should be removed.
All efforts should be made to avoid entering the larynx close to the tumor, keeping in mind the spatial needs for safe margins. For intralaryngeal tumors the approach can be made through the vallecula, removing the tumor under direct vision. If the tumor invades the upper part of the epiglottis, the vallecula or base of the tongue, the approach is made from behind the arytenoids, in an upward direction.
During endoscopic evaluation of the patient, tumor extension to the pyriform fossa mucosa should be recorded. If no infiltration is found, the mucosa is detached from the internal side of the thyroid cartilage, preserving as much mucosa as possible. This will help during pharyngotomy closure, avoiding both tension and stenosis.
Pharyngeal Mucosal Closure
Pharyngeal mucosal closure can be done in two different ways, through either the usual t-shaped closure or the tobacco-pouch technique. The former is made using a Connell suture pattern, but trying not to enter the mucosa of the pharyngeal wall. A 2–0 Vicryl suture is used. The suture goes from the outside toward the pharyngotomy border without entering the mucosa, ~ 0.5 cm. At the opposite side, the sutures enter the pharyngeal wall close to the pharyngotomy border and exit, without entering the mucosa, after 0.5 cm. Independent stitches are made from the inferior border of the pharynx toward the tongue base. It is important to make sure that the suture inverts the mucosal edges into the pharynx. This makes the vertical part of the t. For the horizontal arms of the t, a similar technique is used crossing from the upper pharyngeal mucosa to the tongue base until the midline is reached. Care must be taken to avoid damage to the hypoglossal nerve and the lingual artery during this maneuver. A second layer can be made with the inferior constrictor muscles, to reinforce pharyngeal closure, although this may increase hypopharyngeal tension, making esophageal speech acquisition more difficult.
The tobacco pouch, described in 1945 by García-Hormaeche, is possible when sufficient pharyngeal mucosa is preserved for direct closure.19 Two parallel continuous suture lines are placed around the hypopharyngeal opening. The first one is placed 2 or 3 mm from the mucosal edge, without entering the mucosa, inserting the needle every 6 to 8 mm. By gently pulling from both ends of the sutures, the mucosal edges are approximated and turned inward, creating a safe primary closure. The second line starts at the tongue base and is placed 5 mm lateral and parallel to the first one. The aim of the second stitch is to relieve tension from the first and to retract the suture below the tongue base.
When there is insufficient hypopharyngeal mucosa for direct closure, an apron platysma myocutaneous flap is a fast and reliable reconstruction method with no additional morbidity.20 Reconstruction begins by suturing the base of the tongue to the superior base of the apron platysma flap. The lateral and inferior edges are sutured to the inner surface of the apron flap.
A Montgomery salivary bypass tube (Boston Medical Co., Boston, MA, USA) may be used to buttress the closure, especially in cases of closure with free flaps or in patients with a high risk of pharyngocutaneous fistula. Sectioning both sternal insertions of the sternocleidomastoid muscle results in a more superficial and accessible stoma, facilitating cleaning maneuvers and occlusion in patients with a tracheoesophageal shunt for voice rehabilitation.
Creating a half-moon section in the superior skin flap at the midline results in a circular-shaped stoma, reducing the chances of stomal stenosis. Tracheal opening should avoid cutting the cartilage itself, by making an incision between two tracheal rings. Cartilage exposure and infection should be avoided by using vertical mattress stitches in the skin covering the tracheal stump.
We usually place a Jackson–Pratt drain adjacent to the pharyngotomy closure and keep it in place until swallowing is recovered. This drain helps in early identification of saliva leak, reduces patient discomfort, and simplifies postsurgical care.21
The main advantage of the tobacco pouch is that it allows oral feeding with a soft diet by the 3rd postoperative day.
With an apron platysma myocutaneous flap, the anterior wall of the neopharynx allows a wide food passage in spite of the small amount of remaining pharyngeal mucosa.
A stable, adequate-sized, accessible stoma significantly improves the quality of life of the laryngectomized patient.
A half-moon section in the superior skin flap at the midline should reduce the chances of tracheostoma stenosis.
Neck drains are removed once output is less than 20 mL in 24 hours, usually around the third postoperative day.
The neck aspect should be checked often in the first 48 hours, mainly in patients with cough or nausea in the early postoperative period, to identify hematoma formation. Hematoma may be hidden behind a bulky neck dressing and a nonfunctional drain. An empty drain does not rule out hematoma formation.
A pressure dressing prevents fluid collection, but should be loose enough to avoid venous or arterial interference. To check adequate pressure, a finger should easily be placed underneath the dressing. Slight elevation (30 to 45°) of the patient′s head should be maintained to avoid postoperative edema. Pressure dressings are removed 24 hours after drains are taken out.
Fever, foul odor or a suture line that is inflamed, ischemic, or under tension should be investigated for abscess or hematoma formation.
A cuffed, high-volume, low-pressure laryngectomy tube is placed for the first 24 hours to prevent aspiration in case of acute hemorrhage. It is important to check cuff pressure to avoid necrosis of tracheal wall mucosa and secondary stenosis. A cuffed tube is replaced by a silicon non-cuffed tube after 24 or 48 hours, or the cuff can be deflated in patients at low-risk of aspiration. Airway humidity can be achieved by using moisture and heat exchangers.22,23
The tracheostomy should be carefully cleaned, avoiding tracheal and tube crusting, and it is important to keep the airway clear. Coughing and deep breathing should be encouraged to clear secretions and expand the lungs. In case of ineffective cough or thick secretions, aspiration should be performed every 2 to 3 hours. Saline irrigation of the trachea, 2 to 3 mL, will render secretions more easily removable.
Regular chest X-ray is not necessary unless pulmonary symptoms are present: pulmonary auscultation is sufficient.
Blood test for hemoglobin, protein, leukocytes, and renal function should be performed 12 hours after surgery and on the 4th postoperative day. Thyroid hormones should be checked in previously radiated patients.
Before enteral feeding is started, the tube position should be checked. Diet selection depends on the proteic and caloric requirements of the patient, and should be controlled by a nutritionist.
Instruct the patient to avoid swallowing saliva during the first operative days. Average time to initiate oral feeding ranges between 7 and 10 days,23 unless signs that indicate a fistula are present (odor, fever, skin erythema, saliva in suction drain). Although this is common practice, some authors believe that the time of oral feeding has little to do with fistula formation, with the nasogastric tube exerting a more traumatic effect than oral feeding.24
In the postoperative period the patient and family face the real sequelae of the operation, and such a new unknown and stressful situation may induce depression. Psychologic and emotional support should be given to the patient to encourage active participation in the rehabilitation process. Family instruction about the basic needs of patient care will make it easier for them to understand the patient′s needs and how to provide assistance.
There are multiple factors that may affect wound healing:
Nutrition. Nutritional status may interfere with adequate oxygen transport and tissue perfusion. Low hemoglobin, protein deficiency, and dehydration reduce wound healing.
Co-morbidity. Diabetes, tobacco, and obesity all delay healing.
Drugs. Steroids and nonsteroidal anti-inflammatory drugs reduce fibroblast proliferation and decrease collagen synthesis.
Ischemia. Poor tissue perfusion reduces the inflammatory response, an essential part of wound healing. Previous radiotherapy, diabetes, hematoma, infection, or peripheral vascular disease may be responsible for ischemia.
Foreign bodies, hematoma, necrosis, and suture all prolong the inflammatory process and increase the risk of infection.
Infection. Reduces local tissue oxygenation and has a collagenolytic effect.
Pressure. Pressure dressing is a potential risk of local ischemia, and should be carefully checked, mainly in chronic infections.
Preoperative and postoperative patient evaluation should identify all potential risk factors for adequate wound healing by optimizing nutritional (protein, calories), biochemical (hormones, glucose levels, ions, renal function), and physical (pulmonary, cardiac, hepatic, hematologic) status.
Wound signs like odor, warmth, swelling, and pain should warn of complications.
Every effort should be made to eliminate necrotic tissue and infection by debridement, and to promote wound healing by regular cleaning with hydrogen peroxide or antibiotic solutions.
Iodoform gauze may be used to pack the wound and promote granulation tissue and healing by secondary intention.
Complications after Total Laryngectomy and Pharyngolaryngectomy
Vacuum drains should be checked in the immediate postoperative period. The most frequent area of vacuum failure is the stoma–skin suture, which may be easily corrected if identified. Sudden bulging of the skin flap in the early postoperative period should act as a warning of hematoma or seroma formation. It is usually soft and cystic, and involves oozing under the flap and suction drain obstruction. Exploration and drainage under sterile conditions is mandatory. A Penrose drain and pressure dressings are used to avoid recurrence. If active bleeding is found, the patient must be taken to the operating room to identify and control bleeding points.
Pressure dressing is not recommended if active bleeding is found because blood cloths can be disseminated around the surgical field, increasing the risk of infection.
Blood aspirated during surgery and drying of the normal mucus may produce crusting and mucus plugs that obstruct the trachea. The patient has noisy breathing, dyspnea, and weak airflow through the stoma. When suspected, the tracheostomy tube should be removed and checked for obstruction at the tube lumen and trachea. In case of dyspnea due to tracheal crusting, avoid removal with forceps. The patient should be asked to slowly take a deep breath while the trachea is irrigated with 2 to 3 mL of saline, and to force exhalation so that the tracheal plug can be removed. This should be done repeatedly until the plug is removed. Adequate humidification of inhaled air will decrease tracheal crusting.22,23