Abstract
Purpose
Tracheoesophageal puncture (TEP) is an effective rehabilitation method for postlaryngectomy speech and has already been described as a procedure that is safely performed in the office. We review our long-term experience with office-based TEP over the past 7 years in the largest cohort published to date.
Materials and Methods
A retrospective chart review was performed of all patients who underwent TEP by a single surgeon from 2005 through 2012, including office-based and operating room procedures. Indications for the chosen technique (office versus operating room) and surgical outcomes were evaluated.
Results
Fifty-nine patients underwent 72 TEP procedures, with 55 performed in the outpatient setting and 17 performed in the operating room, all without complication. The indications for performing TEPs in the operating room included 2 primary TEPs, 14 due to concomitant procedures requiring general anesthesia, and 1 due to failed attempt at office-based TEP. Nineteen patients with prior rotational or free flap reconstruction successfully underwent office-based TEP.
Conclusions
TEP in an office-based setting with immediate voice prosthesis placement continues to be a safe method of voice rehabilitation for postlaryngectomy patients, including those who have previously undergone free flap or rotational flap reconstruction. Office-based TEP is now our primary approach for postlaryngectomy voice rehabilitation.
1
Introduction
Following total laryngectomy, a tracheoesophageal puncture (TEP) and subsequent placement of a voice prosthesis in the puncture tract is an effective way to restore speech . The puncture may be performed primarily at the time of the laryngectomy, or as a secondary procedure subsequent to the laryngectomy. Though primary TEP may result in earlier acquisition of speech after laryngectomy, it may also be associated with higher rates of complications such as pharyngocutaneous fistula . Additionally, secondary TEP is required when a patient’s TEP becomes dislodged and the prosthesis tract closes.
The secondary TEP procedure is traditionally performed in the operating room under general anesthesia via rigid esophagoscopy and the patient is sent home with a catheter placed through the puncture tract. After 3 to 5 days, the catheter is replaced with a TEP prosthesis by the speech language pathologist (S.L.P.). With more widespread adoption of office-based unsedated transnasal esophagoscopy (TNE), several techniques for office-based unsedated TEP placement have been described .
Office-based TEP has obvious benefits of decreased procedure time and cost as well as increased convenience for both surgeon and patient, especially since the prosthesis can be placed immediately after the puncture. We previously published our initial experience with office-based TEP in 13 patients, confirmed its feasibility, and found improved post-procedure outcomes compared to operating room TEP . Additionally, for patients with laxity of the party wall and poor visualization, we developed a catheter system to allow placement with decreased risk to the posterior esophageal wall . However, we did not perform office-based TEP in patients who had undergone rotational or free flap reconstruction. With more surgical experience and improved technical expertise, we continue to see the benefits of office-based TEP over operating room TEP, and have now expanded use of this puncture technique to patients who have undergone pharyngoesophageal reconstruction with a flap, including immediate prosthesis placement at the time of puncture. Office-based TEP has become the standard of care at our institution, resulting in the largest clinical experience reported in the literature to date. We undertook this investigation to evaluate our long-term experience with this technique over the past 7 years.
2
Materials and methods
Approval for this study was obtained from the University of California, Los Angeles Institutional Review Board. A retrospective chart review was performed for all patients who underwent TEP by a single surgeon (D.K.C.) from 2005 through 2012. Clinic and hospital records were examined, including history and physical examinations, operative notes, procedure notes, physician progress notes, and SLP progress notes. Historical data, procedure descriptions, and postoperative findings were recorded.
Prior to TEP placement, all patients underwent pre-TEP evaluation and counseling by an experienced SLP. Additionally, pre-TEP evaluation by the surgeon included TNE to evaluate adequate visualization and laxity of the party wall, evaluation of stoma size and location, and assessment for any esophageal stenosis and dysphagia symptoms. If a patient was deemed an inappropriate candidate for in-office TEP due to poor tolerance of endoscopy or unclear anatomy, or required additional procedures under general anesthesia, he or she was scheduled for TEP in the operating room.
TEP in the operating room was performed under general anesthesia. A 16-French introducer set was used to make the puncture and place a red rubber catheter through the puncture site as published previously . The catheter remained in place for 3 to 5 days post-operatively, when it was replaced with a voice prosthesis by the SLP.
For those patients deemed appropriate for in-office TEP, the procedure was performed as previously described and is summarized in Table 1 and Fig. 1 . Of note, the techniques of the procedure have evolved over the study period with a few important changes, highlighted below. First, the nasal cavity is anesthetized and decongested with topical 4% lidocaine and 1% neosynephrine. The tracheal stoma is also sprayed with 4% lidocaine solution. Less than 1 cc of 1% lidocaine with 1:100,000 parts epinephrine is injected to the posterior tracheal wall at the proposed puncture site, approximately 5 to 10 mm from the mucocutaneous junction. Additionally, 5 ml of viscous 2% lidocaine is applied to the base of tongue, and the patient allows this to flow into the esophagus. A transnasal esophagoscope was then passed through the nasal cavity and into the cervical esophagus ( Fig. 1 ). The esophagus was insufflated, and the proposed puncture site was identified using a 25- or 27-gauge needle. Under direct visualization, a number 11 blade was passed through the party wall at this location, and was turned 180 degrees within the stab incision (without withdrawing the blade) once visualized within the esophageal lumen. A hemostat was then passed through the puncture site and spread widely, which reduced the chances of the subsequently placed dilator encountering resistance or falling into a false tract. The puncture site was then dilated with an 18-French TEP dilator, followed by sizing with a voice prosthesis sizer. This was followed by immediate placement of the voice prosthesis using a gel–cap insertion system. At the conclusion of the procedure, the patient was taken to a counseling room to discuss TEP voicing and care by the assisting SLP.
| 1 | Local anesthesia of nasal cavity, pharynx, and stoma |
| 2 | Transnasal esophagoscopy performed to the level of the cervical esophagus |
| 3 | Identification of the puncture site using a 27-gauge needle ( Fig. 1 A) |
| 4 | #11 Blade used to make a stab incision at this location, followed by 180-degree rotation of the blade ( Fig. 1 B) |
| 5 | Hemostat used to spread puncture site ( Fig. 1 C) |
| 6 | Insertion of 18-French TEP dilator ( Fig. 1 D) |
| 7 | Prosthesis sizer used to assess party wall thickness ( Fig. 1 E) |
| 8 | Prosthesis placed by SLP using standard gel–cap insertion system ( Fig. 1 F) |
2
Materials and methods
Approval for this study was obtained from the University of California, Los Angeles Institutional Review Board. A retrospective chart review was performed for all patients who underwent TEP by a single surgeon (D.K.C.) from 2005 through 2012. Clinic and hospital records were examined, including history and physical examinations, operative notes, procedure notes, physician progress notes, and SLP progress notes. Historical data, procedure descriptions, and postoperative findings were recorded.
Prior to TEP placement, all patients underwent pre-TEP evaluation and counseling by an experienced SLP. Additionally, pre-TEP evaluation by the surgeon included TNE to evaluate adequate visualization and laxity of the party wall, evaluation of stoma size and location, and assessment for any esophageal stenosis and dysphagia symptoms. If a patient was deemed an inappropriate candidate for in-office TEP due to poor tolerance of endoscopy or unclear anatomy, or required additional procedures under general anesthesia, he or she was scheduled for TEP in the operating room.
TEP in the operating room was performed under general anesthesia. A 16-French introducer set was used to make the puncture and place a red rubber catheter through the puncture site as published previously . The catheter remained in place for 3 to 5 days post-operatively, when it was replaced with a voice prosthesis by the SLP.
For those patients deemed appropriate for in-office TEP, the procedure was performed as previously described and is summarized in Table 1 and Fig. 1 . Of note, the techniques of the procedure have evolved over the study period with a few important changes, highlighted below. First, the nasal cavity is anesthetized and decongested with topical 4% lidocaine and 1% neosynephrine. The tracheal stoma is also sprayed with 4% lidocaine solution. Less than 1 cc of 1% lidocaine with 1:100,000 parts epinephrine is injected to the posterior tracheal wall at the proposed puncture site, approximately 5 to 10 mm from the mucocutaneous junction. Additionally, 5 ml of viscous 2% lidocaine is applied to the base of tongue, and the patient allows this to flow into the esophagus. A transnasal esophagoscope was then passed through the nasal cavity and into the cervical esophagus ( Fig. 1 ). The esophagus was insufflated, and the proposed puncture site was identified using a 25- or 27-gauge needle. Under direct visualization, a number 11 blade was passed through the party wall at this location, and was turned 180 degrees within the stab incision (without withdrawing the blade) once visualized within the esophageal lumen. A hemostat was then passed through the puncture site and spread widely, which reduced the chances of the subsequently placed dilator encountering resistance or falling into a false tract. The puncture site was then dilated with an 18-French TEP dilator, followed by sizing with a voice prosthesis sizer. This was followed by immediate placement of the voice prosthesis using a gel–cap insertion system. At the conclusion of the procedure, the patient was taken to a counseling room to discuss TEP voicing and care by the assisting SLP.
