Abstract
Educational Objective
At the conclusion of this presentation, the participants should be aware of the technique and success of in-office transnasal esophageal (TNE)–guided tracheoesophageal puncture (TEP) placement in patients who have failed prior attempts in the operating room or are not healthy enough to undergo general anesthesia.
Objectives
The aim of this study was to demonstrate the technique of TEP, which can be completed safely in an office setting when patients are not able to undergo general anesthesia due to medical comorbities or have previously had an unsuccessful attempt at TEP placement in the operating room due to anatomical reasons.
Study Design
This study is a retrospective chart review from 2007 to 2011.
Methods
A total of 13 outpatient adults with a history of total laryngectomy presenting to the laryngology clinic for TEP after either failing prior placement in the operating room or not being able to undergo general anesthesia due to medical comorbities were identified. In-office TNE-guided TEP placement was performed on all 13 patients.
Results
All subjects underwent successful TNE-guided TEP placement in the office. Complications included 1 possible false passage and 1 case of cellulitis.
Conclusions
Patients who could not undergo TEP placement in the operating room due to poor exposure or medical comorbities were able to successfully undergo the procedure in an office setting with good results.
1
Introduction
Tracheoesophageal puncture (TEP) has been used for voice restoration after total laryngectomy since its introduction by Singer and Blom in 1980 . Traditionally, the success rate of voice rehabilitation is slightly higher with primary TEP vs secondary TEP placement . That being said, primary TEP placement is not always feasible because of technical or medical reasons at the time of the initial laryngectomy . Techniques have been described to avoid rigid esophagoscopy in placement of TEPs in the operating room (OR) setting in patients with difficult anatomy. For example, Padya et al describe a technique using a flexible nasopharyngoscope in an endotracheal tube. In recent years, office-based transnasal esophageal (TNE)–guided TEP placement has been on the rise. The value of performing TNE-guided TEP placement in the office setting was first described by Bach et al in 2003. Benefits of office-based TEP placement include using only local anesthetic and visualization of the esophageal lumen during the entire procedure . LeBert et al looked at in-office TEP placement in 39 patients, specifically investigating the role of previous radiation therapy or complex reconstruction on successful secondary TEP outcome. They discovered that in-office TEP was successful in these patients . There has not been a study looking specifically at patients who have previously failed OR placement of TEP or patients who have been unable to tolerate general anesthesia and their ability to tolerate in-office placement of a TEP.
The objectives of this study were to determine if patients with a high anesthetic risk due to medical comorbities could safely undergo in-office TEP placement.
2
Patients and methods
A retrospective chart review of all patients who could not undergo TEP in the OR or who had failed previous TEP attempts between 1 July 2007 and 21 January 2011 was performed. Permission to conduct the investigation was granted by the institutional review board at the Georgia Health Sciences University. Eleven patients who could not undergo TEP placement in the OR for various reasons but were able to successfully undergo TNE-guided TEP in an office setting were identified by the senior author or his fellow. There were 10 men and 3 women whose average age was 62 years (range, 49–76 years). Eleven of the 13 patients had previous radiation therapy. The median interval between laryngectomy and TEP was 2 years (range, 4 months–15 years).
Five patients had associated medical conditions making general anesthesia risky. These conditions included malignant hypertension and various cardiac conditions. Eight patients could not be exposed in the OR, 1 of which had recently sustained a cervical spine fracture from a motor vehicle accident requiring him to be in a halo.
2.1
Surgical technique
Eight patients underwent in-office TNE-guided TEP placement as previously described by Bach et al . The patient was seated in the upright position in an otolaryngology examination chair. The nose was anesthetized and decongested with aerosolized 4% lidocaine and oxymetazoline mixture as well as packed with a cotton pledget soaked in the same solution. The superior aspect of the stoma was injected with 1% lidocaine with epinephrine for anesthesia. After 10 minutes, the cotton was removed, and the transnasal esophagoscope was passed through the nasal cavity and advanced through the neopharynx into the cervical esophagus. After visualization of the light externally through the patient’s stoma, a 22-gauge needle was inserted through the upper part of the patient’s stoma and visualized as it entered the esophagus. A number 11 blade was then used to make a cruciate incision along the needle into the party wall; the site was then dilated with a hemostat. A 14F red rubber catheter was placed through the incision into the esophagus toward the stomach under direct visualization; it was tied in a knot and secured against the anterior neck skin with a 2-0 silk suture. Of note, both the endoscopist and the surgeon can visualize the video monitor throughout the entire procedure, making sure that the posterior esophageal wall is not violated.
The last 5 patients underwent TNE-guided in-office TEP placement using a 16F Cook Medical Peel-Away Introducer Set (model G04500 C-PLI-16.0-38; Cook Medical, Bloomington, IN) as described by Sidell et al . The initial setup for the procedure is unchanged; once the TNE scope is placed in the cervical esophagus and the light is visualized through the stoma, an introducer needle is inserted through the party wall. The needle is visualized intraluminally in the esophagus to be in the correct position. A guidewire is then threaded through the needle to the distal esophagus, and the needle is withdrawn. Using an 11 blade scalpel, a small stab incision is made at the TEP site into the party wall. An introducer dilator is threaded over the guidewire into the distal esophagus and withdrawn leaving the peel-away sheath in place. A 14F red rubber catheter is advanced through the peel-away sheath into the distal esophagus under direct visualization. The sheath is then peeled away leaving the red rubber in place, and it is secured as mentioned previously.
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