Elective pharyngofistula after laryngectomy and neck dissection

Elective

Pharyngofistula after Laryngectomy and Neck Dissection ROBERT

J. SCHWEITZER, M.D., Oakland, Calijornia

From tbe Department of Surgery, University of California Medical School, San Francisco, California, and tbe Department of Surgery, Oakland Veterans Administration Hospital, Oakland, California.

vesseIs are bathed in purulent secretions, the stage is set for rupture and fata hemorrhage. When Ieakage at the pharyngea1 suture Iine is suspected, prompt and adequate drainage wiI1 prevent further eIevation of skin flaps and dissoIution of suture lines. It is not uncommon to see a smaI1 fistuIa enIarge and finaIIy terminate in a wide communication with the pharynx, accompanied by extensive retraction and Ioss of skin. Even more serious can be the occurrence of a fistuIa directIy adjacent to the carotid, wideIy exposing this vesse1 in the necrotic wound. Of considerabIe importance to the patient is the proIongation of hospita1 time spent in controIIing infection and stabiIizing the fistuIa. In those situations in which a f%tuIa is IikeIy to resuIt, an eIective pharyngofistuIa is devised at the time of surgery. It is beIieved this may reIieve tension on the suture Iines during a diffIcuIt cIosure as we11 as to provide adequate drainage for saIiva. Infection and undermining of skin ffaps is minimized. The main advanhowever, is the ability to locate the tage, fistuIa in an area Ieast IikeIy to cause damage to the carotid. Additiona precautions may be taken to prevent carotid hemorrhage by covering that vesse1 with a protective muscIe flap, thus isoIating it from the fistula itseIf [4]. The use of a pharyngostome is not a new idea. Martin [5] has utilized this when radica1 excision of avaiIabIe tissue made primary cIosure impossibIe. The presentIy described eIective pharyngofistuIa is applied in those patients with extensive pharyngoIaryngectomy and neck dissection when radiation had been given, when there is tension on the suture Iines, or when the cIosure of the pharynx has been compIicated or unsatisfactory. The technic empIoyed is a simple one. At the time of closure of the pharyngea1 defect,

pharynx and cervical esophagus often necessitate an extensive surgica1 excision of the primary tumor and adjacent node bearing areas. Certain probIems attendant with this surgery may add to the morbidity, and on occasion, to the mortaIity. NotabIe among these are the compIications arising from an unexpected pharyngea1 fistuIa. A method of minimizing the effects of this troubIesome and often disastrous situation is presented in this report. When either a uniIatera1 or biIatera1 radica1 neck dissection is combined with Iaryngectomy, a pharyngocervlcal fistuIa occurs more frequentIy than with Iaryngectomy aIone. The reasons for this are the added surgica1 mobiIization and dissection with the concomitant sacrifice of major bIood suppIy. Tension on the pharyngea1 suture Iines after extensive remova of tissue wiI1 add to this probIem [I]. Another prediposing factor toward fistuIa formation is the impairment of heaIing at the oropharyngea1 suture Iine in tissues subjected to previous radiation [1,2]. The radiation may have been administered as part of a pIanned pre-operative procedure [J] or in a prior unsuccessfu1 attempt to eradicate the primary cancer without sacrificing the Iarynx. The diminution of bIood suppIy of irradiated tissue aIso makes it more susceptibIe to bacteria1 invasion. This combination of sepsis, tension and impairment of circuIation sets the stage for disruption of the oropharyngeal suture Iine. When this occurs and a f%tuIa resuIts, there may be further undermining and even necrosis of adjacent skin flaps. When the exposed carotid

C

ANCERS of the larynx,

American

Journal

of Surgery.

Volume

req.

November

1962

708

Phsryngofistula

FIG. I. Following Iaryngectomy and neck dissection, the Ievator scapulae is mobilized in preparation for covering the carotid and isolating it from the pharyngofistuIa.

the pharyngofistula is constructed. It may be placed in the mid-line at the most superficial point of the wound or lateral to the mid-line on the side away from the exposed carotid. There wiII be less likelihood of aspiration of saliva if the pharyngofistuIa is not made directly above the mid-line tracheostomy, which is necessary with these procedures. The levator scapulae or posterior scalene muscles may be rotated over the carotid for additional protection and isolation of this vessel. In addition, this muscle will buttress the pharyngeaI suture Iine. MobiIization of this muscle flap is usually done immediately after removal of the specimen thus allowing a short period of observation to insure viability. (Fig. I .) The base of the tongue and mucosa of

pharynx or esophagus is sutured to the superior and inferior skin margins of the pharyngofistula with interrupted No. 3-o DermaIon@ sutures. A suction catheter is then placed through the defect into the oral cavity. (Figs. z and 3.) Constant suction is maintamed for four to six days until the skin haps are adherent and the margins of the pharyngofistula are healed. This eliminates the usual constant drainage of saliva through the defect with frequent dressing changes and maceration of the skin. The Iower aspect of the neck wound is likewise drained with a suction catheter. A nasal feeding tube is placed through the anastomosis at the time of cIosure, and feedings begin the following day after surgery. When extensive removal of portions of the 709

Schweitzer

FEG, 2. Transverse

closure of the pharynx leaving a small pfsitned btufa.

Frc. 3. MarsupiaIization of the fistula margin to the skin with insertion of a suction catheter Frstula. Constant aspiration of saliva reduces frequency of dressing changes. 7x0

through the pharyngn-

PharyngofistuIa

FIG. 4. After extensive removal of pharyngoesophageal wal1, the esophagus is mobilized and the newIy formed tube is sutured to the base of tongue. Pharyngofistula made at the point of anastomosis. Levator scapulae buttresses the suture line.

pharynx and cervical esophagus accompanies laryngectomy, a smalI strip of mucosa of the posterior or contraIatera1 wall of the pharynx or cervica1 esophagus can sometimes be preserved without compromising the margins of resection. (Fig. 4.) The pharynx or cervical esophagus is routineIy reconstructed by suturing this remaining mucosa around the feeding tube even though there is tension. The upper margins of the newIy formed tubuIar structure are sutured to the base of the tongue. This point of the anastomosis has a minima1 bIood suppIy and is often the origin of a spontaneous hstula. UnderstandabIy, this is a source of concern to the surgeon. A pharyngohstula constructed at this point wil1 add a margin of safety to the procedure. When a portion of the cervical esophagus has been sacrihced, mobiIization of the esophagus by blunt dissection into the mediastinum will often decrease the intervening defect between pharynx and

esophagus by severa centimeters. With this planned hstula, primary anastomosis can be done with greater safety, when otherwise a prosthesis, skin graft or secondary reconstruction might be required. When the resection is so extensive that primary anastomosis is not possibIe, an esophagostome is brought out lateral to the tracheostome. The ora cavity is cIosed by suturing the base of the tongue to the posterior pharynx leaving just a smaI1 pharyngohstula with suction catheter in place. (Fig. 3.) This fistula will close after the suction catheter is removed. If no further reconstruction is planned for the immediate future because of an anticipated poor prognosis, ligation of both parotid ducts wiI1 decrease the amount of saIivation [y]. In six patients with an eIective fistula, marginal necrosis of the edges of the pharyngofistula occurred in three patients, of whom two had previous radiation to the area. (TabIe I.)

Schweitzer

Ton pue

Sutured

to

posterior pharynqeal wall with Suction catheter in small pharynqo- fistula.

Trachsostom Esopha

FIG. 9. When primary

anastomosis

is not possible. Complete

closure of oral cavity except for small pharyngofistula.

FIG. 6. (Patient, 0. B.) Appearance of patient with healed eIective pharyngofistula after subtotat gIossectomy and staged biIateral neck dissections.

712

Pharyngohstula TABLE ELECTIVE

-

-i Patient

Operative

I

PHARYNGOFISTULA

PATlENTS

Prior Radiation

Diagnosis

Procedure

IN SIX

Complications

Closure of Fistula

1

-_0. B.

E. G.

\‘. T.

A. H.

J. F.

R. L.

No

Staged biIatera1 radical Advanced squamous carcinoma pyriform sinus neck dissection, pharyngolaryngectomy, subtotal I wrth node metastases. gIossectomy. Radical neck dissection, Squamous carcinoma, pharyngolaryngectomy, valIecula with node subtotal glossectomy. metastases. RadicaI neck dissection, Mutinous adenocarcinoma, larynx involving pharyngotaryngectomy, resection of cervical trachea and esophagus with node metastases. esophagus, clavicle, manubrium, esophaI gostomy. Radical neck dissection, Squamous carcinoma, total laryngectomy. extrinsic larynx with node metastases. Radical neck dissection, Squamous carcinoma, extrinsic larynx with pharyngolaryngectomy. node metastases.

Radical neck dissection, pharyngolaryngectomy and cervical esophagectomy.

I

_!

Squamous carcinoma pyriform sinus.

Yes

j Marginal necrosis of fistula.

i Spontaneous, / 2 52 mo.

1Marginal necrosis ~Spontaneous, of fist&.

Yes

mo.

2

Spontaneous,

I Massive skin necrosis.

I 4 mo.

I / Yes

None.

/ Hemorrhage from opposite lingua1 artery. MarginaI necrosis of fistula and skin retraction. Cardiac arrest during surgery, wound healed.

Yes

No

of

Operative closure, 4 mo. Operative closure. 6 mo.

; Died 7 days post1 operative.

/ L

Massive necrosis of the adjacent heavily radiated neck flaps occurred in one other patient. One patient died seven days after operation from cerebral complications secondary to cardiac arrest at the time of surgery. The neck incision and listula were heaIed at the time of death. One patient hemorrhaged at the pharyngofistula margin from the exposed lingual artery. Th’ IS was controlled with a suture ligature. The average size of the pharyngofistula at the time of surgery measured about z cm. in length. Because of margina necrosis from tension and inadequate blood suppIy, an increase in the size of the frstula is noted in the postoperative period. (Table II.) If an eIective listula had not been present, undoubtedIy this necrosis would have set the stage for further undermining of skin IIaps and sepsis until drainage had been estabIished. However, with direct drainage of saliva through the pharyngofistula, this has not been a problem. When the skin flaps were heaIed, the patients were discharged with a feeding tube in pIace.

Dressings over the tistula were changed by the patient. If the fistula was small, it could be covered with the thumb or a sma11 pressure dressing during ingestion of liquids by mouth. As soon as the margins of the fistula stabilized, the size decreased rapidIy. Spontaneous closure sometimes occurred even though the fistula TABLE COURSE

OF

II

PHARYNGOFISTULA

PHARYNGOLARYNGECTOMY DISSECTION PRIMARY

AS

RELATED

TO

’ Size Of Fistu’a I Sev’n Days / Post;cP-)ative,

I

Prior Radiation

UE<;K

TYPE

Ok

CLOSURE

ANASTOMOTIC

(Initial size of fistula averaged

Patients

AFTER AND

’

Therapy

2

Type of Primary CIOSUX!

I

by I cm.) 1 Spontaneou\ Closure i of Fistrlla

I

* Secondary surgical closure at four and six months. t Died seven days postoperative.

Schweitzer measured up to 4 cm. in size. (Table II.) This was more common when transverse cIosure of the pharyngeal mucosa was possibIe. A comphcated T shaped suture line resuhed in a greater degree of retraction of the edges of the IistuIa. Secondary surgica1 closure of a smaI1 persistent fistuIa was required in two patients. Periodic cauterization of the edges of the pharyngohstuia with silver nitrate was helpful to prevent epitheIiaIization and hasten obliteration of the IistuIa. SUMMARY

A spontaneous Iistula is not an uncommon complication after extensive pharyngolaryngectomy and neck dissection, especiaIIy with prior radiation or after a compIicated pharyngea1 closure. An elective pharyngohstuIa Iocated at a predetermined site wiII minimize the under-

mining of skin flaps and sepsis that accompanies a spontaneous IistuIa. The technic of constructing the IistuIa and the experience with six patients is presented. REFERENCES

I. WISE. R. A. and BAKER, H. W. Surgery of the Head and Neck. Chicago, 1958. The Year Book Publishers Inc. 2. MARCHETTA, F. Comphcations foBowing radical head and neck surgery performed through irradiated tissues. Sot. Head and Neck Surgeons Meeting, BaItimore, April, 1958. 3. KORKIS, F. B. Management of carcinoma of the larynx and Iaryngo-pharynx. Laryngoscope, 6g: 358, 1959. 4. SCHWEITZER, R. J. Use of muscle flaps for protection of carotid arterv after radical neck dissection. Ann. Surg., in p&s. 5. MARTIN, H. E. Surgery of Head and Neck Tumors. New York, 1957. Paul B. Hoeber, Inc.