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A simple closure technique for reversal of tracheoesophageal puncture
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627 – 630 www.elsevier.com/locate/amjoto
A simple closure technique for reversal of tracheoesophageal puncture☆,☆☆ Marcel Geyer, FRCS ORL-HNS⁎, Neil Tan, MRCS, Hasnaa Ismail-Koch, FRCS ORL-HNS, Roberto Puxeddu, FRCS ORL-HNS Department of Otolaryngology Head and Neck Surgery, Queen Alexandra Hospital, Portsmouth, UK Received 6 October 2010
Abstract
Speech restoration after total laryngectomy has been revolutionized by the technique of tracheoesophageal puncture (TEP) and speech valve prosthesis placement. Unfortunately, complications may arise from this procedure, sometimes necessitating reversal and surgical closure of the TEP. We present a simple yet effective method of closing a TEP and review previously described techniques. © 2011 Published by Elsevier Inc.
1. Introduction Tracheoesophageal puncture (TEP) creation and speech valve prosthesis insertion are well-established techniques, enabling voice restoration in patients after total laryngectomy. The techniques were first described in the late 1970s by Singer and Blom [1], who developed the original speaking valve. The valve allows unidirectional passage of air from trachea to the neopharyngoesophagus, facilitating pharyngeal speech. The valve prevents aspiration by stopping the passage of ingested material from passing into the trachea when swallowing. Over the years, numerous refinements have been made; and the authors currently use the Provox II model (Provox II Valve; 8, 10, and 12.5 mm by ATOS Medical, Eastbourne, UK). A TEP can be created either primarily at the time of primary surgery or as a delayed secondary procedure. However, immediate, delayed, and long-term complications may arise from iatrogenic puncture creation. A significant problem is gradual TEP widening and subsequent leakage of saliva and liquids around the valve into the trachea, resulting in recurrent aspiration and pneumonia. A problematic valve ☆
This article has not been presented prior to publication. There are no grantors of financial support for the work done. ⁎ Corresponding author. Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire, PO6 3LY, UK. Tel.: +44 2392 286 000. E-mail address: [email protected] (M. Geyer). ☆☆
0196-0709/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.amjoto.2010.11.015
can be removed to allow the TEP to close spontaneously. Unfortunately, in some instances, a TEP may persist, requiring formal surgical closure. We present a surgical technique for TEP closure that is simple, effective, and with potentially low morbidity rates. 1.1. Surgical technique The procedure is performed under general anesthesia with the patient supine and the tracheostoma intubated with a 5.5-mm tracheal tube. A modified crescentic skin incision is made around the superior aspect of the tracheostoma from 10 o'clock to 2 o'clock, variably extended along the previous laryngectomy scar (Fig. 1). This facilitates retraction of the skin edges and soft tissue dissection in a plane between the neopharyngoesophagus and pars membranacea of the trachea down to the level of the TEP (Figs. 2 and 3). The fistulous tract is identified as a cordlike band running anteroposteriorly between the pars membranacea of the trachea and the esophagus. Three hundred sixty–degree exposure of the fistula is achieved by freeing the puncture circumferentially from the surrounding tissue by careful blunt dissection. Visualization of the lower aspect of the tract can also be enhanced with the aid of a 45° rigid Hopkins rod telescope connected to a videoendoscopic system. When the tract has been completely freed, suture ligation of the fistula with 2/0 nonabsorbable suture is performed at
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M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
Fig. 1. Modified crescentic skin incision is made around the superior aspect of the tracheostoma from 10 to 2 o’clock.
2 points (Figs. 4 and 5). In our patients, we used 2/0 Prolene (Ethicon Inc, Gargrave, UK). Because the tract is not divided, there is no need to place an interposition graft or a flap, as is the case in conventional 3-layer closure. A 10F active drain is sited and kept in place for 24 hours. The skin wound is closed with 3/0 Prolene. The total length of the procedure is usually not more than 90 minutes. Antibiotic cover with co-amoxiclav, 1.2 g TDS intravenously for the first 24 hours, is followed by 625 mg TDS per os for 4 days. A water-soluble (eg, Gastrografin) contrast swallow is performed 24 hours postoperatively (Fig. 6). If no leak is confirmed, then oral
Fig. 2. Dissection of the soft tissue plane between the neo-pharyngoesophagus and pars membranacea of the trachea down to the level of the TEP, with circumferential exposure of the fistula.
Fig. 3. Patient 1: Intraoperative view after circumferential exposure of the TEP.
feeding can be commenced, initially by liquid and soft diet and progressing to a normal diet at home over the following days. Skin sutures are removed 7 days postoperatively in the community. 2. Results 2.1. Patient 1 In 2007, a 69-year-old man underwent radiotherapy for pT1 N0 M0 squamous cell carcinoma of the larynx. The following year, recurrent cancer necessitated a laryngectomy.
Fig. 4. Double suture ligation of the puncture tract without division of the tissue bridge.
M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
629
He had a primary TEP performed and was fitted with a speech valve 10 days postoperatively. He initially recovered well; but at around 9 months postoperatively, his speaking valve started to leak peripherally. He suffered from recurrent aspiration pneumonia with multiple hospital admissions over the following months requiring antibiotic treatment and noninvasive ventilation. His TEP was closed using our technique described above in June 2009. A Gastrografin swallow on the first postoperative day showed no leak, and a full diet was reinstituted without complication. However, at 3-month review, a small leak was noted at the site of the previous TEP (“Discussion”). The patient was reoperated with an identical technique. He made an uneventful recovery and is asymptomatic with no further episodes of aspiration pneumonia after 6 months (Fig. 6). The wound site has healed excellently. 2.2. Patient 2 A 56-year-old male patient underwent a total laryngectomy for pT4 N0 M0 squamous cell carcinoma of the larynx in 2002. A primary TEP was created and a Provox II valve was inserted, producing satisfactory substitutive voice. In 2007, the patient developed a second primary carcinoma of the right tonsil with an N1-positive neck necessitating radical chemoradiotherapy treatment. Unfortunately, intractable leakage ensued around the puncture site, with recurrent episodes of minor aspiration despite a number of attempts to reduce the diameter of the orifice with a submucosal circumferential nonabsorbable suture. The patient requested the closure of his TEP in September 2009 using the technique described for the above first patient. After a negative Gastrografin swallow 24 hours postoperatively, feeding was restarted. His follow-up period thus far is
Fig. 6. Patient 1: postoperative barium swallow at 6 months.
8 months, and he has had no further episodes of aspiration or local complications.
3. Discussion
Fig. 5. Patient 1: Suture ligation of the puncture with 2/0 non-absorbable suture is performed at two points.
Speaking valve placement postlaryngectomy plays a vital role in voice rehabilitation [2]. It provides successful restoration of transesophageal speech in 73% to 78% of cases [3,4] as opposed to 5% of patients who attempt to use purely esophageal speech. In a different series [5] of 103 patients undergoing total laryngectomy (with or without pharyngectomy), successful voice rehabilitation was reported in 82% of cases. However, intermittent leakage occurred in 26% of TEPs; and in 3 of 87 cases, a significant persistent puncture enlargement was noted. Surgical closure of a TEP and true fistulas is not as straightforward as its creation. It can be a challenging operation with significant risk of tissue breakdown, especially in previously irradiated patients. A variety of management options have been advocated. One conservative, nonoperative treatment is insertion of a salivary bypass tube. Although this may facilitate spontaneous puncture closure, it is usually an unsuitable long-term solution.
630
M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
Necrosis from decubitus of the bypass, irritation, and granulation tissue formation can result. It frequently causes considerable patient discomfort and is thus generally poorly tolerated in the long term. Another noninvasive technique involves a silicon septal button with flanges positioned such that one lip lies on the external tracheal surface and the other on the inner pharyngoesophageal lining, thus preventing leakage [6]. Different biocompatible injections have also been reported but without long-term success. Sling sutures around the TEP mucosa and silicone rings placed around the voice prosthesis have also been proposed. Traditional surgical repair usually involves 3-layer closure with interposition of healthy, vascularized tissue between trachea and esophagus. Two-layer closure without interposition has also been described [7]. Interposition tissue used includes dermis [8], de-epithelialized deltopectoral flap [9], or biosynthetic mesh. Muscle rotation flaps such as the sternocleidomastoid and pectoralis major muscles have been recommended, but can be bulky and may compromise the lumen of trachea and/or esophagus. Radial forearm free flap with vascular anastomosis has been used [10] for larger defects. Although our technique uses a skin incision and exposure similar to a previously reported method [7], it is unique in that we carry out suture ligation of the puncture tract rather than division of the fibromucosal tract. We perform double circumferential ligation to ensure permanent successful closure. Double ligation provides a safe, secure barrier, preventing passage of fluid and food through the closed puncture, even though single suture ligation should theoretically also be adequate. We do not recommend dividing the puncture tract because suture slippage could lead to the tract being open to the (potential) space between the pharynx and trachea. The use of nonabsorbable suture such as Prolene (Ethicon Inc) or Novafil (Covidien Plc, Loughlinstown, Ireland) did not induce a foreign body reaction in our patients and is expected to remain in place permanently. The initial failure to close the fistula in the first patient encouraged us to carefully review our surgical technique. We now feel that ligation of the tract too close to the esophagus may have led to tension on the suture and ulti-
mate partial failure. We believe that the best point to perform the suture is as close as possible to the pars membranacea of the trachea. It is encouraging that revision surgery was not more difficult than the primary closure. This provides the option of performing a traditional procedure with more extensive graft or flap repair if our technique were to fail. 4. Conclusion We report a simple yet effective technique for surgical closure of a TEP. Although our case series is limited to 2 patients, we feel that this technique is reproducible, is straightforward to perform, and can offer excellent result in selected patients. References [1] Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;6:529-33. [2] Pou AM. Tracheoesophageal voice restoration with total laryngectomy. Otolaryngol Clin North Am 2004;3:531-45. [3] St Guily JL, Angelard B, el-Bez M, et al. Postlaryngectomy voice restoration. A prospective study in 83 patients. Arch Otolaryngol Head Neck Surg 1992;3:252-5. [4] Mäkitie AA, Niemensivu R, Juvas A, et al. Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience. Ann Otol Rhinol Laryngol 2003;12:1007-10. [5] Bozec A, Poissonnet G, Chamorey E, et al. Results of vocal rehabilitation using tracheoesophageal voice prosthesis after total laryngectomy and their predictive factors. Eur Arch Otorhinolaryngol 2010;5:751-8. [6] Schmitz S, Van Damme JP, Hamoir M. A simple technique for closure of persistent tracheoesophageal puncture after total laryngectomy. Otolaryngol Head Neck Surg 2009;4:601-3. [7] Hosal SA, Myers EN. How I do it: closure of tracheoesophageal puncture site. Head Neck 2001;3:214-6. [8] Rosen A, Scher N, Panje WR. Surgical closure of persisting failed tracheoesophageal voice puncture. Ann Otol Rhinol Laryngol 1997;9: 775-8. [9] McMurtrie A, Georgeu GA, Kok K, et al. Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap. J Laryngol Otol 2005;2:129-31. [10] Wreesmann VB, Smeele LE, Hilgers FJ, et al. Closure of tracheoesophageal puncture with prefabricated revascularized bilaminar radial forearm free flap. Head Neck 2009;6:838-42.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627 – 630 www.elsevier.com/locate/amjoto
A simple closure technique for reversal of tracheoesophageal puncture☆,☆☆ Marcel Geyer, FRCS ORL-HNS⁎, Neil Tan, MRCS, Hasnaa Ismail-Koch, FRCS ORL-HNS, Roberto Puxeddu, FRCS ORL-HNS Department of Otolaryngology Head and Neck Surgery, Queen Alexandra Hospital, Portsmouth, UK Received 6 October 2010
Abstract
Speech restoration after total laryngectomy has been revolutionized by the technique of tracheoesophageal puncture (TEP) and speech valve prosthesis placement. Unfortunately, complications may arise from this procedure, sometimes necessitating reversal and surgical closure of the TEP. We present a simple yet effective method of closing a TEP and review previously described techniques. © 2011 Published by Elsevier Inc.
1. Introduction Tracheoesophageal puncture (TEP) creation and speech valve prosthesis insertion are well-established techniques, enabling voice restoration in patients after total laryngectomy. The techniques were first described in the late 1970s by Singer and Blom [1], who developed the original speaking valve. The valve allows unidirectional passage of air from trachea to the neopharyngoesophagus, facilitating pharyngeal speech. The valve prevents aspiration by stopping the passage of ingested material from passing into the trachea when swallowing. Over the years, numerous refinements have been made; and the authors currently use the Provox II model (Provox II Valve; 8, 10, and 12.5 mm by ATOS Medical, Eastbourne, UK). A TEP can be created either primarily at the time of primary surgery or as a delayed secondary procedure. However, immediate, delayed, and long-term complications may arise from iatrogenic puncture creation. A significant problem is gradual TEP widening and subsequent leakage of saliva and liquids around the valve into the trachea, resulting in recurrent aspiration and pneumonia. A problematic valve ☆
This article has not been presented prior to publication. There are no grantors of financial support for the work done. ⁎ Corresponding author. Queen Alexandra Hospital, Cosham, Portsmouth, Hampshire, PO6 3LY, UK. Tel.: +44 2392 286 000. E-mail address: [email protected] (M. Geyer). ☆☆
0196-0709/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.amjoto.2010.11.015
can be removed to allow the TEP to close spontaneously. Unfortunately, in some instances, a TEP may persist, requiring formal surgical closure. We present a surgical technique for TEP closure that is simple, effective, and with potentially low morbidity rates. 1.1. Surgical technique The procedure is performed under general anesthesia with the patient supine and the tracheostoma intubated with a 5.5-mm tracheal tube. A modified crescentic skin incision is made around the superior aspect of the tracheostoma from 10 o'clock to 2 o'clock, variably extended along the previous laryngectomy scar (Fig. 1). This facilitates retraction of the skin edges and soft tissue dissection in a plane between the neopharyngoesophagus and pars membranacea of the trachea down to the level of the TEP (Figs. 2 and 3). The fistulous tract is identified as a cordlike band running anteroposteriorly between the pars membranacea of the trachea and the esophagus. Three hundred sixty–degree exposure of the fistula is achieved by freeing the puncture circumferentially from the surrounding tissue by careful blunt dissection. Visualization of the lower aspect of the tract can also be enhanced with the aid of a 45° rigid Hopkins rod telescope connected to a videoendoscopic system. When the tract has been completely freed, suture ligation of the fistula with 2/0 nonabsorbable suture is performed at
628
M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
Fig. 1. Modified crescentic skin incision is made around the superior aspect of the tracheostoma from 10 to 2 o’clock.
2 points (Figs. 4 and 5). In our patients, we used 2/0 Prolene (Ethicon Inc, Gargrave, UK). Because the tract is not divided, there is no need to place an interposition graft or a flap, as is the case in conventional 3-layer closure. A 10F active drain is sited and kept in place for 24 hours. The skin wound is closed with 3/0 Prolene. The total length of the procedure is usually not more than 90 minutes. Antibiotic cover with co-amoxiclav, 1.2 g TDS intravenously for the first 24 hours, is followed by 625 mg TDS per os for 4 days. A water-soluble (eg, Gastrografin) contrast swallow is performed 24 hours postoperatively (Fig. 6). If no leak is confirmed, then oral
Fig. 2. Dissection of the soft tissue plane between the neo-pharyngoesophagus and pars membranacea of the trachea down to the level of the TEP, with circumferential exposure of the fistula.
Fig. 3. Patient 1: Intraoperative view after circumferential exposure of the TEP.
feeding can be commenced, initially by liquid and soft diet and progressing to a normal diet at home over the following days. Skin sutures are removed 7 days postoperatively in the community. 2. Results 2.1. Patient 1 In 2007, a 69-year-old man underwent radiotherapy for pT1 N0 M0 squamous cell carcinoma of the larynx. The following year, recurrent cancer necessitated a laryngectomy.
Fig. 4. Double suture ligation of the puncture tract without division of the tissue bridge.
M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
629
He had a primary TEP performed and was fitted with a speech valve 10 days postoperatively. He initially recovered well; but at around 9 months postoperatively, his speaking valve started to leak peripherally. He suffered from recurrent aspiration pneumonia with multiple hospital admissions over the following months requiring antibiotic treatment and noninvasive ventilation. His TEP was closed using our technique described above in June 2009. A Gastrografin swallow on the first postoperative day showed no leak, and a full diet was reinstituted without complication. However, at 3-month review, a small leak was noted at the site of the previous TEP (“Discussion”). The patient was reoperated with an identical technique. He made an uneventful recovery and is asymptomatic with no further episodes of aspiration pneumonia after 6 months (Fig. 6). The wound site has healed excellently. 2.2. Patient 2 A 56-year-old male patient underwent a total laryngectomy for pT4 N0 M0 squamous cell carcinoma of the larynx in 2002. A primary TEP was created and a Provox II valve was inserted, producing satisfactory substitutive voice. In 2007, the patient developed a second primary carcinoma of the right tonsil with an N1-positive neck necessitating radical chemoradiotherapy treatment. Unfortunately, intractable leakage ensued around the puncture site, with recurrent episodes of minor aspiration despite a number of attempts to reduce the diameter of the orifice with a submucosal circumferential nonabsorbable suture. The patient requested the closure of his TEP in September 2009 using the technique described for the above first patient. After a negative Gastrografin swallow 24 hours postoperatively, feeding was restarted. His follow-up period thus far is
Fig. 6. Patient 1: postoperative barium swallow at 6 months.
8 months, and he has had no further episodes of aspiration or local complications.
3. Discussion
Fig. 5. Patient 1: Suture ligation of the puncture with 2/0 non-absorbable suture is performed at two points.
Speaking valve placement postlaryngectomy plays a vital role in voice rehabilitation [2]. It provides successful restoration of transesophageal speech in 73% to 78% of cases [3,4] as opposed to 5% of patients who attempt to use purely esophageal speech. In a different series [5] of 103 patients undergoing total laryngectomy (with or without pharyngectomy), successful voice rehabilitation was reported in 82% of cases. However, intermittent leakage occurred in 26% of TEPs; and in 3 of 87 cases, a significant persistent puncture enlargement was noted. Surgical closure of a TEP and true fistulas is not as straightforward as its creation. It can be a challenging operation with significant risk of tissue breakdown, especially in previously irradiated patients. A variety of management options have been advocated. One conservative, nonoperative treatment is insertion of a salivary bypass tube. Although this may facilitate spontaneous puncture closure, it is usually an unsuitable long-term solution.
630
M. Geyer et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 627–630
Necrosis from decubitus of the bypass, irritation, and granulation tissue formation can result. It frequently causes considerable patient discomfort and is thus generally poorly tolerated in the long term. Another noninvasive technique involves a silicon septal button with flanges positioned such that one lip lies on the external tracheal surface and the other on the inner pharyngoesophageal lining, thus preventing leakage [6]. Different biocompatible injections have also been reported but without long-term success. Sling sutures around the TEP mucosa and silicone rings placed around the voice prosthesis have also been proposed. Traditional surgical repair usually involves 3-layer closure with interposition of healthy, vascularized tissue between trachea and esophagus. Two-layer closure without interposition has also been described [7]. Interposition tissue used includes dermis [8], de-epithelialized deltopectoral flap [9], or biosynthetic mesh. Muscle rotation flaps such as the sternocleidomastoid and pectoralis major muscles have been recommended, but can be bulky and may compromise the lumen of trachea and/or esophagus. Radial forearm free flap with vascular anastomosis has been used [10] for larger defects. Although our technique uses a skin incision and exposure similar to a previously reported method [7], it is unique in that we carry out suture ligation of the puncture tract rather than division of the fibromucosal tract. We perform double circumferential ligation to ensure permanent successful closure. Double ligation provides a safe, secure barrier, preventing passage of fluid and food through the closed puncture, even though single suture ligation should theoretically also be adequate. We do not recommend dividing the puncture tract because suture slippage could lead to the tract being open to the (potential) space between the pharynx and trachea. The use of nonabsorbable suture such as Prolene (Ethicon Inc) or Novafil (Covidien Plc, Loughlinstown, Ireland) did not induce a foreign body reaction in our patients and is expected to remain in place permanently. The initial failure to close the fistula in the first patient encouraged us to carefully review our surgical technique. We now feel that ligation of the tract too close to the esophagus may have led to tension on the suture and ulti-
mate partial failure. We believe that the best point to perform the suture is as close as possible to the pars membranacea of the trachea. It is encouraging that revision surgery was not more difficult than the primary closure. This provides the option of performing a traditional procedure with more extensive graft or flap repair if our technique were to fail. 4. Conclusion We report a simple yet effective technique for surgical closure of a TEP. Although our case series is limited to 2 patients, we feel that this technique is reproducible, is straightforward to perform, and can offer excellent result in selected patients. References [1] Singer MI, Blom ED. An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 1980;6:529-33. [2] Pou AM. Tracheoesophageal voice restoration with total laryngectomy. Otolaryngol Clin North Am 2004;3:531-45. [3] St Guily JL, Angelard B, el-Bez M, et al. Postlaryngectomy voice restoration. A prospective study in 83 patients. Arch Otolaryngol Head Neck Surg 1992;3:252-5. [4] Mäkitie AA, Niemensivu R, Juvas A, et al. Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience. Ann Otol Rhinol Laryngol 2003;12:1007-10. [5] Bozec A, Poissonnet G, Chamorey E, et al. Results of vocal rehabilitation using tracheoesophageal voice prosthesis after total laryngectomy and their predictive factors. Eur Arch Otorhinolaryngol 2010;5:751-8. [6] Schmitz S, Van Damme JP, Hamoir M. A simple technique for closure of persistent tracheoesophageal puncture after total laryngectomy. Otolaryngol Head Neck Surg 2009;4:601-3. [7] Hosal SA, Myers EN. How I do it: closure of tracheoesophageal puncture site. Head Neck 2001;3:214-6. [8] Rosen A, Scher N, Panje WR. Surgical closure of persisting failed tracheoesophageal voice puncture. Ann Otol Rhinol Laryngol 1997;9: 775-8. [9] McMurtrie A, Georgeu GA, Kok K, et al. Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap. J Laryngol Otol 2005;2:129-31. [10] Wreesmann VB, Smeele LE, Hilgers FJ, et al. Closure of tracheoesophageal puncture with prefabricated revascularized bilaminar radial forearm free flap. Head Neck 2009;6:838-42.