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Staple-assisted laryngectomy for intractable aspiration
Staple-Assisted Laryngectomy for Intractable Aspiration Mitsuhiko Nakahira, MD, Kasumi Higashiyama, MD, Hiroaki Nakatani, MD, and Taizo Takeda, MD Staple-assisted laryngectomy is a unique method previously reported by Lukyanchenko to prevent wound contamination by using a stapling device for suturing pharyngeal defects in total laryngectomy. We have modified his method and applied it to prevent a postoperative pharyngocutaneous fistula in the treatment of intractable aspiration. In contrast to laryngeal cancer patients, a combined use of an intraluminal light to guide the dissection and laryngofissure to pull the epiglottis can be used to facilitate the use of the stapling device. For most patients with intractable aspiration who have significant malnutrition and drugresistant bacterial colonization of the pharynx, this method offers certain advantages. This report describes our successful experience with this method in the management of patients with intractable aspiration. (Am J Otolaryngol 2003;24:70-74. Copyright 2003, Elsevier Science (USA). All rights reserved.) (Editorial comment: This article provides useful information to the reader by describing a modification of laryngectomy techniques, which will benefit this patient population.)
Staple-assisted laryngectomy is a unique method previously reported by Lukyanchenko1 to prevent wound contamination by using a stapling device for suturing pharyngeal defects in total laryngectomy. The purpose of this report is to present our modified method with a combined use of an intraluminal light and laryngofissure indicated for patients with intractable aspiration.
way, were not expected to recover to a degree to warrant reversal of a procedure. Because they were not able to tolerate oral feeding because of aspiration, they required nutrient delivery by nasogastric tube or total parental alimentation. Although this nutritional support was performed, they had suffered from recurrent pneumonia, and 3 of 4 patients presented with hypoalbuminemia. Pharyngeal cultures revealed that they all had pharyngeal colonization with pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, or both.
PATIENTS
TECHNIQUE
We treated 4 patients with intractable aspiration using our method (Table 1). Their etiology varied but existed long-term. It was considered that their laryngeal functions, including phonation and protection of the air-
From the Department of Otolaryngology, Kochi Medical School, Kochi, Japan. Presented at the Sixth Taiwan-Japan Conference in Otolaryngology Head and Neck Surgery, Taipei, Taiwan, December 6-7, 2001. Address correspondence to: Mitsuhiko Nakahira, MD, Department of Otolaryngology, Kochi Medical School, Nankoku, Kochi, 783-8505 Japan. E-mail: nakahira@ kochi-ms.ac.jp. Copyright 2003, Elsevier Science (USA). All rights reserved. 0196-0709/03/2401-0012$30.00/0 10.1053/ajot.2003.3 70
Tracheostomy is performed initially in the usual location, if not previously performed. The patient is then anesthetized. The nasal and oral cavity must be carefully irrigated with 10% povidone-iodine solution. After a U-shaped flap elevation in the neck, the larynx is systematically skeletonized. The inferior constrictors of the pharynx are transected. The pharyngeal mucosa of the bilateral pyriform sinuses is dissected from the posterior aspect of ala of the thyroid cartilage. With the hyoid bone exposed, the attachments of the suprahyoid muscles are transected. The submucosal tissue in the suprahyoid region is incised to be secured with staples. During the procedures, care is taken to avoid inadvertent
American Journal of Otolaryngology, Vol 24, No 1 (January-February), 2003: pp 70-74
STAPLE-ASSISTED LARYNGECTOMY
71
TABLE 1. Preoperative Conditions of 4 Patients With Intractable Aspiration Patient Age/Sex
Aspiration Etiology/Comorbidity
35/M
Cerebral palsy Tracheostomy Recurrent stroke Aphasia Recurrent stroke Severe dysarthria Tracheostomy Neuromuscular disease on a respirator Tracheostomy
67/M 72/M
69/M
Verbal Communication
Period of Aspiration
Nutrient Delivery
Albumin* (g/dL)
Impossible
2Y
NGT
3.8
Impossible Impossible
1Y1M 1Y
NGT NGT
2.8 3.4
Impossible
1Y9M
TPA
3.1
Pharyngeal Culture Ps MRSA MRSA Ps
Ps MRSA
Abbreviations: NGT, nasogastric tube feeding; TPA, total parental alimentation; Ps, pseudomonas aeruginosa; MRSA, methicillin-resistant Staphylococcus aureus. *Reference range of serum albumin is 3.8 –5.1 g/dL.
entry into the pharynx. For this purpose, a flexible endoscope is used as a light guide to enable the safe dissection of the pharyngeal mucosa (Fig 1). The larynx is mobilized from below by transecting the trachea at the appropriate level, entering the space between the
trachea and esophagus, and dissecting the postcricoid mucosa from the surface of the cricoid lamina. In this manner, the maximum postcricoid mucosa is preserved. At this point, the larynx is connected only by its mucosal attachment. A laryngofissure is
Fig 1. This figure shows the use of an intraluminal light. (A) Note a transnasal endoscope (arrow). We cut the tissue toward the illumination (arrowhead). (B) During suprahyoid dissection, endoscopic transillumination (arrowhead) is a useful guide to identify the appropriate plane of dissection (hyoid bone [arrow]).
72
NAKAHIRA ET AL
Fig 2. This figure shows the laryngofissure approach. (A) A laryngofissure makes it easy to pull the epiglottis (arrow) away from the staple line. A line indicates the staple line. (B) We are pulling the epiglottis (white arrow) with a clamp through a laryngofissure.
then performed to pull the epiglottis away from the staple line, to which the stapling device is later applied (Fig 2). The stapling device (Autosuture premium multifire TA 60 long disposable stapler with staples 4.8mm long and 4 mm wide; United States Surgical Corp, Norwalk, CT) is then positioned between the larynx and pharynx. The section of the greater horn of the hyoid bone and the superior horn of the thyroid cartilage allows the device to be positioned close to the larynx for maximize preservation of the normal mucosa. The device is then clamped, and staples are applied by activating the trigger handle mechanism. The larynx is sharply transected during the clamping of the device (Fig 3). The procedure usually takes only a few minutes. After releasing the device, a longitudinal suture line is created. RESULTS Aspiration was prevented successfully in all patients. A postoperative barium swallow showed there was no pharyngeal fistula or
stenosis at the laryngectomy site in any of the 4 patients. All patients started oral intake within 2 weeks, except a 35-year-old man, who had a gastric hemorrhage postoperatively. He started oral intake on postoperative day 27 after the gastric hemorrhage improved. Consequently, 2 patients tolerated oral alimentation postoperatively. The others required nasogastric tube feeding because of insufficient swallowing function. DISCUSSION Our method is profitable for patients with intractable aspiration, for whom no chance of recovery of the laryngeal function is expected. Total laryngectomy is uniformly successful in controlling aspiration2,3 and is a familiar practice for otolaryngologists. However, the postoperative pharyngocutaneous fistula after laryngectomy is one of the greatest concerns among them. This is the major reason why surgeons do not prefer laryngectomy for the treatment of intractable aspiration.4 A major risk factor of the fistula in patients with laryn-
STAPLE-ASSISTED LARYNGECTOMY
73
Fig 3. Staple-assisted laryngectomy. (A) After stapling, the larynx is sharply transected with a scalpel (arrow). (B) Shows that the larynx has already been removed, and a simultaneous closure of the pharyngeal defect has been completed.
geal cancer is radiation therapy,5 whereas in patients with intractable aspiration, there are 2 risk factors that we must take into consideration as seen in this report. First, nutritional failure occurs in the majority of patients with an incompetent larynx.6-8 Preoperative nutritional failure has a potential to worsen the wound healing. Second, oropharyngeal secretions in most patients with aspiration may contain drug-resistant organisms such as Pseudomonas aeruginosa and methicillinresistant Staphylococcus aureus.6-9 This method constantly provides a reliable watertight closure of the pharyngeal defect without wound contamination by pharyngeal secretions, which is unavoidable in the conventional procedure. There are more advantages when this method is applied to patients with aspiration. In contrast to laryngeal cancer patients, the pharyngeal mucosa could be preserved as much as possible to allow a tension-free closure and reduce the possibility of a postoperative fistula. The suprahyoid tissue should be
incised sufficiently because it is too thick to be secured with staples. In that case, it is not necessary to avoid an entry into the preepiglottic space. However, the danger of mucosal perforation during the dissection is not negligible. Perforation is associated with an increase in the postoperative complication rate. With simultaneous endoscope, the surgeon has transmucosal illumination during the dissection. The thickness of the tissue, which should be cut, is clearly estimated. We also had no hesitation in undertaking the laryngofissure to facilitate the use of the stapling device in nonlaryngeal cancer patients. It provides improved visualization and more direct access to the epiglottis. The epiglottis can be pulled out not to be involved in the staple line. The aim of this method is not to improve swallowing functions but to prevent lifethreatening aspiration pneumonia. In this report, all patients had irreversible neurological disturbances in producing voice, such as cerebral palsy, aphasia, severe dysarthria, and
74
the use of mechanical ventilation before surgery. It is not necessary to consider the reversible procedure such as laryngotracheal separation and tracheoesophageal diversion procedure.4 Moreover, they did not have primary tracheoesophageal puncture or voice rehabilitation postoperatively, except a ventilator-dependent 69-year-old man, who occasionally uses the electrolarynx. Two patients still required nasogastric tube feeding because they had weak movement of the tongue and their swallows were poorly coordinated. However, this means that 50% of patients treated surgically were able to eat. In conclusion, this report shows that our method offers certain advantages in the management of patients with intractable aspiration. REFERENCES 1. Lukyanchenko AG: Suturing of a laryngeal defect in laryngectomy. Vestn Otorinolaringol 33:29-31, 1971
NAKAHIRA ET AL
2. Cannon CR, McLean WC: Laryngectomy for chronic aspiration. Am J Otolaryngol 3:145-149, 1982 3. Hawthorne M, Gray R, Cottam C: Conservative laryngectomy. (An effective treatment for severe aspiration in motor neuron disease). J Laryngol Otol 101:283-285, 1987 4. Eisele DW: Surgical approaches to aspiration. Dysphagia 6:71-78, 1991 5. Briant TDR: Spontaneous pharyngeal fistula and wound infection following laryngectomy. Laryngoscope 85:829-834, 1975 6. Niederman MS, Merrill WW, Ferranti RD, et al: Nutritional status and bacterial binding in the lower respiratory tract in patients with chronic tracheostomy. Ann Intern Med 100:795-800, 1984 7. Niederman MS, Mantovani R, Schoch P, et al: Patterns and routes of tracheobronchial colonization in mechanically ventilated patients: The role of nutritional status in colonization of the lower airways by Pseudomonas species. Chest 95:155-161, 1989 8. Rikitomi N, Nagatake T, Sakamoto T, et al: The role of MRSA (methicillin-resistant Staphylococcus aureus) adherence and colonization in the upper respiratory tract of geriatric patients in nosocomial pulmonary infections. Microbiol Immunol 38:607-614, 1994 9. Troillet J, Chastre J, Vuagnat A, et al: Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 157:531-539, 1998
Staple-assisted laryngectomy is a unique method previously reported by Lukyanchenko1 to prevent wound contamination by using a stapling device for suturing pharyngeal defects in total laryngectomy. The purpose of this report is to present our modified method with a combined use of an intraluminal light and laryngofissure indicated for patients with intractable aspiration.
way, were not expected to recover to a degree to warrant reversal of a procedure. Because they were not able to tolerate oral feeding because of aspiration, they required nutrient delivery by nasogastric tube or total parental alimentation. Although this nutritional support was performed, they had suffered from recurrent pneumonia, and 3 of 4 patients presented with hypoalbuminemia. Pharyngeal cultures revealed that they all had pharyngeal colonization with pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, or both.
PATIENTS
TECHNIQUE
We treated 4 patients with intractable aspiration using our method (Table 1). Their etiology varied but existed long-term. It was considered that their laryngeal functions, including phonation and protection of the air-
From the Department of Otolaryngology, Kochi Medical School, Kochi, Japan. Presented at the Sixth Taiwan-Japan Conference in Otolaryngology Head and Neck Surgery, Taipei, Taiwan, December 6-7, 2001. Address correspondence to: Mitsuhiko Nakahira, MD, Department of Otolaryngology, Kochi Medical School, Nankoku, Kochi, 783-8505 Japan. E-mail: nakahira@ kochi-ms.ac.jp. Copyright 2003, Elsevier Science (USA). All rights reserved. 0196-0709/03/2401-0012$30.00/0 10.1053/ajot.2003.3 70
Tracheostomy is performed initially in the usual location, if not previously performed. The patient is then anesthetized. The nasal and oral cavity must be carefully irrigated with 10% povidone-iodine solution. After a U-shaped flap elevation in the neck, the larynx is systematically skeletonized. The inferior constrictors of the pharynx are transected. The pharyngeal mucosa of the bilateral pyriform sinuses is dissected from the posterior aspect of ala of the thyroid cartilage. With the hyoid bone exposed, the attachments of the suprahyoid muscles are transected. The submucosal tissue in the suprahyoid region is incised to be secured with staples. During the procedures, care is taken to avoid inadvertent
American Journal of Otolaryngology, Vol 24, No 1 (January-February), 2003: pp 70-74
STAPLE-ASSISTED LARYNGECTOMY
71
TABLE 1. Preoperative Conditions of 4 Patients With Intractable Aspiration Patient Age/Sex
Aspiration Etiology/Comorbidity
35/M
Cerebral palsy Tracheostomy Recurrent stroke Aphasia Recurrent stroke Severe dysarthria Tracheostomy Neuromuscular disease on a respirator Tracheostomy
67/M 72/M
69/M
Verbal Communication
Period of Aspiration
Nutrient Delivery
Albumin* (g/dL)
Impossible
2Y
NGT
3.8
Impossible Impossible
1Y1M 1Y
NGT NGT
2.8 3.4
Impossible
1Y9M
TPA
3.1
Pharyngeal Culture Ps MRSA MRSA Ps
Ps MRSA
Abbreviations: NGT, nasogastric tube feeding; TPA, total parental alimentation; Ps, pseudomonas aeruginosa; MRSA, methicillin-resistant Staphylococcus aureus. *Reference range of serum albumin is 3.8 –5.1 g/dL.
entry into the pharynx. For this purpose, a flexible endoscope is used as a light guide to enable the safe dissection of the pharyngeal mucosa (Fig 1). The larynx is mobilized from below by transecting the trachea at the appropriate level, entering the space between the
trachea and esophagus, and dissecting the postcricoid mucosa from the surface of the cricoid lamina. In this manner, the maximum postcricoid mucosa is preserved. At this point, the larynx is connected only by its mucosal attachment. A laryngofissure is
Fig 1. This figure shows the use of an intraluminal light. (A) Note a transnasal endoscope (arrow). We cut the tissue toward the illumination (arrowhead). (B) During suprahyoid dissection, endoscopic transillumination (arrowhead) is a useful guide to identify the appropriate plane of dissection (hyoid bone [arrow]).
72
NAKAHIRA ET AL
Fig 2. This figure shows the laryngofissure approach. (A) A laryngofissure makes it easy to pull the epiglottis (arrow) away from the staple line. A line indicates the staple line. (B) We are pulling the epiglottis (white arrow) with a clamp through a laryngofissure.
then performed to pull the epiglottis away from the staple line, to which the stapling device is later applied (Fig 2). The stapling device (Autosuture premium multifire TA 60 long disposable stapler with staples 4.8mm long and 4 mm wide; United States Surgical Corp, Norwalk, CT) is then positioned between the larynx and pharynx. The section of the greater horn of the hyoid bone and the superior horn of the thyroid cartilage allows the device to be positioned close to the larynx for maximize preservation of the normal mucosa. The device is then clamped, and staples are applied by activating the trigger handle mechanism. The larynx is sharply transected during the clamping of the device (Fig 3). The procedure usually takes only a few minutes. After releasing the device, a longitudinal suture line is created. RESULTS Aspiration was prevented successfully in all patients. A postoperative barium swallow showed there was no pharyngeal fistula or
stenosis at the laryngectomy site in any of the 4 patients. All patients started oral intake within 2 weeks, except a 35-year-old man, who had a gastric hemorrhage postoperatively. He started oral intake on postoperative day 27 after the gastric hemorrhage improved. Consequently, 2 patients tolerated oral alimentation postoperatively. The others required nasogastric tube feeding because of insufficient swallowing function. DISCUSSION Our method is profitable for patients with intractable aspiration, for whom no chance of recovery of the laryngeal function is expected. Total laryngectomy is uniformly successful in controlling aspiration2,3 and is a familiar practice for otolaryngologists. However, the postoperative pharyngocutaneous fistula after laryngectomy is one of the greatest concerns among them. This is the major reason why surgeons do not prefer laryngectomy for the treatment of intractable aspiration.4 A major risk factor of the fistula in patients with laryn-
STAPLE-ASSISTED LARYNGECTOMY
73
Fig 3. Staple-assisted laryngectomy. (A) After stapling, the larynx is sharply transected with a scalpel (arrow). (B) Shows that the larynx has already been removed, and a simultaneous closure of the pharyngeal defect has been completed.
geal cancer is radiation therapy,5 whereas in patients with intractable aspiration, there are 2 risk factors that we must take into consideration as seen in this report. First, nutritional failure occurs in the majority of patients with an incompetent larynx.6-8 Preoperative nutritional failure has a potential to worsen the wound healing. Second, oropharyngeal secretions in most patients with aspiration may contain drug-resistant organisms such as Pseudomonas aeruginosa and methicillinresistant Staphylococcus aureus.6-9 This method constantly provides a reliable watertight closure of the pharyngeal defect without wound contamination by pharyngeal secretions, which is unavoidable in the conventional procedure. There are more advantages when this method is applied to patients with aspiration. In contrast to laryngeal cancer patients, the pharyngeal mucosa could be preserved as much as possible to allow a tension-free closure and reduce the possibility of a postoperative fistula. The suprahyoid tissue should be
incised sufficiently because it is too thick to be secured with staples. In that case, it is not necessary to avoid an entry into the preepiglottic space. However, the danger of mucosal perforation during the dissection is not negligible. Perforation is associated with an increase in the postoperative complication rate. With simultaneous endoscope, the surgeon has transmucosal illumination during the dissection. The thickness of the tissue, which should be cut, is clearly estimated. We also had no hesitation in undertaking the laryngofissure to facilitate the use of the stapling device in nonlaryngeal cancer patients. It provides improved visualization and more direct access to the epiglottis. The epiglottis can be pulled out not to be involved in the staple line. The aim of this method is not to improve swallowing functions but to prevent lifethreatening aspiration pneumonia. In this report, all patients had irreversible neurological disturbances in producing voice, such as cerebral palsy, aphasia, severe dysarthria, and
74
the use of mechanical ventilation before surgery. It is not necessary to consider the reversible procedure such as laryngotracheal separation and tracheoesophageal diversion procedure.4 Moreover, they did not have primary tracheoesophageal puncture or voice rehabilitation postoperatively, except a ventilator-dependent 69-year-old man, who occasionally uses the electrolarynx. Two patients still required nasogastric tube feeding because they had weak movement of the tongue and their swallows were poorly coordinated. However, this means that 50% of patients treated surgically were able to eat. In conclusion, this report shows that our method offers certain advantages in the management of patients with intractable aspiration. REFERENCES 1. Lukyanchenko AG: Suturing of a laryngeal defect in laryngectomy. Vestn Otorinolaringol 33:29-31, 1971
NAKAHIRA ET AL
2. Cannon CR, McLean WC: Laryngectomy for chronic aspiration. Am J Otolaryngol 3:145-149, 1982 3. Hawthorne M, Gray R, Cottam C: Conservative laryngectomy. (An effective treatment for severe aspiration in motor neuron disease). J Laryngol Otol 101:283-285, 1987 4. Eisele DW: Surgical approaches to aspiration. Dysphagia 6:71-78, 1991 5. Briant TDR: Spontaneous pharyngeal fistula and wound infection following laryngectomy. Laryngoscope 85:829-834, 1975 6. Niederman MS, Merrill WW, Ferranti RD, et al: Nutritional status and bacterial binding in the lower respiratory tract in patients with chronic tracheostomy. Ann Intern Med 100:795-800, 1984 7. Niederman MS, Mantovani R, Schoch P, et al: Patterns and routes of tracheobronchial colonization in mechanically ventilated patients: The role of nutritional status in colonization of the lower airways by Pseudomonas species. Chest 95:155-161, 1989 8. Rikitomi N, Nagatake T, Sakamoto T, et al: The role of MRSA (methicillin-resistant Staphylococcus aureus) adherence and colonization in the upper respiratory tract of geriatric patients in nosocomial pulmonary infections. Microbiol Immunol 38:607-614, 1994 9. Troillet J, Chastre J, Vuagnat A, et al: Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 157:531-539, 1998