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Year : 2017  |  Volume : 54  |  Issue : 4  |  Page : 621--625

Total laryngectomy: Surgical morbidity and outcomes – A case series

Gouri H Pantvaidya, Sheetal Raina, Arindam Mondal, Anuja Deshmukh, Deepa Nair, Prathamesh Pai, Pankaj Chaturvedi, Anil D'Cruz 
 Department of Head and Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Gouri H Pantvaidya
Department of Head and Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra
India

Abstract

BACKGROUND: Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies. AIM: The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center. SETTING AND DESIGN: This was a retrospective review of a prospective database of TL patients operated during 2012–2013. MATERIALS AND METHODS: Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien–Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan–Meier survival curves. RESULTS: A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts. CONCLUSION: TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.



How to cite this article:
Pantvaidya GH, Raina S, Mondal A, Deshmukh A, Nair D, Pai P, Chaturvedi P, D'Cruz A. Total laryngectomy: Surgical morbidity and outcomes – A case series.Indian J Cancer 2017;54:621-625


How to cite this URL:
Pantvaidya GH, Raina S, Mondal A, Deshmukh A, Nair D, Pai P, Chaturvedi P, D'Cruz A. Total laryngectomy: Surgical morbidity and outcomes – A case series. Indian J Cancer [serial online] 2017 [cited 2020 Oct 29 ];54:621-625
Available from: https://www.indianjcancer.com/text.asp?2017/54/4/621/237901


Full Text



 Introduction



Total laryngectomy (TL) is the standard surgical treatment for management of locally advanced laryngeal and hypopharyngeal cancers. Its primary indication is locally advanced laryngeal and hypopharyngeal cancers which show transcartilage involvement and exolaryngeal spread. With the advent of organ preservation using chemoradiation,[1],[2] TL is now being performed in a significant number of patients for radiation failures and recurrences after organ preservation.[3] A small number of patients also undergo TL for dysfunctional larynx and chondronecrosis as sequelae of chemoradiation. TL is therefore a widely performed procedure, even after the advent of chemoradiation (chemotherapy radiotherapy [CTRT]).

The aim of this review is to report the 30-day postoperative morbidity and survival outcomes after TL performed for all the above-mentioned indications in a tertiary referral center.

 Materials and Methods



We conducted a retrospective study for patients undergoing a laryngectomy during 2012–2013 at Tata Memorial Hospital. Data were extracted from a prospectively maintained surgical database. Demographic data, details of surgery and previous treatment, histopathology details, 30-day morbidity, and recurrence and survival data were collected from the prospectively maintained database and electronic medical records (EMRs). Outcome data with regard to recurrence and survival were collected in a retrospective manner from EMR and case files.

As per the policy at our center, all patients undergo counseling in the preoperative period for voice rehabilitation. Primary tracheo-esophageal prosthesis (TEP) placement at the time of surgery is the procedure and rehabilitation of choice at our institute.

Antibiotic prophylaxis was instituted in all patients, with the first dose given at the time of induction with repeat doses every 4 h during the surgery. Patients were continued on three-drug antibiotic regimen (injectable cefuroxime, metronidazole, and amikacin) for 5 days after which antibiotics were stopped unless there is a need to continue the same. All changes or prolongation of antibiotics along with their reason were documented in the database.

Postsurgical complications were recorded as per Clavien–Dindo (CD) grading system.[4] A minor complication was defined as one which was managed by the addition of medications, bedside dressings, and/or watchful waiting. Major complications were defined as complications that required prolongation of hospital stay beyond 3 weeks and repeat surgery or explorations under anesthesia. Any readmissions into the intensive care unit were also considered as major complications.

Histopathology was reported in standard reporting format. Adjuvant radiotherapy was prescribed to patients who were not previously irradiated and had one or more of the following factors: T3–T4 tumors, node positivity, and poorly differentiated cancers. Adjuvant CTRT was given to patients who had cut margins positive or perinodal extension to the cervical nodes.

Disease-free survival (DFS) and overall survival (OAS) were calculated using Kaplan–Meier estimates. Data were analyzed using SPSS 21 for Windows software (SPSS Inc., Philadelphia, PA, USA).

 Results



In all, 178 patients were considered for laryngectomy during 2012–2013. Of these, nine patients were found to be inoperable at the time of surgery either because of unresectable nodal disease or the primary disease involving prevertebral fascia. The demographic details of patients included in this review (n = 169) are shown in [Table 1]. In our cohort, 43.7% of patients had received some form of treatment before undergoing laryngectomy. Of the entire cohort, 34.9% patients had received radiation therapy (RT) before laryngectomy. About 34% of the patients had significant comorbidities at the time of surgery. Only 1.1% of our patients had an albumin <3 mg/dL and 9% of the patients had a hemoglobin value <10 g/dL. Laryngeal cancers were the commonest cancer to undergo a TL. Within laryngeal cancers, glottis was the most common subsite constituting 58% of laryngeal cancers.{Table 1}

The details of surgery and reconstruction performed are shown in [Table 2].{Table 2}

Tracheo-esophageal prosthesis

Ten patients had voice conserving surgery in the form of near-total laryngectomy or supracricoid laryngectomy and TEPs were not placed in these patients. Among the remaining 159 patients, 40 patients (25%) did not receive primary TEP placements. The reasons for nonplacement of primary TEP are as follows: patient choice in 4, absence of party wall contiguity because of circumferential excisions and reconstructions with gastric pull-ups or free jejunum in 22, lack of finances in 2, reconstruction for pharyngeal augmentations in 7, and reason not known in 5 cases.

Morbidity of surgery

Of the 169 patients who underwent surgery, 43.5% had some form of complication. Of these, only 18.8% patients had major complications. Complications as per CD grading system are shown in [Table 3].{Table 3}

Infections requiring prolongation or change in antibiotics were seen in 15.8% of the patients. Eighteen of the 26 who developed infections were in patients with pharyngocutaneous fistulas (PCFs) (P = 0.001).

PCFs were seen in 38 patients (22.4%), of which 22 patients had minor fistulae and were managed conservatively with dressings, antibiotics, and supportive care. Major PC fistulas needing surgical intervention or a hospital stay >3 weeks were seen in 16 patients (9.4%). On comparing the type of PCF with the addition of reconstruction during initial surgery, we found that patients with microvascular reconstruction had the lowest incidence (7.8%) of PCF among all the reconstructions performed. [Table 4] summarizes the details of this comparison. However, only 21% of our patients who required reconstruction received free flaps.{Table 4}

Of the patients with PCFs, 16 (42.1%) were post RT. There was no statistically significant correlation between development of PCFs and prior RT (P = 0.22). Of the patients with major PCFs, six were in post RT patients, but this was not statistically significant.

We had three postoperative deaths with a postoperative mortality of 1.7%. Two of these were associated with major PCFs and blow outs. One patient died because of stomach tube necrosis after a gastric pull-up.

Histopathology

The details of postoperative histopathology are shown in [Table 5].{Table 5}

Recurrence and survival

About 19% of our patients were lost to follow-up. Forty-two (24.8%) patients developed recurrences. The patterns of recurrence among patients undergoing laryngectomy are shown in [Table 6]. Distant metastases were seen in 20 of the 42 recurrences (47.6%).{Table 6}

The 3-year OAS and DFS for the entire cohort were 72% and 66%, respectively. Kaplan–Meier survival graphs for OAS and DFS are shown in [Figure 1] and [Figure 2], respectively. We also compared OAS and DFS of patients who were treated with per primum laryngectomy versus those who had a salvage procedure post RT/CTRT. There was no statistically significant survival difference between the two groups for OAS or DFS (P = 0.8 and 0.3, respectively) [Figure 3] and [Figure 4].{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



TL is a time-tested surgery for cancers of the larynx and hypopharynx. Its safety and efficacy are well documented. The most common subsite for which a TL was done in our series was for glottic cancers. Hypopharyngeal cancers constituted only 28% of the cancers in our series. Hypopharyngeal cancers are known to be more common in India;[5] however, most series from India also have laryngeal cancers as the most common subsite for performing TL.[5] This could be probably because hypopharyngeal cancers present in an advanced stage and may not be amenable to resection either per primum or in the salvage setting.

Contrary to the opinion that most laryngectomies are now done in the post CTRT setting, 65% of our patients were operated per primum for advanced laryngeal and hypopharyngeal cancers or if patients had a dysfunctional larynx. The indications for per primum laryngectomy include transcartilage erosion and presence of a dysfunctional larynx. Chemoradiation as a primary modality in this group of patients having advanced cancers has shown to have detrimental outcomes.[6],[7]

Around 42% of our patients had some form of reconstruction performed at the time of TL. Pectoralis major myocutaneous flap to augment the remnant pharyngeal mucosa was the most common type of reconstruction performed. Our series had a higher incidence of reconstructions performed than what is seen in other series.[8] This could be because of the higher number of hypopharyngeal cancers in our series or because of the advanced stage at presentation requiring pharyngeal excisions.

The most common major complication following laryngectomy is the development of a PCF, an abnormal communication between the pharynx and skin.[9] The incidence of PCFs ranges from 2% to 65%.[10],[11] A number of factors have been identified that may contribute to PCF formation and include preoperative RT, preoperative tracheostomy, concurrent radical neck dissection, postoperative hemoglobin level, technique of pharyngeal closure, antibiotic prophylaxis, positive margins, and poor nutritional status.[11],[12] PCFs were seen in 38 patients (22.4%), of which 22 patients had minor fistulae and were managed conservatively with dressings, antibiotics, and supportive care. Of patients with PCFs, 16 (42.1%) were post RT. Our rate of PCFs was similar to those reported in literature.[13],[14] In a previous publication from our institution, we had shown a PCF rate of 43%. However, this was the fistula rate in a cohort of patients who were all post radiation and had undergone surgery as salvage.[15] Most of the patients who developed PCFs in our study were treated in a conservative fashion with adequate neck drainage, use of antibiotics, and injection glycopyrrolate when necessary. Only 9% of patients required surgical intervention and a hospital stay >3 weeks. Similar findings were seen in a study by Virtaniemi et al., in which 80% of the PCFs showed a spontaneous closure.[16]

Mortality after TL is reported in the literature at around 2%.[17] In our institution, we had three postoperative deaths with a postoperative mortality of 1.7%. Two of these were associated with major PCFs and blow outs. One patient died because of stomach tube necrosis after a gastric pull-up.

The 3-year OAS and DFS in our patients were 72% and 66%, respectively. This is in concordance with most other series reporting outcomes after TL for laryngeal and hypopharyngeal cancers.[18],[19]

There has been a recent report of improved survivals in patients undergoing surgery when compared with those undergoing chemoradiation. In a population-based SEER review, it was found that patients who were treated with surgical therapy had a better 2- and 5-year disease-specific survival and OAS.[20] This difference in survival was seen across all stages and time periods. We did not find a significantly different survival in patients who underwent salvage laryngectomy (post CTRT) versus a per primum laryngectomy. This could be because all patients who had received CTRT originally had small volume disease when compared with patients who had per primum surgery who had much larger volume of disease. The patients undergoing surgery thus constituted a poorer prognostic group. We had a high percentage of distant metastases forming 42% of the total recurrences.

 Conclusion



TL with or without a pharyngectomy is the gold standard of treatment for T4 cancers, patients with dysfunctional larynx, and chemoradiation failures. The overall morbidity in this group is acceptable and there should be appropriate use of reconstruction as and when necessary. Although a mutilating surgery, TL gives patients good survivals with adequate rehabilitation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091-8.
2Department of Veterans Affairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG, Hong WK, Hillman R, Spaulding M, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324:1685-90.
3Tan HK, Giger R, Auperin A, Bourhis J, Janot F, Temam S, et al. Salvage surgery after concomitant chemoradiation in head and neck squamous cell carcinomas - Stratification for post salvage survival. Head Neck 2010;32:139-47.
4Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien–Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187-96.
5Cervado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, et al. Cancer incidence in five continents. International Agency for Research on Cancer (IARC): Scientific Publication No. 160. Vol. IX. Lyon: IARC; 2007.
6Lee SC, Shores CG, Weissler MC. Salvage surgery after failed primary concomitant chemoradiation. Curr Opin Otolaryngol Head Neck Surg 2008;16:135-40.
7Ganly I, Patel SG, Matsuo J, Singh B, Kraus DH, Boyle JO, et al. Results of surgical salvage after failure of definitive radiation therapy for early-stage squamous cell carcinoma of the glottic larynx. Arch Otolaryngol Head Neck Surg 2006;132:59-66.
8Sousa AA, Castro SM, Porcaro-Salles JM, Soares JM, de Moraes GM, Carvalho JR, et al. The usefulness of a pectoralis major myocutaneous flap in preventing salivary fistulae after salvage total laryngectomy. Braz J Otorhinolaryngol 2012;78:103-7.
9Paydarfar JA, Birkmeyer NJ. Complications in head and neck surgery: A meta-analysis of postlaryngectomy pharyngocutaneous fistula. Arch Otolaryngol Head Neck Surg 2006;132:67-72.
10Thawley SE. Complications of combined radiation therapy and surgery for carcinoma of the larynx and inferior hypopharynx. Laryngoscope 1981;91:677-700.
11Violaris N, Bridger M. Prophylactic antibiotics and post laryngectomy pharyngocutaneous fistulae. J Laryngol Otol 1990;104:225-8.
12Papazoglou G, Doundoulakis G, Terzakis G, Dokianakis G. Pharyngocutaneous fistula after total laryngectomy: Incidence, cause, and treatment. Ann Otol Rhinol Laryngol 1994;103:801-5.
13Mäkitie AA, Niemensivu R, Hero M, Keski-Säntti H, Bäck L, Kajanti M, et al. Pharyngocutaneous fistula following total laryngectomy: A single institution's 10-year experience. Eur Arch Otorhinolaryngol 2006;263:1127-30.
14Pinar E, Oncel S, Calli C, Guclu E, Tatar B. Pharyngocutaneous fistula after total laryngectomy: Emphasis on lymph node metastases as a new predisposing factor. J Otolaryngol Head Neck Surg 2008;37:312-8.
15Sharma S, Chaukar DA, Laskar SG, Kapre N, Deshmukh A, Pai P, et al. Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy. J Laryngol Otol 2016;130:860-4.
16Virtaniemi JA, Kumpulainen EJ, Hirvikoski PP, Johansson RT, Kosma VM. The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae. Head Neck 2001;23:29-33.
17Arriaga MA, Kanel KT, Johnson JT, Myers EN. Medical complications in total laryngectomy: Incidence and risk factors. Ann Otol Rhinol Laryngol 1990;99:611-5.
18Woodard TD, Oplatek A, Petruzzelli GJ. Life after total laryngectomy: A measure of long-term survival, function, and quality of life. Arch Otolaryngol Head Neck Surg 2007;133:526-32.
19Leong SC, Kartha SS, Kathan C, Sharp J, Mortimore S. Outcomes following total laryngectomy for squamous cell carcinoma: One centre experience. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:302-7.
20Megwalu UC, Sikora AG. Survival outcomes in advanced laryngeal cancer. JAMA Otolaryngol Head Neck Surg 2014;140:855-60.