DELAYED ORAL FEEDING IN PATIENTS OF SALVAGE LARYNGECTOMY AND ITS EFFECT ON DEVELOPMENT OF PHARYNGOCUTANEOUS FISTULA

Objective: Pharyngocutaneous fistula (PCF) is a complication of post radiotherapy total laryngectomy. Early post operative feeding is a risk factor for development of PCF. Delayed oral feeding (DOF) and inserting a nasogastric tube has been considered a safe practice among head and neck surgeons, and there is no general agreement on the timing of initiation of the oral intake. This study compared the effect of EOF and DOF on PCF formation. Study Design: Prospective case-controlled trial. Place and Duration of Study: Combined Military Hospital Rawalpindi, from Apr 2019 to Jul 2020. Methodology: Non-probability convenience sampling was done for both groups. The patients were not matched and were assigned to either EOF or DOF alternately. EOF was defined as feeding at seventh post operative day and DOF criterion was feeding on fourteenth post operative day. The primary outcome was development of PCF within the 30th post operative day. A total of 20 patients with prior radiotherapy for laryngeal cancer who presented with recurrence of carcinoma were included in the study. Same technique closure of neopharynx was done in all cases of laryngectomy. Results: Overall PCF frequency was 20% (4/20). In EOF group, 30% (3/10) of patients developed PCF whereas 10% (1/10) of patients in DOF developed PCF. However, the difference in outcome of two groups was not statistically significant. Conclusion: DOF in cases of Salvage total laryngectomy is a safe practice and it might help to reduce the frequency of pharyngocutaneous fistula.

Non-Surgical Strategies for Assisting Closure of Pharyngocutaneous Fistula after Total Laryngectomy: A Systematic Review of the Literature

Background: Pharyngocutaneous fistula (PCF) is a frequent complication after total laryngectomy, with an incidence of up to 65%. Many conservative or invasive approaches are available and the choice among them is usually made on a case-by-case basis. The aim of the present review is to critically summarize the available evidence of the effectiveness of the non-surgical management of PCF. Methods: A systematic review and a meta-analysis of the literature were conducted, according to the PRISMA guidelines. Studies investigating botulinum toxin therapy, scopolamine transdermal patch, hyperbaric oxygen therapy (HBOT), and negative pressure wound therapy (NPWT) were assessed. Complete fistula closure after the initiation of non-surgical treatment was the main outcome. Results: After the application of selection criteria, a total of seven articles and 27 patients were included in the present review. All the eligible studies were descriptive case series, while only one article used a standard group as a comparison. The mean age was 63.3 and 14 patients (51.9%) had previously received RT. The reported comorbidities were diabetes, ischemic heart disease, hypertension, dyslipidemia, COPD, and atrial fibrillation. With a mean healing time of 25.0 days, the overall success rate was 92.6%. Conclusions: Non-surgical treatment of PCF is only based on the experience of small series. Although success rates seem promising, the absence of properly designed comparative studies does not allow us, at present, to identify ideal candidates for these non-invasive management strategies for PCF.

Near total laryngectomy: a single institutional experience

Background: Near total laryngectomy (NTL) aims to remove cancer of larynx and hypopharynx while maintaining a lung powered, prosthesis free voice. The oncological and functional outcomes of NTL have been encouraging but the surgical procedure is complex. In this study, we present our experience with NTL in order to encourage more ENT and head and neck surgeons to take up the procedure.Methods: Twenty-eight patients, who had undergone NTL at State cancer institute, Guwahati are analysed retrospectively for survival, disease free status, functional outcomes and complications.Results: There were two recurrences: one local recurrence which was salvaged by a completion total laryngectomy. The other patient had distant metastasis and died eventually. Overall survival (OS) was 96.43% and event free survival (EFS) was 92.86%. The patient who died had extra-nodal extension (ENE) on post op histology (p=0.274). Two patients failed to develop any speech had stenosis of the shunt. One of these was the only Salvage NTL case (p=0.057). Tracheostome stenosis, poor swallow and shunt stenosis were the common complications in our series. Most of them resolved with some intervention. Multiple complications were seen in the salvage NTL cases.Conclusions: Careful case selection and well executed surgery leads to acceptable results following NTL. Special attention should be paid to the salvage cases as they are prone to develop complications and failure to attain speech. Patients with adverse post-op histopathological examination (HPE), like ENE should be kept under close follow up.