746 EXPERIENCE IN RECONSTRUCTION OF LARYNGOPHARYNGOESOPHAGECTOMIES IN A THIRD LEVEL CENTER

Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy, due to malignant or benign causes, is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps, such as the pectoralis major flap, or free grafts, such as the anterolateral thigh-ALT). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy. Methods This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (ingestion of caustic) or malignant (cancer of the larynx, pharynx, parathyroid and cervical esophagus) with circumferential pharyngeal reconstruction with flap, from 2008 to November 2020. Demographic variables, neoadjuvant treatment, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, functional result of the flap, hospital stay, recurrence and mortality were collected. Results Twelve patients, with a median age of 59 years (45–78), underwent surgery, 1 case due to benign cause and 11 cases with an oncological diagnosis. There were complications related to the reconstruction in 42% of the patients (see table 1). Postoperative morbidity was 67% (75% Clavien-Dindo ≥ III). The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75% (only 3 patients with poor results). The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8% (1 case). Conclusion Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications (fistulas and stenosis) and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections (laryngopharyngeal) with ALT free flap reconstruction.

Reconstruction of the pharynx

Reconstruction of the pharynx and cervical oesophagus represents a significant challenge for the plastic surgeon due to the complex functions and anatomical structures to be restored. Malignancy is the most common cause of pharyngeal defects, and this patient cohort has a generally poor prognosis due to the tendency to present late with advanced disease. While tumours of the hypopharynx make up only 5% of all head and neck cancers, the surgical management of laryngeal and upper oesophageal malignancy frequently involves the need to reconstruct or reinforce the pharynx. Reconstruction for these patients is further complicated by medical comorbidity, synchronous malignancy, and the patients’ poor nutritional state. With the move in recent years to chemoradiotherapy protocols for advanced disease, surgery is performed less frequently. Nevertheless, there is still a need for surgical management in both primary treatment and salvage cases following chemoradiotherapy. As survival is poor in this group, it is important that quality of life after reconstruction is considered, and hospital stay minimized. The restoration of an oral diet and intelligible speech is the priority, but there are a multitude of factors which must be considered when selecting the best reconstruction. This chapter outlines some historical methods of pharyngeal reconstruction, followed by the indications, advantages, and disadvantages of the methods in current use.

Functional requirements for polymeric implant materials in head and neck surgery

BACKGROUND: The pharyngeal reconstruction is a challenging aspect after pharyngeal tumor resection. The pharyngeal passage has to be restored to enable oral alimentation and speech rehabilitation. Several techniques like local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps have been developed to reconstruct pharyngeal defects following surgery, in order to restore function and aesthetics. The reconstruction of the pharynx by degradable, multifunctional polymeric materials would be a novel therapeutical option in head and neck surgery. MATERIALS AND METHODS: Samples of an ethylene-oxide sterilized polymer (diameter 10 mm, 200μm thick) were implanted for the reconstruction of a standardized defect of the gastric wall in rats in a prospective study. The stomach is a model for a “worst case” application site to test the stability of the implant material under extreme chemical, enzymatical, bacterial, and mechanical load. RESULTS: Fundamental parameters investigated in this animal model were a local tight closure between the polymer and surrounding tissues, histological findings of tissue regeneration and systemic responses to inflammation. A tight anastomosis between the polymer and the adjacent stomach wall was found in all animals after polymer implantation (n = 42). Histologically, a regeneration with glandular epithelium was found in the polymer group. No differences in the systemic responses to inflammation were found between the polymer group (n = 42) and the control group (n = 21) with primary wound closure of the defect of the gastric wall. CONCLUSIONS: A sufficient stability of the polymeric material is a requirement for the pharyngeal reconstruction with implant materials.

CO2 Laser Division of Neo-Vallecula Improves Dysphagia in the Postlaryngectomy Patient: A Case Series and Review of the Literature

Objectives. To review the literature on neo-vallecula diagnosis and management and to report our findings regarding 3 patients who developed neo-vallecula in the context of free-flap pharyngeal reconstruction following total laryngectomy. Methods. This case series reports three patients who developed a neo-vallecula following a laryngectomy and free-flap pharyngeal reconstruction. All three patients were treated with a CO2 laser endoscopic procedure. Results. Neo-vallecula formation is thought to be related to tension on the neopharyngeal closure or closure technique following total laryngectomy. Diagnosis may be obtained with swallow studies, videofluoroscopy, or endoscopy. Treatment has included external excision and endoscopic procedures such as stapling, harmonic scalpel excision, and laser removal. We utilized an endoscopic approach entailing the use of a CO2 laser to divide the neo-vallecula, and all our patients reported improvement in their dysphagia. Conclusions. Treatment of an anterior neo-vallecula endoscopically using a CO2 laser is an effective way to treat dysphagia in patients following total laryngectomy with free-flap pharyngeal reconstruction.

Reconstruction of Pharyngeal Defects

The management of pharyngeal defects is one of the most challenging tasks for reconstructive surgeons. The reconstructive method is driven by the amount of tissue loss as well as patient-related factors. Since the advent of organ preservation strategies in the 1990s as described by the Department of Veterans Affairs Laryngeal Cancer Study, salvage surgery has become a common pharyngeal procedure to obtain local control when nonsurgical treatment fails. This chapter is divided into preoperative, intraoperative, and postoperative phases of patient management. Each section will focus on particular aspects of management that are essential to achieve the best therapeutic outcome for patients who need pharyngeal reconstruction.