Stapler-assisted closure in total laryngectomy.
A 43-year-old male presented to clinic with a four-year history of progressively worsening hoarseness. Associated symptoms included bilateral otalgia, stridor, and dysphagia. His social history denotes a 15 pack-year history of tobacco abuse and a five-year history of drinking a six-pack of beer per day.
Flexible laryngoscopy was performed in the office, revealing irregular thickening at the petiole of the epiglottis with bilateral false vocal cord fullness and granulation changes noted at the anterior aspects of both true vocal cords. There was decreased bilateral adduction and abduction noted on functional examination. No extralaryngeal abnormalities were noted.
High-resolution computed tomography was obtained revealing a 4.2 cm cranio-caudal soft tissue mass in the larynx extending from the epiglottis down through the level of the false vocal cords, vestibule, and true vocal cords. Anterior commissure involvement was also noted with an ill-defined thyroid cartilage, suspicious for invasion of the inner cortex. No visualized cervical lymphadenopathy was noted.
Given the high suspicion for malignancy based on the patients clinical, physical, and radiographic findings, a direct laryngoscopy with biopsy was arranged. Intraoperative findings confirmed our office laryngoscopy, in addition, to returning a diagnosis of poorly differentiated squamous cell carcinoma, staging the patient as a T3N0M0.
A total laryngectomy with bilateral neck dissections and a right thyroid lobectomy were performed. Prior to extirpating the surgical specimen, the entire larynx was skeletonized to its pharyngeal mucosal attachments (Figure 1). Following this, a mini-pharyngostomy was created just above the hyoid bone. The epiglottis was grasped and fixed to the hyoid with an Allis clamp. This prevents the epiglottis from falling dorsally. The Ethicon TX60B proximate linear stapler was then inserted beneath the larynx (Figure 2,3). Stapler application is then carried out, followed by sharply severing the specimen from the device with a scalpel. The remaining pharyngeal mucosa is effectively sealed (Figure 4).
Operative pathology revealed a main specimen with negative margins and inner cortical erosion of the thyroid cartilage. The cervical lymphadenectomy revealed one right cervical lymph node with metastatic squamous cell carcinoma and extracapsular extension. The final pathologic staging was pT3N1M0.
On postoperative day six, an esophagram was performed, revealing no evidence of contrast extravasation or fistula. At this point, a full liquid diet was initiated; and on postoperative day seven, the patient was tolerating a soft mechanical diet and was discharged home. Given the adverse pathologic findings of the surgical specimen, the patient was set up for adjuvant chemotherapy and radiation therapy.
A total laryngectomy is a reliable oncologic procedure for the local control of laryngeal malignancy. Traditionally, after tumor extirpation, a primary closure of the defect is accomplished so as to invert the pharyngeal mucosa via a running or interrupted suture closure. This usually takes about 30 to 60 minutes to perform, and it creates a watertight neopharynx, thereby allowing the patient to resume oral intake after a period of healing. This process has its advantages in that it allows the surgeon to directly inspect the innards of the pharynx during tumor resection and also send true mucosal margins for frozen section examination. Disadvantages include increased operative time and cost, as well as contamination of the operative field by endopharyngeal secretions.
The idea of staple-assisted closure for a post-laryngectomy defect has been around for more than two decades. (1) Early descriptions related an open technique during which a total laryngectomy was performed in the standard fashion. Following this, an assistant would hold the pharyngeal mucosal remnants in apposition as the surgeon applied a linear stapler. (2,3) A closed technique has also been described in which the larynx is separated from the esophagus and skeletonized circumferentially. Ventral traction is provided as a linear stapler is then inserted beneath the specimen and applied. The drawback to this approach is that the suprahyoid epiglottis may fall dorsally, thereby becoming caught in the suture line of the stapling device. For a malignancy with epiglottic involvement, this could compromise oncologic control. One method utilized to gain control of the epiglottis is inserting a single hook through the inferior aspect of the specimen via the trachea, thereby blindly hooking the epiglottis and displacing it inferiorly or superiorly, thus removing it from the suture line and retaining it in total as part of the specimen. Another approach utilizes a semi-closed technique. A median pharyngotomy is created after dissecting off the suprahyoid musculature. This allows direct visualization of the epiglottis. It is then grasped with a clamp and pulled ventrally, at which point it can be sutured around the hyoid or held in place while the stapler is fired. It is important to place the stapler below the pharyngostomy in order to seal off any connection between the cervical contents and neopharynx.
Staple-assisted closure for total larygectomy is not suitable for all laryngeal malignancies. The indications for its usage require a thorough preoperative endoscopic and radiographic examination during which the tumor is confirmed to occupy only the endolarynx, and there is no need for hypopharyngeal or base of tongue exploration. The importance of this approach cannot be overemphasized, as stapler-assisted closure prevents the surgeon from inspecting the internal aspect of the pharynx.
In comparing traditional handsewn technique versus the stapler-assisted technique, studies have shown that the stapler-assisted closure produces fewer incidences of fistula and decreases operative time. After controlling for age, gender, co-morbidities, and TNM status, a study comparing 61 patients who underwent staple-assisted closure to 121 patients who underwent handsewn closure revealed a pharyngocutaneous fistula rate of 4.9% and 19.8%, respectively. (4) One institution's 25-year experience with the linear stapler reviewed 1,415 patients, of whom 98% were radiation failures. (5) The initial fistula rate was 12%, however, as proficiency with the device increased, the rates dropped to 5.5%.
The acceptance of the stapler as a means of closure for total laryngectomies is limited not only by the selection criteria for its application in laryngeal malignancies but also by the comfort of individual head and neck surgeons. The majority of total laryngectomies are reconstructed utilizing the handsewn technique. While this is an important skill to master, its limitations in producing consistent results are exemplified by the wide range of fistula percentages noted in the literature. (6) On the other hand, the stapler provides a consistent closure that is reproducible.
In conclusion, stapler-assisted closure for select types of laryngeal cancers is a proven method of reconstructing the neopharynx and yields decreased fistula rates when compared to handsewn techniques.
(1.) Westmore GA, Knowles MB. The use of a stapling instrument for post-laryngectomy pharyngeal repair. J Laryngol Otol. 1983;97:775-778.
(2.) Talmi YP, Finkelstein Y, Gal R, et al. Use of a linear stapler for postlaryngectomy pharyngeal repair: a preliminary report. Laryngoscope. 1990;100:552-555.
(3.) Agrawal A, Schuller DE. Closed laryngectomy using the automatic linear stapling device. Laryngoscope. 2000;110:1402-1405.
(4.) Calli C, Pinar E, Oncel S. Pharyngocutaneous fistula after total laryngectomy: less common with mechanical stapler closure. Annals of Otology, Rhinology, & Laryngology. 2011;120(5):339-344.
(5.) Bedrin L, Ginsburg G, Horowitz Z, et al. 25 year experience of using a linear stapler in laryngectomy. Head and Neck. 2005;27(12):1073-1079.
(6.) Cavalot AL, Gervasio C, Nazionale G, et al. Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records. Otolaryngology--Head and Neck Surgery. 2000;123:587-592.
Dr. Anand is Attending Head and Neck Surgeon in the Department of Otolaryngology-Head and Neck Surgery at Ochsner Medical Center in Jefferson, LA.
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|Author:||Anand, Akash G.|
|Publication:||The Journal of the Louisiana State Medical Society|
|Article Type:||Clinical report|
|Date:||Mar 1, 2013|
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