Our experience in postoperative management of total laryngectomy — A case series

Introduction

Total laryngectomy (TL) sometimes removes the entire larynx, strap muscles, paratracheal lymphatics, and the ipsilateral thyroid lobe (1). Even if TL often provides the best odds of recovery, the side effects include a permanent tracheostomy and loss of natural voice. TL stands as the preferred treatment for patients with locally advanced laryngeal cancer who have not improved after conservative laryngeal surgery or initial chemoradiation treatment. Because of a change in the therapeutic strategy toward organ preservation—either by nonsurgical intervention or by less invasive methods—TL is declining (2–4).

Following a TL, the patient’s anatomy undergoes substantial changes, impacting essential functions such as breathing, communication, and swallowing. The postoperative care for laryngectomy patients is inherently challenging, demanding a specialized skill set from caregivers and healthcare providers. Failure to acknowledge the limitations of these patients can lead to severe and potentially devastating outcomes. After a total laryngectomy, complications are frequent and expensive; they can impact up to 34% of patients, and up to 26% of patients will require unexpected readmission (5). Post-laryngectomy complications, including pharyngocutaneous fistula (PCF), wound infection, chyle leak, and issues with swallowing and airway, exert a substantial influence on morbidity. These complications lead to extended length of stays and a consequent rise in healthcare expenses. Numerous factors contribute to the occurrence of complications, encompassing prior radiotherapy (RT), preoperative tracheostomy, radical neck dissection, as well as extensive surgical procedures and flap reconstruction. It is important to know about the postoperative complications and care to shorten hospital stays, lower expenses, and enhance patient outcomes.

The purpose of this study was to share our experiences and the challenges we encountered during the postoperative period and to provide insight into risk factors associated with complications and management in the perioperative care of TL patients.

Materials and methods

For this retrospective analysis, we collected all of the case data for 10 patients who were brought to the ENT ward at Rajiv Gandhi Government General Hospital in Chennai and were diagnosed with laryngeal squamous cell carcinoma (SCC) recurrence following the failure of initial definitive RT with or without chemotherapy and without any signs of distant disease. Preoperative assessment included detailed clinical ENT examination, computed tomography (CT) scans, magnetic resonance imaging (MRI) of the neck, positron emission tomography (PET)-CT, and pan endoscopy with biopsy for the recurrent cases.

In total, 10 male patients were included in the study. Notably, 4 out of the 10 had recurrent laryngeal cancer following the failure of the first definitive RT with or without chemotherapy. The duration between the end of radiotherapy and salvage surgery of these four patients was 11, 13, 15, and 18 months. Following the presentation at our institution’s Tumor Board panel, the surgical procedure was scheduled. In total, three surgeons used the same surgical approach for every laryngectomy operation. Every case involved the extramucosal Connell method with an inverted T-shaped suture for pharyngeal closure. Just in cases where the neck nodes were clinically or radiologically positive, radical neck dissection was scheduled. Patients were followed up for 6 months without any preventative flap covering of the pharyngoplasty.

Table 1 shows the analysis of the management of the postoperative period of TL patients under study.

Table 1. Analysis of management of post-operative period of total laryngectomy patients.

Post-operative complications faced

Case 1

A 63-year-old male diagnosed with radio-recurrent malignant growth in the larynx (glottis)—SCC (T3N0M0)—underwent TL and total thyroidectomy. Following the procedure, the patient developed a PCF. To address this complication, a right deltopectoral flap cover was performed 1 month after the TL. Figures 1A, B illustrates the pre- and post-operative images of the flap cover procedure.

Figure 1. (A) Pre-operative image of pharyngocutaneous fistula. (B) Post-operative image of healed flap cover.

Case 2

A 65-year-old male diagnosed with radio-recurrent malignant growth in the larynx (supraglottis)—SCC (T4aN1M0)—underwent TL with total thyroidectomy. Following the procedure, the patient developed a PCF. To address this complication, a right deltopectoral flap cover was performed 1 month after the TL. Figures 2A, B depicts the pre- and post-operative images of the flap cover procedure.

Figure 2. (A) Pre-operative image of pharyngocutaneous fistula. (B) Post-operative image of flap cover.

Case 3

A 62-year-old male diagnosed with radio-recurrent malignant growth in the larynx (glottis)—SCC (T4aN1M0)—underwent a comprehensive surgical intervention, including TL with total thyroidectomy and right radical neck dissection. Subsequently, the patient experienced laryngectomy flap necrosis, prompting the performance of pectoralis major muscle flap cover 1 month after TL. Figures 3A, B displays the pre- and post-operative images of the pectoralis major flap cover procedure.

Figure 3. (A) Pre-operative image of the pharyngocutaneous fistula. (B) Post-operative image of the flap cover.

Case 4

A 65-year-old male diagnosed with malignant growth larynx (supraglottis) (T4aN1M0)—SCC—underwent TL with total thyroidectomy with right radical neck dissection and subsequently developed wound dehiscence for which secondary suturing was done 15 days after total laryngectomy.

Figure 4A illustrates the wound dehiscence, and Figure 4B displays the wound after the secondary suturing procedure.

Figure 4. (A) Pre-operative image of the wound dehiscence. (B) Post-operative image of the wound after secondary suturing.

Results

In total, 10 patients were included in the study. It included six primary TL (PTL) and four salvage TL (STL). The mean age of presentation was 63.9 years. All the patients included were male. Various factors were considered in the study to assess the outcome of the surgery postoperatively. It included patient factors such as age and comorbidity, treatment-associated factors such as radiation status, day of feed started, postoperative complications, and management. Among the 10 patients, four experienced postoperative complications, with three of them being radio-recurrent cases. All four patients with operative complications had underlying health conditions with three being known diabetic patients and one being hypertensive. Ryle’s tube feed was started on the second day of the postoperative period for all the patients and oral feeds on the 11th day of the postoperative period. Higher-order antibiotics were started preoperatively for all the patients, and the duration of antibiotic administration varied depending upon the wound status. The common complications we encountered were PCF, which developed in three patients followed by wound dehiscence in one patient. Flap cover was performed for three patients out of which two were deltopectoral flap and one was pectoralis major muscle flap. All the reconstructions were done after the complications developed. All the flap cover reconstructed patients had a longer duration of antibiotics and postoperative time but had good wound closure.

Figure 5 represents the number of PTL and STL operated.

Figure 5. Primary TL vs salvage TL.

Figure 6 compares the occurrence of complications in PTL and salvage TL.

Figure 6. Post-operative complications in primary TL vs salvage TL.

Discussion

The contemporary management of advanced laryngeal carcinoma has undergone a significant transformation, primarily driven by the intensification of nonsurgical treatments. Despite this shift, TL continues to play a crucial role, whether as a primary intervention for advanced tumors, salvage therapy, or in cases of a dysfunctional larynx resulting from prior treatments (1, 3, 6). However, there is still limited availability of outcomes data from extensive patient samples treated with TL in the current era (7–9).

Early complications after TL include bleeding/hematoma, infection, wound breakdown, and PCF formation. Corticosteroids should be given to reduce airway compromise and postoperative edema (5) in addition to hematoma or seroma, which should be surgically removed right away, and wound infection brought on by the wound’s perioperative exposure to germs, which can be reduced with broad-spectrum antibiotic use. The reported incidence of PCF is 14.3% for PTL and 27.6% for STL, according to the meta-analysis published in the international literature (10). Hasan et al. (11) stated that the total complication rate reported across the 25 studies was 67.5%.

Various factors can lead to postoperative complications like—

1. Preop hemoglobin levels,

2. Preop albumin levels,

3. Comorbidities,

4. Preop radiation,

5. Age, and

6. T-shaped closure vs vertical closure—vertical closure of the neopharynx in laryngectomy surgery showed a higher risk for developing a pseudo-diverticulum than “T”-shaped closure.

The prevalent and commonly reported complication following STL is the occurrence of a PCF. The systematic review reveals that it occurs in around a quarter of cases (28.9%) of all patients who undergo STL (11).

Preoperative radiation was linked in a meta-analysis to an increased relative risk of PCF (12). Preoperative hypoalbuminemia and comorbidities—diabetes mellitus in particular—were shown by Boscolo-Rizzo et al. to be strong predictors of PCF development (5, 13). To reduce the risk of PCF and avoid a delayed TL, optimization of comorbidities and correction of nutritional deficiencies with enteral or parenteral nutritional supplements should be attained as early as possible (5, 14). Given the high morbidity of PCF, STL stands out as one of the most common indications within head and neck surgery for regional or free tissue reconstruction (7, 15). The implementation of vascularized tissue reconstruction for the neopharynx, even in an onlay manner, has significantly diminished the occurrence of PCF and associated wound complications (14, 16, 17). Other complications, such as wound infection, dehiscence, and bleeding, are less frequently reported and are likely underreported. Late complications encompass stomal stenosis, pharyngoesophageal stricture/stenosis, and hypothyroidism (2).

Conclusion

Postoperative management of TL patients is highly variable. Assessing the vascularity and viability of the skin flap preoperatively will give better outcomes in these patients. In our study, about one-third of TL patients experienced problems, especially those with risk factors for poor wound healing such as comorbidities like diabetes mellitus and radiation. It would be prudent that in cases where complications are expected, prophylactic PMMC onlay flap cover can be done to augment the anastomosis. Expectedly, hospital stay, antibiotic duration, and time to initiate oral feeds were longer among reconstructed patients (11, 18). Moreover, a multidisciplinary head and neck team should oversee patients, with extra assistance from speech and swallowing therapists, dietitians, psychiatrists, dermatologists, and enough counseling regarding potential side effects of TL both before and after surgery (11, 19).

Authors’ contributions

VS: concept and design, manuscript preparation, and treating otolaryngologist. NK: revision of manuscript and treating otolaryngologist. SS: revision of manuscript and treating otolaryngologist. MV: revision of manu- script and treating otolaryngologist. TK: resident in charge. PR: resident in charge.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References