Staple-assisted laryngectomy for intractable aspiration☆

Patients 

We treated 4 patients with intractable aspiration using our method (Table 1).

Table 1. Preoperative conditions of 4 patients with intractable aspiration

	Patient Age/Sex	Aspiration Etiology/Comorbidity	Verbal Communication	Periodof Aspiration	Nutrient Delivery	Albumin* (g/dL)	Pharyngeal Culture
	35/M	Cerebral palsy Tracheostomy	Impossible	2Y	NGT	3.8	Ps
							MRSA
	67/M	Recurrent stroke Aphasia	Impossible	1Y1M	NGT	2.8	MRSA
	72/M	Recurrent stroke Severe dysarthria Tracheostomy	Impossible	1Y	NGT	3.4	Ps
	69/M	Neuromuscular disease on a respirator Tracheostomy	Impossible	1Y9M	TPA	3.1	Ps
							MRSA
	*Reference range of serum albumin is 3.8–5.1 g/dL.

Abbreviations: NGT, nasogastric tube feeding; TPA, total parental alimentation; Ps, pseudomonas aeruginosa; MRSA, methicillin-resistant Staphylococcus aureus.

Technique 

Tracheostomy is performed initially in the usual location, if not previously performed. The patient is then anesthetized. The nasal and oral cavity must be carefully irrigated with 10% povidone-iodine solution. After a U-shaped flap elevation in the neck, the larynx is systematically skeletonized. The inferior constrictors of the pharynx are transected. The pharyngeal mucosa of the bilateral pyriform sinuses is dissected from the posterior aspect of ala of the thyroid cartilage. With the hyoid bone exposed, the attachments of the suprahyoid muscles are transected. The submucosal tissue in the suprahyoid region is incised to be secured with staples. During the procedures, care is taken to avoid inadvertent entry into the pharynx. For this purpose, a flexible endoscope is used as a light guide to enable the safe dissection of the pharyngeal mucosa (Fig 1).

View Large Image Download to PowerPoint

Fig. 1. This figure shows the use of an intraluminal light. (A) Note a transnasal endoscope (arrow). We cut the tissue toward the illumination (arrowhead). (B) During suprahyoid dissection, endoscopic transillumination (arrowhead) is a useful guide to identify the appropriate plane of dissection (hyoid bone [arrow]).

At this point, the larynx is connected only by its mucosal attachment. A laryngofissure is then performed to pull the epiglottis away from the staple line, to which the stapling device is later applied (Fig 2).

View Large Image Download to PowerPoint

Fig. 2. This figure shows the laryngofissure approach. (A) A laryngofissure makes it easy to pull the epiglottis (arrow) away from the staple line. A line indicates the staple line. (B) We are pulling the epiglottis (white arrow) with a clamp through a laryngofissure.

The stapling device (Autosuture premium multifire TA 60 long disposable stapler with staples 4.8mm long and 4 mm wide; United States Surgical Corp, Norwalk, CT) is then positioned between the larynx and pharynx. The section of the greater horn of the hyoid bone and the superior horn of the thyroid cartilage allows the device to be positioned close to the larynx for maximize preservation of the normal mucosa. The device is then clamped, and staples are applied by activating the trigger handle mechanism. The larynx is sharply transected during the clamping of the device (Fig 3).

View Large Image Download to PowerPoint

Fig. 3. Staple-assisted laryngectomy. (A) After stapling, the larynx is sharply transected with a scalpel (arrow). (B) Shows that the larynx has already been removed, and a simultaneous closure of the pharyngeal defect has been completed.

Results 

Aspiration was prevented successfully in all patients. A postoperative barium swallow showed there was no pharyngeal fistula or stenosis at the laryngectomy site in any of the 4 patients. All patients started oral intake within 2 weeks, except a 35-year-old man, who had a gastric hemorrhage postoperatively. He started oral intake on postoperative day 27 after the gastric hemorrhage improved. Consequently, 2 patients tolerated oral alimentation postoperatively. The others required nasogastric tube feeding because of insufficient swallowing function.

Discussion 

Our method is profitable for patients with intractable aspiration, for whom no chance of recovery of the laryngeal function is expected. Total laryngectomy is uniformly successful in controlling aspiration2, 3 and is a familiar practice for otolaryngologists. However, the postoperative pharyngocutaneous fistula after laryngectomy is one of the greatest concerns among them. This is the major reason why surgeons do not prefer laryngectomy for the treatment of intractable aspiration.4 A major risk factor of the fistula in patients with laryngeal cancer is radiation therapy,5 whereas in patients with intractable aspiration, there are 2 risk factors that we must take into consideration as seen in this report. First, nutritional failure occurs in the majority of patients with an incompetent larynx.6, 7, 8 Preoperative nutritional failure has a potential to worsen the wound healing. Second, oropharyngeal secretions in most patients with aspiration may contain drug-resistant organisms such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.6, 7, 8, 9 This method constantly provides a reliable watertight closure of the pharyngeal defect without wound contamination by pharyngeal secretions, which is unavoidable in the conventional procedure.

There are more advantages when this method is applied to patients with aspiration. In contrast to laryngeal cancer patients, the pharyngeal mucosa could be preserved as much as possible to allow a tension-free closure and reduce the possibility of a postoperative fistula. The suprahyoid tissue should be incised sufficiently because it is too thick to be secured with staples. In that case, it is not necessary to avoid an entry into the pre-epiglottic space. However, the danger of mucosal perforation during the dissection is not negligible. Perforation is associated with an increase in the postoperative complication rate. With simultaneous endoscope, the surgeon has transmucosal illumination during the dissection. The thickness of the tissue, which should be cut, is clearly estimated. We also had no hesitation in undertaking the laryngofissure to facilitate the use of the stapling device in nonlaryngeal cancer patients. It provides improved visualization and more direct access to the epiglottis. The epiglottis can be pulled out not to be involved in the staple line.

The aim of this method is not to improve swallowing functions but to prevent life-threatening aspiration pneumonia. In this report, all patients had irreversible neurological disturbances in producing voice, such as cerebral palsy, aphasia, severe dysarthria, and the use of mechanical ventilation before surgery. It is not necessary to consider the reversible procedure such as laryngotracheal separation and tracheoesophageal diversion procedure.4 Moreover, they did not have primary tracheoesophageal puncture or voice rehabilitation postoperatively, except a ventilator-dependent 69-year-old man, who occasionally uses the electrolarynx. Two patients still required nasogastric tube feeding because they had weak movement of the tongue and their swallows were poorly coordinated. However, this means that 50% of patients treated surgically were able to eat. In conclusion, this report shows that our method offers certain advantages in the management of patients with intractable aspiration.