Near total laryngectomy: a versatile approach for voice restoration in advanced T3 and T4 laryngeal cancer: functional results and survival

Creation of a tunneled mucosal shunt between the trachea and pharynx that is controlled by remaining intrinsic laryngeal musculature with its nerve supply is an acceptable voice restoration procedure for advanced T3 and T4 laryngeal cancer. Such a tunnel will allow unilateral direction of air from lung to pharynx during phonation and will prevent aspiration since deglutition is a vagal mediated response which will induce contraction of tubed laryngeal musculature preventing aspiration. We previously reported our preliminary experience with the technique and we adopted the voice restoration approach based on the concept of the near total laryngectomy thereafter, Forty five patients with histologically proven squamous cell carcinoma of the larynx were included in this study [between January 1998 and February 2001]. They were 42 males and 3 females with a mean age of 52.6 years. Criteria for selection were a normal vocal process and arytenoid cartilage on the opposite side of the lesion as evidenced by endoscopy and CT scan with no major subglottic extension. In two patients supraglottic laryngectomy was carried out and in four other patients, complete tumor extirpation necessitated total laryngectomy. Accordingly, near total Iaryngectomy was carried out in the remaining 39 patients. Following a near total laryngectomy, where all laryngeal mucosa and cartilages are resected sparing the contralateral arytenoid cartilage with the overlying mucosa and surrounding musculature, the shunt was created by tubing the remaining mucosa with augmentation by pyriform sinus mucosa if necessary. The resulting tube was fashioned over 14 FG catheter for diameter control only and the remaining muscles were sutured over the tube. A permanent tracheostomy was established. Voice training was started postoperatively following resumption of oral feeding. Only one patient died in the immediate postoperative period due to massive myocardial infarction. One patient developed reactionary hemorrhage that was explored and controlled. Minor salivary fistula developed in nine patients [23.1%] and all were managed conservatively, none required intervention. Two patients [7.6%] had a retracted tracheostomy that required refashioning. Thirteen patients [33.3%] suffered transient aspiration that resolved spontaneously, none required intervention. Six patients developed recurrent disease [15.8%]. The overall two year disease free survival was 76%. None of the cases developed laryngeal mucosal recurrences, Intelligible speech was achieved in 31 patients [81.6%]. In the seven patients with shunt failure, insertion of a one way valve was successful in five patients in restoring a good quality voice. Near total laryngectomy is an oncologically safe procedure with acceptable complications that are well tolerated. It represents an ideal solution for patients with advanced T3 and T4 laryngeal cancer. Voice quality is very good and it does not require further management as is the ease with prosthetic voice shunt valves

Anatomical classification and results of surgical treatment for adenocarcinoma of the cardia

One hundred and eight patients with histologically proven adenocarcinoma of the cardia were treated. The Siewert's classification was used to categorize these lesions into three types according to the relation of the tumor mass to the anatomical cardia. Total esophagectomy with resection of lymph nodes in the paracardial and posterior mediastinal regions was carried out for all type I lesions and a total gastrectomy with D2 lymphadenectomy as described for gastric cancer was the principal procedure for type III disease. For type II disease, a D2 lymphadenectomy was the essential part of the procedure in addition to either total gastrectomy or total esophagectomy based on the tumor extent. The average follow up period was 15-108 months [median 42.8 +/- 13.7 months]. The analysis included the surgical approaches used, the extent of resection, 30-day death rate, postoperative complications, depth of tumor invasion [pT], nodal status in resected specimens and the overall survival. The study concluded that adenocarcinoma of the cardia continues to carry a dismal prognosis. The topographic and anatomical classification of these lesions provides a useful tool for selecting the surgical approach and guide the extent of resection

radial forearm flap in reconstruction of head and neck cancer defects

The radial forearm fasciocutaneous flap possesses several criteria that favours its use in head and neck reconstruction: thin pliable skin, large caliber of vascular pedicle with possible inclusion of tendons or bone with flap harvesting. The absence of bulk and sufficient pedicle length are particularly important for intraoral reconstruction. Twenty cases underwent primary reconstruction of their head and neck defects with the radial forearm flap. There were 12 males and 8 females. The tongue was the most common site [12 cases]. Four cases had carcinoma of the lip and the remaining four had their primary in the facial skin. Flap design was modified according to the defect; a bibbed flap was used to reconstruct tongue and floor of mouth defects [12 cases]. Palmaris longus tendon was used to fashion a commissure [two cases]. Three cases had complete loss of their flaps due to venous obstruction. In two cases, partial loss of the flap was evident, they were managed by debridement of the gangrenous area. The overall success rate was 85%. Donor site morbidity consisted of loss of split thickness graft in two cases that required regrafting. Functional and aesthetic results were satisfactory. The radial forearm flap has a established role in the management of head and neck cancer patients; and a success rate of over 85% is expected which should improve with experience in the technique of microvascular anastomosis