The Laryngoscope C 2013 The American Laryngological, V
Rhinological and Otological Society, Inc.
Voice Outcomes Following Reconstruction of Laryngopharyngectomy Defects Using the Radial Forearm Free Flap and the Anterolateral Thigh Free Flap Peter C. Revenaugh, MD; P. Daniel Knott, MD; Daniel S. Alam, MD; Joann Kmiecik, MA; Michael A. Fritz, MD Objectives/Hypothesis: Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes. Study Design: Retrospective cohort study. Methods: We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted. Results: Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications. Conclusions: These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results. Key Words: Laryngopharyngectomy, tracheoesophageal prosthesis, anterolateral thigh free flap, radial forearm free flap, tracheoesophageal speech. Level of Evidence: 2b. Laryngoscope, 124:397–400, 2014
INTRODUCTION Management of upper aerodigestive tract malignancies often alters vital functions such as speech and swallowing. Total laryngectomy with or without pharyngectomy can be reconstructed in a number of ways, but voice restoration usually occurs via creation of a fistula and placement of a tracheoesophageal voice prosthesis. Following chemoradiation protocol failures, free tissue transfer is commonly employed during salvage surgery, when the defect may not be amenable to From the Head and Neck Institute, Cleveland Clinic (P.C.R., D.S.A., Cleveland, Ohio; and the Department of Otolaryngology (D.K.), UCSF Medical Center, San Francisco, California, U.S.A. Editor’s Note: This Manuscript was accepted for publication September 7, 2012. Presented at the Combined Otolaryngology Spring Meetings, San Diego, California, U.S.A., April 18–22, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Michael A. Fritz, MD, Head and Neck Institute, Department of Otolaryngology—Head and Neck Surgery, Cleveland Clinic, 9500 Euclid Ave., Desk A71, Cleveland, OH 44195. E-mail: [email protected] J.K., M.A.F.),
DOI: 10.1002/lary.23785
Laryngoscope 124: February 2014
primary closure or there is high risk of fistula formation.1 Various donor flaps have been proposed including radial forearm, anterolateral thigh, jejunal, and gastroomental free flaps. Although swallowing abilities after free tissue reconstruction have generally been acceptable, voice outcomes have been considered suboptimal by some.2 Tracheoesophageal prosthesis (TEP) technology is well studied, yet surgical techniques in reference to voice outcomes lack consistent measures.3,4 Radial forearm free flaps (RFFFs) have been successfully used for reconstruction of laryngopharyngectomy defects for many years. Previously, Alam et al. reported no difference between primary closure and RFFF reconstruction when comparing standard speech outcome measures.5 The anterolateral thigh free flap (ALT) has been used with increasing frequency for the last several years for laryngopharyngectomy reconstruction.6 To date, there have been no studies illustrating voice outcomes at a single institution with the two most commonly used cutaneous free flaps. The purpose of this study was to retrospectively analyze the voice outcomes of patients who had a TEP following reconstruction of laryngopharyngectomy defects with either RFFF or ALT. Revenaugh et al.: Voice Outcomes After RFFF or ALT
397
MATERIALS AND METHODS A retrospective chart review was performed to identify consecutive patients who underwent laryngopharyngectomy between April 2001 and August 2010 and had reconstruction with either RFFF or ALT flaps. The institutional review board of the Cleveland Clinic approved the study. All flaps were performed in a two-team fashion with the reconstructive surgeon harvesting simultaneously with the extirpative team to minimize operative time. Decision for free flap choice was generally based upon surgeon preference; in several cases, the defect was deemed too large for a standard forearm flap closure. Twenty patients underwent RFFF reconstruction of their laryngopharyngectomy defects. Surgically, the radial forearm flap patients had a flap raised in the standard method following a preoperative Allen’s test to confirm adequate perfusion via the ulnar artery. The flap was designed with a trapezoidal skin paddle with a distal width of between 6 and 8 cm that was used for the cervicoesophageal anastomosis. ALT reconstruction was performed in 22 patients with similar laryngopharyngectomy defects. This flap was harvested after locating cutaneous perforators from the circumflex femoral system and dissecting them to isolate the vascular pedicle between the rectus femoris and vastus lateralis muscles proximally. A minimal amount of vastus lateralis muscle was included in the flap, as it was harvested using perforator techniques. Excess adipose tissue was trimmed before flap inset. If a remnant strip of viable mucosa remained in the posterior pharynx, this was incorporated within the closure. Otherwise, the flap was tubed upon itself. In all cases, flaps were revascularized with microvascular anastomoses performed with 9-0 monofilament sutures with the aid of an operating microscope. Extirpative preference dictated the performance of primary or secondary TEP. All patients eventually underwent voice restoration with the Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA). A single speech therapist (J.K.) performed all speech assessments. The voice outcomes of the two cohorts were compared using reproducible, standardized measurements of vocal function and speech. Tools included maximum sustained phonation time (MSP) in seconds and fluent count in seconds. MSP was measured using an average of at least five attempts to sustain the sound ‘‘ah’’ for as long as possible on a single exhalation. Fluent count was measured as the highest number attained when counting upward on a single breath. A fluent count of 15 is considered excellent for TEP speech. As another method of intelligibility during everyday speech, patients were asked to repeat sentences with standard number of syllables. The maximum attained number of voiced syllables with good speech cadence was recorded. These variables were assessed af-
TABLE I. Age, Sex, and Radiation Therapy Statistics Between Groups.
Factor
Age, mean (range)
Radial Forearm Free Flap, n ¼ 20
Anterolateral Thigh Free Flap, n ¼ 22
P Value
62.5 (46–79)
63.4 (39–81)
.390
Male Sex, % No. undergoing preoperative XRT (%)
75 14 (70)
77 15 (68)
.433 .451
No. undergoing postoperative XRT (%)
6 (30)
5 (25)
.301
P < .05 was considered significant. XRT ¼ radiation.
Laryngoscope 124: February 2014
398
TABLE II. Operative and Postoperative Reconstruction Statistics.
Factor 2
Size (cm )ze (cm Circumferential flap (%) Hospital length of stay, d (mean) Primary TEP (%) Secondary TEP (%)
Radial Forearm Free Flap, n ¼ 20
Anterolateral Thigh Free Flap, n ¼ 22
P Value
125.1 8 (40)
113.6 7 (32)
.160 .295
9.45
11.35
.245
9 (45) 11 (55)
18 (81) 4 (18.2)
.006 .006
Postoperative leak (%)
1 (5)
2 (9)
.309
Stoma stenosis (%) Esophageal dilation (%)
2 (10) 7 (35)
3 (13.6) 8 (36)
.362 .464
P < .05 was considered significant. TEP ¼ tracheoesophageal prosthesis.
ter an average of two TEP teaching and rehabilitation appointments. Standard protocol included TEP fitting 4 to 6 weeks after primary TEP and 7 to 14 days after secondary TEP. Evaluation occurred an average of 29.3 days after tracheoesophageal fistula creation. Postoperative complications were also recorded. Postoperative leaks were defined as any duration of pharyngocutaneous fistula. Stoma stenosis was defined as stenosis at the tracheal stoma necessitating a surgical revision. Swallowing function was evaluated based upon the need for postoperative dilation and whether or not there was stricture identified on imaging or endoscopy. Surgical groups were compared using means and standard deviations for the data sets. A nonparametric Wilcoxon rank sum test was used to compare continuous measures of interest between the two groups. Box plots were used to compare each of the four outcomes. A significance level of .05 was assumed for all tests, and analysis was performed using SAS software (SAS Inc., Cary, NC).
RESULTS Patients in retrospective RFFF or ALT groups underwent stated reconstruction immediately following laryngopharyngectomy. There were 20 patients in the RFFF group and 22 in the ALT group. Mean age at operation was 62.5 years (range, 46–79) for the RFFF group and 63.4 years (range, 39–81) for the ALT group. No differences were noted in the mean age or the sex distribution between the two groups (Table I). All patients underwent total laryngectomy with total or near total pharyngectomy. All patients in the RFFF underwent radiation therapy either pre- or postoperatively, and two of the 22 ALT patients did not undergo radiation therapy. (Table I). Preoperative conventional radiation was administered in 70% and 68% of RFFF patients and ALT patients, respectively; 30% of RFFF patients and 25% of ALT patients had postoperative radiation therapy. All patients in both groups were treated for squamous cell carcinoma, and 80% of patients in each group were treated for recurrent disease. The size of the cutaneous portion of the flaps utilized did not differ significantly, nor did the amount of tubed free flaps (Table II). There was also no difference Revenaugh et al.: Voice Outcomes After RFFF or ALT
in the mean hospital length of stay between the two groups. There were no instances of microvascular compromise or failure. Rates of postoperative leak, fistula, or stoma stenosis did not differ between the two groups (Table II). The number of patients eventually requiring esophageal dilation for symptomatic dysphagia also did not differ between the two groups. Those patients necessitating dilation underwent this procedure an average of 7.3 months following initial surgery, after the voice assessment had been accomplished. Primary TEP was performed in 45% and 81.8% of the RFFF and ALT patients, respectively. This finding was significantly different between the two groups (Table II). Voice outcomes were assessed using the four outcomes described. There was no statistically significant difference between the two groups using any of the voice measurement parameters (Table III).
DISCUSSION The treatment options for pharyngoesophageal reconstruction have improved with the advent of microvascular free tissue transfer. Before microvascular techniques, pharyngoesophageal reconstruction was associated with high perioperative morbidity, including fistula, wound breakdown, great vessel rupture, and death. With more frequent use of ‘‘organ preservation’’ radiation or chemoradiation protocols, microvascular reconstruction has been increasingly employed in salvage cases where the postradiation changes, large defect, and patient comorbidities may preclude optimal wound healing for primary closure. Fasciocutaneous, cutaneous, or enteric flaps are now the mainstay of microvascular reconstruction for pharyngoesophageal defects. Radial forearm and jejunal flaps have commonly been utilized for this type of reconstruction owing to their reliability and ability to create a tubed conduit similar to that of the esophagus. The RFFF and ALT are preferentially used at our institution over the jejunal flap because of the ease of harvest, reliability, possibly better voice outcomes, and avoidance of a laparotomy for harvest. Currently, our institution performs the majority of reconstructions using either the RFFF or ALT technique. Since the advent of the Blom-Singer prosthesis in 1980, tracheoesophageal speech has been the preferred method of voice rehabilitation. Although surgical techniques have evolved, there are still few studies objectively assessing voice parameters. When voice outcomes are reported in reference to free flap reconstruction, many authors report presence or absence of voice and rates of vocal use as the primary method of communication. Objective voice parameters have previously been used to compare RFFF closure with primary closure and have found no difference in the quality of attainable voice.5 Mendelsohn et al. compared jejunal free flap closure and primary closure and found inferior qualitative measures in the jejunal flap group.7 Laryngoscope 124: February 2014
TABLE III. The Relationship Between Surgical Group and the Four Voice Outcomes of Interest. Radial Forearm Free Flap
Factor
Anterolateral Thigh Free Flap
P Value
No.
Mean (SD)
No.
Mean (SD)
MSP, s Syllable no.
20 20
9.9 (3.9) 7.5 (1.9)
22 20
9.3 (3.6) 8.3 (3.4)
.93 .77
Fluent count, s
20
9.4 (4.0)
21
8.6 (4.5)
.65
Intelligibility
20
6.2 (1.8)
22
5.9 (2.3)
.66
P < .05 was considered significant. MSP ¼ maximum sustained phonation time; SD ¼ standard deviation.
Given the high rate of microvascular success, the ideal flap should offer low donor site morbidity, ease of harvest, and low fistula rates and be associated with superior speech production. Fasciocutaneous or cutaneous free flaps have demonstrated superior voice outcomes when compared to enteric flaps, and several authors have supported the use of fasciocutaneous flaps for pharyngoesophageal reconstruction in a panel discussion.8 Lewin et al. reported that 78% of ALT versus 25% of jejunal patients in their study used TEP speech for communication.9 However, in their study, only 30% of patients in each group had a TEP placed, and there was no mention of the voice quality. The disparity between outcomes for each flap type may be due to the asynchronous contractions of the jejunal and native esophageal segment during peristalsis or the secretory nature of the jejunum, leading to a voice characterized as ‘‘wet’’ and low in pitch. Few studies regarding free tissue reconstruction of laryngopharyngectomy defects include quantified voice measures. To our knowledge, this is the first study to compare the two most common cutaneous reconstructive techniques in regard to quantifiable voice outcomes. We found no difference in MSP, fluent count, number of syllables attained, and rating of observer intelligibility between RFFF and ALT techniques. The parameters used to assess the voice in our study have consistently been used by our group in postlaryngectomy voice rehabilitation and are acceptable standards as described by Blom and Singer.10 Further, the rates of postoperative and donor site complications did not differ between the two groups. These data would suggest that either technique may afford the patient a quality voice restoration without additional morbidity and that each flap should be used based on the defect size, geometry, and surgeon comfort. In the RFFF group, there was a significantly higher number of patients undergoing secondary TEP placement. This was due to practice patterns of the extirpative surgeon who performed many of the cases in the RFFF group. Post hoc analysis did not reveal a significant difference in voice parameters for those patients undergoing primary versus secondary TEP placement (Table IV). This finding is consistent with a recent study comparing primary and secondary TEP placement in Revenaugh et al.: Voice Outcomes After RFFF or ALT
399
TABLE IV. The Relationship Between Primary or Secondary Tracheoesophageal Prosthesis Placement and Voice Outcomes of Interest. Primary TEP
Secondary TEP
Factor
No.
Mean (SD)
No.
Mean (SD)
P Value
MSP, s
15
9.3 (3.9)
27
9.7 (3.7)
.51
Syllable no.
15
8.1 (2.0)
25
7.8 (3.1)
.35
Fluent count, s Intelligibility
15 15
9.1 (4.1) 6.2 (2.0)
26 27
8.9 (4.4) 5.9 (2.1)
.53 .56
P < .05 was considered significant. MSP ¼ maximum sustained phonation time; SD ¼ standard deviation; TEP ¼ tracheoesophageal prosthesis.
free flap reconstruction of laryngopharyngectomy defects.11 To maximize quality of life improvement with more rapid voice rehabilitation, we are now performing immediate prosthesis fitting as opposed to waiting until 3 to 4 weeks postreconstruction. As with retrospective studies, there are several inherent limitations in this study. Although all patients were evaluated by a single speech pathologist, which allowed for consistency in the assessment, she was not specifically blinded as to the type of reconstruction, introducing a potential for bias. However, the data collection occurred before the study proposal. Surgical parameters that could affect voice outcome, such as size of pharyngeal remnant, base of tongue, and remnant esophageal lengths were not available. There was no significant difference in the number of patients in each group requiring dilation for symptomatic dysphagia. As mentioned, the patients underwent this dilation an average of 7.3 months after their initial surgery; therefore, development of stricture was not presumed to influence initial voice assessment. This was confirmed by post hoc analysis that indicated no difference in the voice parameters of those patients who went on to require dilation. In a future prospective study, assessment of voice parameters before and after dilation may be beneficial. Patient postoperative motivation and degree of speech practice were also not quantifiable, accounting for somewhat large standard deviations within the parameters measured. Finally, patient self-assessments
Laryngoscope 124: February 2014
400
and quality-of-life measurements were not included. Individual patients have different voice expectations and requirements. Therefore, perceptions of voice quality may differ from patient to patient. Because objective voice measures do not necessarily correlate with selfassessments, it would be beneficial in future research to include patient-generated assessments.
CONCLUSION With the emergence of reliable fasciocutaneous methods for pharyngoesophageal reconstruction, it is important to ensure patients may have similar functional outcomes. Our study did not identify differences in voice quality measures between the two methods of reconstruction. Patients can attain high-quality, usable, and consistent voice function, regardless of whether an RFFF or ALT flap is performed.
BIBLIOGRAPHY 1. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope 2007;117:781–784. 2. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope 2006; 116:173–181. 3. Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ, van Tinteren H. A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution’s experience with consistent application of provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 2000;126:1320–1328. 4. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg 2008;61:1148–1156. 5. Alam DS, Vivek PP, Kmiecik J. Comparison of voice outcomes after radial forearm free flap reconstruction versus primary closure after laryngectomy. Otolaryngol Head Neck Surg 2008;139:240–244. 6. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer 2010;116:1718–1724. 7. Mendelsohn M, Morris M, Gallagher R. A comparative study of speech after total laryngectomy and total laryngopharyngectomy. Arch Otolaryngol Head Neck Surg 1993;119:508–510. 8. Robb GL, Lewin JS, Deschler DG, Haughey BH, Brown DH, Langmore SE. Speech and swallowing outcomes in reconstructions of the pharynx and cervical esophagus. Head Neck 2003;25:232–244. 9. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after circumferential pharyngoesophageal reconstruction. Laryngoscope 2005; 115:1266–1271. 10. Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol 1985;111:182–186. 11. Sinclair CF, Rosenthal EL, McColloch NL, et al. Primary versus delayed tracheoesophageal puncture for laryngopharyngectomy with free flap reconstruction. Laryngoscope 2011;121:1436–1440.
Revenaugh et al.: Voice Outcomes After RFFF or ALT
Rhinological and Otological Society, Inc.
Voice Outcomes Following Reconstruction of Laryngopharyngectomy Defects Using the Radial Forearm Free Flap and the Anterolateral Thigh Free Flap Peter C. Revenaugh, MD; P. Daniel Knott, MD; Daniel S. Alam, MD; Joann Kmiecik, MA; Michael A. Fritz, MD Objectives/Hypothesis: Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes. Study Design: Retrospective cohort study. Methods: We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted. Results: Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications. Conclusions: These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results. Key Words: Laryngopharyngectomy, tracheoesophageal prosthesis, anterolateral thigh free flap, radial forearm free flap, tracheoesophageal speech. Level of Evidence: 2b. Laryngoscope, 124:397–400, 2014
INTRODUCTION Management of upper aerodigestive tract malignancies often alters vital functions such as speech and swallowing. Total laryngectomy with or without pharyngectomy can be reconstructed in a number of ways, but voice restoration usually occurs via creation of a fistula and placement of a tracheoesophageal voice prosthesis. Following chemoradiation protocol failures, free tissue transfer is commonly employed during salvage surgery, when the defect may not be amenable to From the Head and Neck Institute, Cleveland Clinic (P.C.R., D.S.A., Cleveland, Ohio; and the Department of Otolaryngology (D.K.), UCSF Medical Center, San Francisco, California, U.S.A. Editor’s Note: This Manuscript was accepted for publication September 7, 2012. Presented at the Combined Otolaryngology Spring Meetings, San Diego, California, U.S.A., April 18–22, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Michael A. Fritz, MD, Head and Neck Institute, Department of Otolaryngology—Head and Neck Surgery, Cleveland Clinic, 9500 Euclid Ave., Desk A71, Cleveland, OH 44195. E-mail: [email protected] J.K., M.A.F.),
DOI: 10.1002/lary.23785
Laryngoscope 124: February 2014
primary closure or there is high risk of fistula formation.1 Various donor flaps have been proposed including radial forearm, anterolateral thigh, jejunal, and gastroomental free flaps. Although swallowing abilities after free tissue reconstruction have generally been acceptable, voice outcomes have been considered suboptimal by some.2 Tracheoesophageal prosthesis (TEP) technology is well studied, yet surgical techniques in reference to voice outcomes lack consistent measures.3,4 Radial forearm free flaps (RFFFs) have been successfully used for reconstruction of laryngopharyngectomy defects for many years. Previously, Alam et al. reported no difference between primary closure and RFFF reconstruction when comparing standard speech outcome measures.5 The anterolateral thigh free flap (ALT) has been used with increasing frequency for the last several years for laryngopharyngectomy reconstruction.6 To date, there have been no studies illustrating voice outcomes at a single institution with the two most commonly used cutaneous free flaps. The purpose of this study was to retrospectively analyze the voice outcomes of patients who had a TEP following reconstruction of laryngopharyngectomy defects with either RFFF or ALT. Revenaugh et al.: Voice Outcomes After RFFF or ALT
397
MATERIALS AND METHODS A retrospective chart review was performed to identify consecutive patients who underwent laryngopharyngectomy between April 2001 and August 2010 and had reconstruction with either RFFF or ALT flaps. The institutional review board of the Cleveland Clinic approved the study. All flaps were performed in a two-team fashion with the reconstructive surgeon harvesting simultaneously with the extirpative team to minimize operative time. Decision for free flap choice was generally based upon surgeon preference; in several cases, the defect was deemed too large for a standard forearm flap closure. Twenty patients underwent RFFF reconstruction of their laryngopharyngectomy defects. Surgically, the radial forearm flap patients had a flap raised in the standard method following a preoperative Allen’s test to confirm adequate perfusion via the ulnar artery. The flap was designed with a trapezoidal skin paddle with a distal width of between 6 and 8 cm that was used for the cervicoesophageal anastomosis. ALT reconstruction was performed in 22 patients with similar laryngopharyngectomy defects. This flap was harvested after locating cutaneous perforators from the circumflex femoral system and dissecting them to isolate the vascular pedicle between the rectus femoris and vastus lateralis muscles proximally. A minimal amount of vastus lateralis muscle was included in the flap, as it was harvested using perforator techniques. Excess adipose tissue was trimmed before flap inset. If a remnant strip of viable mucosa remained in the posterior pharynx, this was incorporated within the closure. Otherwise, the flap was tubed upon itself. In all cases, flaps were revascularized with microvascular anastomoses performed with 9-0 monofilament sutures with the aid of an operating microscope. Extirpative preference dictated the performance of primary or secondary TEP. All patients eventually underwent voice restoration with the Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA). A single speech therapist (J.K.) performed all speech assessments. The voice outcomes of the two cohorts were compared using reproducible, standardized measurements of vocal function and speech. Tools included maximum sustained phonation time (MSP) in seconds and fluent count in seconds. MSP was measured using an average of at least five attempts to sustain the sound ‘‘ah’’ for as long as possible on a single exhalation. Fluent count was measured as the highest number attained when counting upward on a single breath. A fluent count of 15 is considered excellent for TEP speech. As another method of intelligibility during everyday speech, patients were asked to repeat sentences with standard number of syllables. The maximum attained number of voiced syllables with good speech cadence was recorded. These variables were assessed af-
TABLE I. Age, Sex, and Radiation Therapy Statistics Between Groups.
Factor
Age, mean (range)
Radial Forearm Free Flap, n ¼ 20
Anterolateral Thigh Free Flap, n ¼ 22
P Value
62.5 (46–79)
63.4 (39–81)
.390
Male Sex, % No. undergoing preoperative XRT (%)
75 14 (70)
77 15 (68)
.433 .451
No. undergoing postoperative XRT (%)
6 (30)
5 (25)
.301
P < .05 was considered significant. XRT ¼ radiation.
Laryngoscope 124: February 2014
398
TABLE II. Operative and Postoperative Reconstruction Statistics.
Factor 2
Size (cm )ze (cm Circumferential flap (%) Hospital length of stay, d (mean) Primary TEP (%) Secondary TEP (%)
Radial Forearm Free Flap, n ¼ 20
Anterolateral Thigh Free Flap, n ¼ 22
P Value
125.1 8 (40)
113.6 7 (32)
.160 .295
9.45
11.35
.245
9 (45) 11 (55)
18 (81) 4 (18.2)
.006 .006
Postoperative leak (%)
1 (5)
2 (9)
.309
Stoma stenosis (%) Esophageal dilation (%)
2 (10) 7 (35)
3 (13.6) 8 (36)
.362 .464
P < .05 was considered significant. TEP ¼ tracheoesophageal prosthesis.
ter an average of two TEP teaching and rehabilitation appointments. Standard protocol included TEP fitting 4 to 6 weeks after primary TEP and 7 to 14 days after secondary TEP. Evaluation occurred an average of 29.3 days after tracheoesophageal fistula creation. Postoperative complications were also recorded. Postoperative leaks were defined as any duration of pharyngocutaneous fistula. Stoma stenosis was defined as stenosis at the tracheal stoma necessitating a surgical revision. Swallowing function was evaluated based upon the need for postoperative dilation and whether or not there was stricture identified on imaging or endoscopy. Surgical groups were compared using means and standard deviations for the data sets. A nonparametric Wilcoxon rank sum test was used to compare continuous measures of interest between the two groups. Box plots were used to compare each of the four outcomes. A significance level of .05 was assumed for all tests, and analysis was performed using SAS software (SAS Inc., Cary, NC).
RESULTS Patients in retrospective RFFF or ALT groups underwent stated reconstruction immediately following laryngopharyngectomy. There were 20 patients in the RFFF group and 22 in the ALT group. Mean age at operation was 62.5 years (range, 46–79) for the RFFF group and 63.4 years (range, 39–81) for the ALT group. No differences were noted in the mean age or the sex distribution between the two groups (Table I). All patients underwent total laryngectomy with total or near total pharyngectomy. All patients in the RFFF underwent radiation therapy either pre- or postoperatively, and two of the 22 ALT patients did not undergo radiation therapy. (Table I). Preoperative conventional radiation was administered in 70% and 68% of RFFF patients and ALT patients, respectively; 30% of RFFF patients and 25% of ALT patients had postoperative radiation therapy. All patients in both groups were treated for squamous cell carcinoma, and 80% of patients in each group were treated for recurrent disease. The size of the cutaneous portion of the flaps utilized did not differ significantly, nor did the amount of tubed free flaps (Table II). There was also no difference Revenaugh et al.: Voice Outcomes After RFFF or ALT
in the mean hospital length of stay between the two groups. There were no instances of microvascular compromise or failure. Rates of postoperative leak, fistula, or stoma stenosis did not differ between the two groups (Table II). The number of patients eventually requiring esophageal dilation for symptomatic dysphagia also did not differ between the two groups. Those patients necessitating dilation underwent this procedure an average of 7.3 months following initial surgery, after the voice assessment had been accomplished. Primary TEP was performed in 45% and 81.8% of the RFFF and ALT patients, respectively. This finding was significantly different between the two groups (Table II). Voice outcomes were assessed using the four outcomes described. There was no statistically significant difference between the two groups using any of the voice measurement parameters (Table III).
DISCUSSION The treatment options for pharyngoesophageal reconstruction have improved with the advent of microvascular free tissue transfer. Before microvascular techniques, pharyngoesophageal reconstruction was associated with high perioperative morbidity, including fistula, wound breakdown, great vessel rupture, and death. With more frequent use of ‘‘organ preservation’’ radiation or chemoradiation protocols, microvascular reconstruction has been increasingly employed in salvage cases where the postradiation changes, large defect, and patient comorbidities may preclude optimal wound healing for primary closure. Fasciocutaneous, cutaneous, or enteric flaps are now the mainstay of microvascular reconstruction for pharyngoesophageal defects. Radial forearm and jejunal flaps have commonly been utilized for this type of reconstruction owing to their reliability and ability to create a tubed conduit similar to that of the esophagus. The RFFF and ALT are preferentially used at our institution over the jejunal flap because of the ease of harvest, reliability, possibly better voice outcomes, and avoidance of a laparotomy for harvest. Currently, our institution performs the majority of reconstructions using either the RFFF or ALT technique. Since the advent of the Blom-Singer prosthesis in 1980, tracheoesophageal speech has been the preferred method of voice rehabilitation. Although surgical techniques have evolved, there are still few studies objectively assessing voice parameters. When voice outcomes are reported in reference to free flap reconstruction, many authors report presence or absence of voice and rates of vocal use as the primary method of communication. Objective voice parameters have previously been used to compare RFFF closure with primary closure and have found no difference in the quality of attainable voice.5 Mendelsohn et al. compared jejunal free flap closure and primary closure and found inferior qualitative measures in the jejunal flap group.7 Laryngoscope 124: February 2014
TABLE III. The Relationship Between Surgical Group and the Four Voice Outcomes of Interest. Radial Forearm Free Flap
Factor
Anterolateral Thigh Free Flap
P Value
No.
Mean (SD)
No.
Mean (SD)
MSP, s Syllable no.
20 20
9.9 (3.9) 7.5 (1.9)
22 20
9.3 (3.6) 8.3 (3.4)
.93 .77
Fluent count, s
20
9.4 (4.0)
21
8.6 (4.5)
.65
Intelligibility
20
6.2 (1.8)
22
5.9 (2.3)
.66
P < .05 was considered significant. MSP ¼ maximum sustained phonation time; SD ¼ standard deviation.
Given the high rate of microvascular success, the ideal flap should offer low donor site morbidity, ease of harvest, and low fistula rates and be associated with superior speech production. Fasciocutaneous or cutaneous free flaps have demonstrated superior voice outcomes when compared to enteric flaps, and several authors have supported the use of fasciocutaneous flaps for pharyngoesophageal reconstruction in a panel discussion.8 Lewin et al. reported that 78% of ALT versus 25% of jejunal patients in their study used TEP speech for communication.9 However, in their study, only 30% of patients in each group had a TEP placed, and there was no mention of the voice quality. The disparity between outcomes for each flap type may be due to the asynchronous contractions of the jejunal and native esophageal segment during peristalsis or the secretory nature of the jejunum, leading to a voice characterized as ‘‘wet’’ and low in pitch. Few studies regarding free tissue reconstruction of laryngopharyngectomy defects include quantified voice measures. To our knowledge, this is the first study to compare the two most common cutaneous reconstructive techniques in regard to quantifiable voice outcomes. We found no difference in MSP, fluent count, number of syllables attained, and rating of observer intelligibility between RFFF and ALT techniques. The parameters used to assess the voice in our study have consistently been used by our group in postlaryngectomy voice rehabilitation and are acceptable standards as described by Blom and Singer.10 Further, the rates of postoperative and donor site complications did not differ between the two groups. These data would suggest that either technique may afford the patient a quality voice restoration without additional morbidity and that each flap should be used based on the defect size, geometry, and surgeon comfort. In the RFFF group, there was a significantly higher number of patients undergoing secondary TEP placement. This was due to practice patterns of the extirpative surgeon who performed many of the cases in the RFFF group. Post hoc analysis did not reveal a significant difference in voice parameters for those patients undergoing primary versus secondary TEP placement (Table IV). This finding is consistent with a recent study comparing primary and secondary TEP placement in Revenaugh et al.: Voice Outcomes After RFFF or ALT
399
TABLE IV. The Relationship Between Primary or Secondary Tracheoesophageal Prosthesis Placement and Voice Outcomes of Interest. Primary TEP
Secondary TEP
Factor
No.
Mean (SD)
No.
Mean (SD)
P Value
MSP, s
15
9.3 (3.9)
27
9.7 (3.7)
.51
Syllable no.
15
8.1 (2.0)
25
7.8 (3.1)
.35
Fluent count, s Intelligibility
15 15
9.1 (4.1) 6.2 (2.0)
26 27
8.9 (4.4) 5.9 (2.1)
.53 .56
P < .05 was considered significant. MSP ¼ maximum sustained phonation time; SD ¼ standard deviation; TEP ¼ tracheoesophageal prosthesis.
free flap reconstruction of laryngopharyngectomy defects.11 To maximize quality of life improvement with more rapid voice rehabilitation, we are now performing immediate prosthesis fitting as opposed to waiting until 3 to 4 weeks postreconstruction. As with retrospective studies, there are several inherent limitations in this study. Although all patients were evaluated by a single speech pathologist, which allowed for consistency in the assessment, she was not specifically blinded as to the type of reconstruction, introducing a potential for bias. However, the data collection occurred before the study proposal. Surgical parameters that could affect voice outcome, such as size of pharyngeal remnant, base of tongue, and remnant esophageal lengths were not available. There was no significant difference in the number of patients in each group requiring dilation for symptomatic dysphagia. As mentioned, the patients underwent this dilation an average of 7.3 months after their initial surgery; therefore, development of stricture was not presumed to influence initial voice assessment. This was confirmed by post hoc analysis that indicated no difference in the voice parameters of those patients who went on to require dilation. In a future prospective study, assessment of voice parameters before and after dilation may be beneficial. Patient postoperative motivation and degree of speech practice were also not quantifiable, accounting for somewhat large standard deviations within the parameters measured. Finally, patient self-assessments
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and quality-of-life measurements were not included. Individual patients have different voice expectations and requirements. Therefore, perceptions of voice quality may differ from patient to patient. Because objective voice measures do not necessarily correlate with selfassessments, it would be beneficial in future research to include patient-generated assessments.
CONCLUSION With the emergence of reliable fasciocutaneous methods for pharyngoesophageal reconstruction, it is important to ensure patients may have similar functional outcomes. Our study did not identify differences in voice quality measures between the two methods of reconstruction. Patients can attain high-quality, usable, and consistent voice function, regardless of whether an RFFF or ALT flap is performed.
BIBLIOGRAPHY 1. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope 2007;117:781–784. 2. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope 2006; 116:173–181. 3. Op de Coul BM, Hilgers FJ, Balm AJ, Tan IB, van den Hoogen FJ, van Tinteren H. A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution’s experience with consistent application of provox indwelling voice prostheses. Arch Otolaryngol Head Neck Surg 2000;126:1320–1328. 4. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg 2008;61:1148–1156. 5. Alam DS, Vivek PP, Kmiecik J. Comparison of voice outcomes after radial forearm free flap reconstruction versus primary closure after laryngectomy. Otolaryngol Head Neck Surg 2008;139:240–244. 6. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer 2010;116:1718–1724. 7. Mendelsohn M, Morris M, Gallagher R. A comparative study of speech after total laryngectomy and total laryngopharyngectomy. Arch Otolaryngol Head Neck Surg 1993;119:508–510. 8. Robb GL, Lewin JS, Deschler DG, Haughey BH, Brown DH, Langmore SE. Speech and swallowing outcomes in reconstructions of the pharynx and cervical esophagus. Head Neck 2003;25:232–244. 9. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after circumferential pharyngoesophageal reconstruction. Laryngoscope 2005; 115:1266–1271. 10. Hamaker RC, Singer MI, Blom ED, Daniels HA. Primary voice restoration at laryngectomy. Arch Otolaryngol 1985;111:182–186. 11. Sinclair CF, Rosenthal EL, McColloch NL, et al. Primary versus delayed tracheoesophageal puncture for laryngopharyngectomy with free flap reconstruction. Laryngoscope 2011;121:1436–1440.
Revenaugh et al.: Voice Outcomes After RFFF or ALT
