Gastroesophageal reflux disease and postlaryngectomy tracheoesophageal fistula

Abstract

The objective of this study is to evaluate the incidence of pathologic gastroesophageal reflux in laryngectomized patient with phonatory prosthesis, analyzing potential related problems and appraising, at the same time, the effectiveness of a therapeutic protocol. A retrospective study was conducted on 43 phonatory prosthesis patients who had problems with regard to recurrent tracheoesophageal granulations, the need of frequent prosthesis replacement, within a 3-month period, and unsatisfactory vocal results. Such patients underwent physical examination of the fistula region and of the neopharynx and were submitted to esophagogastroduodenoscopy. Moreover the group of patients underwent a therapeutic protocol and were re-evaluated posttreatment, examining fistula region both on the tracheal side and on the esophageal side through videolaryngostroboscopy. Of the 43 recruited patients 13 (30%) presented tracheoesophageal granulations, 20 (46.5%) unsatisfactory vocal results and 10 (23.5%) frequent prosthesis replacement, within a 3-month period, due to abnormal biofilm development. In particular, of the 13 patients who had recurrent granulations, the evaluation results revealed the presence of gastroesophageal reflux disease (GERD) in 6 cases (46%). In the group of patients presenting unsatisfactory vocal results GERD was shown in 13 cases (65%). In the third group of patients GERD was found in two cases (20%). The overall analysis of the data gathered, allowed to identify GERD in 21 (49%) of the 43 patients submitted to the study. The results posttreatment indicated, in the first group, the disappearance or a significant (>75%) volume reduction of such formation in five cases (38%, p = 0.002). In the second group an overall improvement in the quality of voice was displayed at least for 12 patients (60%, p = 0.0001). Finally in the last group an increase of the prosthesis life was recorded in four (40%, p = 0.05) of the ten patients who had the need of prosthesis replacement within 3 months. Also the 22 GERD negative cases (51%) underwent the treatment, therefore representing the control group, whose posttreatment results showed substantial modifications in just two cases (9%). The data obtained suggest a high degree of correlation between the presence of pathologic gastric reflux and the partial or total prosthesis failure. The introduction of a specific therapeutic protocol has allowed to improve the quality of prosthesis (QoP) in 22 of the 43 patients (p < 0.001) who had a pathologic condition of the fistula and of the prosthesis.

Riabilitazione vocale post laringectomia con voce protesica: 15 anni di esperienza della Clinica Otorinolaringoiatrica dell’Università di Catania. Analisi retrospettiva dei dati e revisione della letteratura

“…In this context, a retrospective study recorded the therapeutic outcomes in patients with trachea-oesophageal granulations, unsatisfactory vocal results and frequent prosthesis replacement, within a 3-month period, due to abnormal biofilm development, using a therapeutic protocol characterised by full-dose PPI treatment given twice daily for 2 months and a maintenance-dose PPI treatment for 1 month, with the addition of alginate at the maximum dose three times daily for 3 months and correct diet indications. The introduction of a specific therapeutic protocol improved the quality of prosthesis (QoP) in 22 of the 43 patients 32 .…”

Gastro-pharyngeal reflux and total laryngectomy. Increasing knowledge about its management

“…Thus the lack of protective mechanisms against gastric acid exposure, even minor exposure of the trachea, can lead to massive damage, which may be caused by a low pH value, pepsin, pancreatic enzymes, and bile acid [3,45]. Even if the risk of periprosthetic leakage and fistula enlargement seems to rise up to 2.3 times higher in patients with pathologic reflux, the complete resolution of peri-prosthetic complications has been documented in N70% of patients who have been taking oral proton pomp inhibitors (PPIs) for at least 6 consecutive months [38,43,[46][47][48]. Recently, Stephenson and colleagues have confirmed the presence of a statistically significant reduction in fistulae with PPI prophylaxis, as well, suggesting to perform further research to better define the role of reflux in laryngeal cancer patients management [49].…”

Effect of perioperative proton pump inhibitors on the incidence of pharyngocutaneous fistula after total laryngectomy: A prospective randomized controlled trial

“…Laryngectomy results in changes in pharyngeal plexus innervation and in esophageal motility; a pressure decrease at the level of the upper esophageal sphincter has been observed . Reflux is also recognized as a key factor in phonatory prosthesis problems in the context of postlaryngectomy speech rehabilitation …”

“…28,29 Reflux is also recognized as a key factor in phonatory prosthesis problems in the context of postlaryngectomy speech rehabilitation. 30,31 Evaluation of reflux by pH-monitoring for the first 48 hours of the immediate postoperative period after laryngectomy has also detected proximal reflux at the level of the pharyngeal closure in 40% of patients. 32 The effect of this refluxate upon the upper aerodigestive tract mucosal lining has been examined; mucosal erosion, ulceration, and submucosal hemorrhages were recorded as a result of exposure to pepsin or to pepsin and hydrochloric acid in animal models.…”