Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction

Abstract

Objectives Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS‐assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control. Study Design: Retrospective cohort analysis. Methods Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019. Results Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin. Conclusion In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS. Level of Evidence 3 Laryngoscope, 131:E821–E827, 2021

Reconstruction following transoral robotic surgery for head and neck cancer: Systematic review

“…Of these, 51 articles were reviewed in full following screening and removal of duplicates. A total of 26 final studies met inclusion based on appropriateness of patient population, intervention performed, and outcome of interest adequately specified 15–40 . One study detailing reconstructive strategies of TORS defects was excluded due to lack of description regarding specific reconstructive modalities used in the patient cohort described 11 .…”

Neck Dissection Timing in Transoral Robotic or Laser Microsurgery in Oropharyngeal Cancer: A Systematic Review

“…Of these articles, 5 were prospective studies, 13 , 16 , 21 , 22 and 14 were retrospective studies ( Tables 2 and 3 ). 6 , 12 , 14 , 15 , 17 - 20 , 23 , 25 - 29 There was significant heterogeneity among study designs and recorded outcomes, meaning that a formal meta-analysis was not possible.…”

“…Long-term patient outcomes such as DSS and OS were not mentioned in 9 studies. 6 , 12 , 13 , 15 , 17 , 22 , 23 , 25 , 29 In studies reporting DSS and OS for concurrent ND, the mean DSS was calculated to be 96% and mean OS was 99%, with a follow-up period ranging from 2 to 29 months. 15 , 18 , 19 , 21 , 27 , 28 One study cited DSS and OS rates of 89% and 100% at 2 years, respectively, for patients undergoing ND after TORS/TLM.…”

“…6,13,20,24 Four studies (79 patients) did not include fistula rates as outcome measures. 24,25,27,28 Of the concurrent cohort of patients, 13% had intraoperative fistulae, and 2% had postoperative fistulae (n = 429). There were no recorded fistulas in patients with ND before TORS/TLM (n = 19).…”

“…Two articles described ND as a separate procedure before TORS/TLM 17,20 ; 3 as concurrent before procedures 23,24,26 ; 10 as concurrent procedures [13][14][15]18,19,21,22,[27][28][29] ; 2 as concurrent after procedures 12,25 ; 1 as a separate procedure after TORS/ TLM 16 ; and 1 as before, after, and concurrently to TORS/ TLM. 6 Of the 19 studies, 8 cited the level of ND.…”