Topicality: According to the 2019-2020 cancer registry, the incidence of laryngeal and laryngopharyngeal cancer remains high in Ukraine. Malignant tumours of the larynx rank first among ENT organs accounting for 50-70%. The incidence of laryngeal cancer has a tendency to constantly increase. At the same time, 70% of patients with malignant tumours of the larynx are men of working age which is 41-60 years.
The vast majority of cases of malignant tumours of the larynx (60-75%) are diagnosed in stage 3-4 of the disease, when the main method of treatment is laryngectomy. Total laryngectomy, which is necessary from an oncological point of view, leads to a deep disability of the patient, namely loss of voice. Difficulty or inability to communicate, social isolation cause severe psychological trauma and is the main reason for refusal of radical surgery.
According to various authors, 35% of patients after extirpation of the larynx use whispered speech, 30% use writing for communication. Rehabilitation of the voice function in such patients would not only improve the functional results of treatment and quality of life, but would also facilitate social adaptation, thus reducing the number of refusals of surgical treatment.
At the Department of Oncological Diseases of ENT Organs of the State Institution “O. S. Kolomiychenko Institute of Otolaryngology of the National Academy of Medical Sciences of Ukraine” to restore voice function after laryngectomy, the TEP technique is used with Рrovox, Provox2, Vega, Voice Master prostheses with low pressure for long-term use. The principle of sound formation during rehabilitation with voice prostheses and shunting is common and is based on the use of a strong flow of air from the lungs (about 3 litres), which is directed into the pharynx during exhalation with a closed tracheostomy. The sound is formed at the level of the socalled neoglottis. Thus, sufficient volume, speech intelligibility, fluidity, emotional colouring is ensured, and individual characteristics of the voice of each patient are preserved. The barrier function of the transmission mechanism (prosthesis, shunt) is of great importance as it ensures the absence of return current from the pharynx to the respiratory tract during swallowing.
However, this technique of voice rehabilitation is noted to have a number of problems that can be predicted and prevented, particularly in the intraoperative period.
Aim: to analyse the difficulties and complications of TEP in patients after laryngectomy and to develop measures for their prevention.
Materials and methods: The observation included 74 patients who underwent treatment at the Department of Oncological Diseases of ENT Organs of the State Institution “O.S. Kolomiychenko Institute of Otolaryngology of the National Academy of Medical Sciences of Ukraine”. There were 65 men and 9 women aged 41-75 years.
The average age was 58 years. All patients underwent laryngectomy for laryngeal or laryngopharyngeal cancer.
Eighteen patients underwent simultaneous laryngectomy with TEP, 44 patients had delayed prosthesis fitting (within 2 months to 2 years), 6 patients underwent TEP during pharyngostomy, and 6 patients had prosthesis fitting in a previously formed shunt.
Patients with lesions of various parts of the larynx and laryngopharynx of stage 2 (with subsequent recurrence of the tumour), stages 3 and 4 were among the prosthetic patients. The course of treatment included pre- or postoperative radiation therapy, polychemotherapy, total laryngectomy with resection of the pharynx, tongue root, thyroid gland, selective and radical neck dissection, and various combinations of these methods. In addition, 7 patients underwent tracheostomy.
Results and discussion: Surgical rehabilitation by the TEP technique in patients with laryngeal and laryngopharyngeal cancer after laryngectomy was carried out. The obtained results showed the following complications during the surgery:
- Impossibility of the posterior tracheal wall perforation due to its cicatricial-sclerotic changes in the area of tracheostomy, narrowing and deformation – 5 cases;
- Injury to the walls of the pharynx and esophagus with a tube or trocar (in case of cicatricial changes, tracheostoma deformations, cervical osteochondrosis) – 3 cases;
- Detachment of the band from the prosthesis (due to excessive tension, rigidity of the tracheal tissues, narrowing of the stoma and difficulty of manipulations in this area) – 3 cases;
- Swallowing or aspiration of prosthesis – 1 case;
- Bleeding from the edges of the fistula – 6 cases;
- Difficulties during esophagoscope introduction (difficulty in extending the neck due to cervical osteochondrosis, narrowing of the pharyngoesophageal junction, difficulty in opening the mouth) – 12 cases;
- Prosthesis descent in fistula (the length of the prosthesis does not match the length of the shunt) – 2 cases.
It should be noted that some patients had a combination of the above mentioned problems and complications.
To overcome problems arising during surgery and to prevent complications, a number of diagnostic and treatment measures have been introduced.
The formation of a permanent tracheostomy during laryngectomy is an important stage of the operation.
The course of the postoperative period and the subsequent condition of the patient depend on the shape and size of the tracheostomy opening. It should be noted that under the influence of force of tracheobronchial apparatus, the trachea stump is lowered to varying degrees, which contributes to the narrowing of the stoma. In addition, gross post-operative and post-radiation scar changes negatively affect the effectiveness of plastic surgery in this area.
The main method of forming a tracheostomy is based on a racquet-shaped excision of the skin around the stoma (suggested by Professor O. S. Kolomiychenko in 1943) to stretch the edges of the tracheostomy. At the Department of Oncological Diseases of ENT Organs of the State Institution “O. S. Kolomiychenko Institute of Otolaryngology of the National Academy of Medical Sciences of Ukraine” there has been developed a method that consists in cutting the trachea in the anterior half parallel to the ring, then obliquely to the top, with the excision of subcutaneous fatty tissue and fixation of the tracheal wall to the connective tissue of the sternoclavicular joint for 4 and 8 hours. In some cases, the anterior pedicles of the sternocleidomastoid muscle are crossed (patent No. 117057 from 12.06.17).
The proposed method of forming a tracheostomy makes it possible to avoid using a tracheostomy tube from the first day of the postoperative period, form a permanent tracheostomy of the correct shape for further voice and respiratory rehabilitation, reduces the risk of complications, does not limit the oncological plan of surgery, does not make it difficult to perform laryngectomy.
The stage of inserting the tube into the esophagus is also of great importance. The implementation of the technique with an introduction of the straight tube of the esophagoscope with the extension of the patient’s neck is complicated by a number of factors such as: cervical osteochondrosis, postoperative and post-radiation fibrosis, keloidosis of the soft tissues of the front surface of the neck and pharynx. This increases the risk of a fracture in the neck and the risk of tooth injury, as well as injury to the soft tissues of the pharynx and esophagus.
At the Department of Oncological Diseases of ENT Organs of the State Institution “O. S. Kolomiychenko Inst itute of Otolaryngology of the National Academy of Medical Sciences of Ukraine”, the TES technique has been improved by changing the design of the tube, which ensures minimal trauma, reduces the time of surgical intervention, improves treatment outcomes and increases the number of patients that can be treated (patent No. 117058).
Conclusions: The proposed method of forming a tracheostomy makes it possible to create a permanent stoma of the correct shape for further voice and respiratory rehabilitation in patients who underwent laryngectomy. In patients of the risk group (hypersthenics, patients with a small diameter of the trachea, in cases of tracheal resection), it makes it possible to avoid using a tracheostomy tube from the first day of the postoperative period, reduces the risk of complications, does not limit the oncological plan of the operation.
An improved TES technique due to changes in the design of the esophageal tube reduces the time of surgical intervention, improves treatment outcomes and expands the possibilities for rehabilitat ion of pat ients.
Thorough preoperative preparation taking into account each patient’s individual situation, compliance with the indications and technique of surgery using the specified improvements help prevent and overcome the most common intraoperative complications during TEP.
