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Treatment of Stomal Recurrence

last modified on: Sun, 04/14/2024 - 20:57

return to: Laryngeal Surgery (Malignant Disease) Protocols

see also: Mediastinal tracheostomy for total laryngectomy with resection of manubrium

GENERAL CONSIDERATIONS

  • Stomal recurrence occurs in approximately 3% to 5% of patients following total laryngectomy. The majority of cases present within the first one to two years after total laryngectomy. Postoperative radiotherapy that includes the stoma has likely decreased the incidence of stomal recurrence over the last 15 to 20 years. Stomal recurrence following treatment for laryngeal cancer is often a grave clinical situation with a poor prognosis for prolonged survival. Many patient-related and disease-related factors must be considered in making the decision to proceed with stomal resection and mediastinal dissection. The following indications and contraindications must be considered in the context of the individual patient and the palliative or curative goals of the intervention.
  1. Indications for Surgery
    1. Stage I, II, and selected cases of stage III stomal recurrence (see below).
    2. In rare cases, surgery on stage IV stomal recurrence may be indicated for palliative purposes (see below).
    3. Subglottic tumors or recurrence of previously-treated laryngeal cancer may present a clinical situation requiring completion laryngectomy and mediastinal dissection.
    4. Mediastinal dissection may be indicated in selected thyroid cancers with tracheal and Level VI node involvement. Sleeve resection of the trachea or subtotal laryngectomy may also be required.
  2. Contraindications to Surgery
    1. Stomal recurrence classified as stage IV is, in the majority of cases, inoperable both with regard to a reasonable chance of cure and with regard to providing safe palliation.
    2. Prior mediastinal surgery with a second recurrence at the stoma or upper mediastinum is a contraindication.
    3. Patient is medically unable to tolerate mediastinal surgery.
  3. Pertinent Anatomy
    1. Sisson stages of stomal recurrence
      1. Stage I: Tumor above tracheostome in 9:00 to 3:00 area; upper mediastinum is not involved, esophagus is not involved
      2. Stage II: Tumor above or within the tracheostome in 9:00 to 3:00 area; if above tracheostome, the esophagus must be involved to be stage II
      3. Stage III: Lesion within tracheostome in 9:00 to 3:00 area; esophagus is involved, and tumor may extend to invade the upper mediastinum
      4. Stage IV: Tumor invades upper mediastinum with lateral extension under clavicles and great vessel involvement or tumor invades trachea distally to the level of the carina (tracheal extension may be extramucosal and only evident on surgical exploration or mediastinoscopy)
    2. A shortened trachea may not easily reach the surface of the chest if not relocated anterior to the innominate artery.

PREOPERATIVE PREPARATION

  1. Evaluation
    1. Thorough head and neck examination including tracheoscopy and esophagoscopy.
    2. CT scan from base of skull through chest with attention to mediastinum.
    3. In selected cases, mediastinoscopy may be useful to evaluate peritracheal involvement.
    4. Surgical planning is done in conjunction with thoracic surgery service
      1. Combined endoscopy procedure
      2. Evaluation for gastric pull-up procedure: Exclude prior abdominal surgery or trauma that would preclude a gastric-pull up. If a gastric pull-up is not feasible and tumor does not involve the thoracic esophagus, free tissue transfer or other method for reconstruction of pharyngoesophageal conduit should be planned (see Gastric pull-up protocol).
  2. Potential Complications
    1. Need to abort curative intent procedure based on operative findings
    2. Potential inability to reestablish pharyngoesophageal conduit
    3. Postoperative fistula or infection with resultant mediastinitis and potential major vascular rupture
    4. Complications associated with gastric-pull up
    5. Permanent hypocalcemia (expected)
    6. Perioperative death due to major vessel rupture or irreparable posterior tracheal wall tear extending to involve carina

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
    2. Special
      1. Nerve stimulator control unit and instrument
      2. Separate set-up for Thoracic/General Surgery teams for harvesting and transferring of gastric pull-up for reconstruction.
      3. Cummings retractor, large and medium
      4. Dura/Derma elastic attach hook, 7.5 in x .25 in
      5. Varidyne vacuum suction controller
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. 1% lidocaine with 1:100,000 epinephrine
  4. Prep and Drape
    1. Standard prep, 10% providone iodine
      1. Prep from eyes to pubis; may need to prep for lateral thoracotomy
    2. Drape
      1. Head drape
      2. Ioban drape for abdomen and chest
      3. Place towels outlining the chin, neck, and chest to groin area
      4. Split sheet
  5. Drains and Dressings
    1. Varidyne vacuum suction: 7 mm to 10 mm or Penrose drain
    2. Antibiotic ointment to suture line
  6. Special Considerations
    1. Separate setup for cardiothoracic team
    2. The neck, chest, and abdomen should be prepped and draped as one field.
    3. Sternotomy equipment available per thoracic service preference

ANESTHESIA CONSIDERATIONS

  1. General
    1. Patient supine, and head turned 180° from anesthesiologist
  2. Specific
    1. Potential for brisk bleeding at various points during the case

OPERATIVE PROCEDURE (see Gastric pull-up protocol.)

  1. Most cases will begin with determination of tumor resectability.
    1. A 2 cm margin around stoma with lateral cervical extensions and vertical extension down midline over sternum.
    2. If tumor invasion along lateral trachea or under clavicles is suspected, begin with manubrial and clavicular resection to allow inspection of upper mediastinum.
  2. Resection involves en bloc removal of all involved tissues between carotid arteries, anterior to prevertebral fascia, and above innominate artery. This is done in conjunction with removal of upper mediastinal fat pad and lymph nodes.
  3. Removal of ipsilateral clavicular head (if tumor has predominant side) and manubrium should be done initially. This maneuver will allow easy access to the trachea and afford direct vision and protection of the great vessels.
  4. The tumor, involved trachea and resected esophagus (if involved) are then mobilized from superior to inferior. The esophagus is mobilized into the thorax as far as possible.
  5. The thoracic duct should be identified and ligated.
  6. The upper mediastinal fat pad and lymph nodes are excised.
  7. The trachea is transected, which leaves the specimen tethered only by the lower esophagus.
  8. The thoracic surgery team mobilizes the stomach and esophagus. With the thoracic surgery service working from below and the otolaryngologist working from above, the final attachments of the esophagus are divided. This is generally done with blunt dissection (see Gastric pull-up protocol).
  9. The stomach is mobilized into the neck, and the esophagus is divided with a GI stapler at the gastroesophageal junction. The specimen is passed off.
  10. Frozen section margins at the tracheal stump and upper pharyngoesophageal incision should be sent.
  11. The esophagus is pulled superiorly and mobilized into the neck. From 6 to 8 tacking sutures of 2-0 vicryl are placed from the posterior aspect of the stomach to the prevertebral fascia to maintain its position.
  12. A 4 to 6 cm transverse incision is placed through the anterior fundus of the stomach. The incision should curve up slightly at both ends allowing a small flap of stomach to be sutured to the posterior pharyngeal mucosa with no tension. Care should be taken not to put this incision through the vessels on the greater curvature of the stomach.
  13. The stomach is sutured to the pharynx in two layers. The mucosa is closed with 3-0 vicryl and the serosa is closed to the pharyngeal musculature with 2-0 or 3-0 vicryl.
  14. It is crucial that the tacking sutures placed to the prevertebral fascia support the stomach so that the suture line does not have any tension.
  15. If required, the trachea is externalized inferior to the innominate artery.
  16. A rotational pectoralis myocutaneous flap is harvested by extending the vertical thoracic incision around the distal margin of the pectoralis muscle medially, inferiorly and to approximately the midaxillary line laterally. This will allow the muscle and overlying skin to be mobilized up into the defect.
  17. If required, a small hole can be made in the skin through which the trachea can be brought and sutured to the skin. If this is done, the muscle through which the trachea passes should be separated bluntly.
  18. It is important that pectoralis muscle be used to obliterate the dead space in the mediastinum around the great vessels and trachea. Often, a slip of muscle may be separated from the main muscle and insinuated between the trachea and innominate artery.
  19. Muscle can also be insinuated around the pharyngogastric suture line and used to separate this closure from the great vessels.
  20. Large suction drains should be used to drain the right and left neck and chest. One suction drain should be placed close to the anastomosis and brought out in a "safe" course over the muscle and away from the great vessels. This is a safety drain in case the anastomosis should break down.
  21. The thoracic surgery service closes the abdominal wound and a jejunostomy tube is placed while the neck is being closed.

POSTOPERATIVE CARE

  1. Close observation of drainage for evidence of salivary leakage
  2. Drains removed when output is less than 30 cc per 24 hours
  3. Management of hypocalcemia
  4. Patient on H2 blocker during surgery and postoperatively
  5. NPO for 7 days if no prior XRT; if prior XRT then NPO for 2 weeks
  6. Hypaque swallow prior to beginning oral feedings
  7. Dumping syndrome and reflux are frequently problems; improved with medical intervention and dietary consultation

REFERENCES

Biller HF, Drespe YP, Lawson W, Baek SE. A one-stage flap reconstruction following resection for stomal recurrence. Otolaryngol Head Neck Surg. 1980;88:357-360.

Gluckman JL, Hamaker RC, Schuller DE, Weissler MC, Charles GA. Surgical salvage for stomal recurrence: a multi-institutional experience. Laryngoscope. 1987;97: 1025-1029.

Ogura Memorial Lecture: Mediastinal dissection. Laryngoscope. 1989; 99:1262-1266.

Rockley TJ, Powill J, Robin PE, Reid AP. Post-laryngectomy stomal recurrence: tumour implantation or paratracheal lymphatic metastasis. Clin Otolaryngol. 1991;16:43-47.

Rubin J, Johnson JT. Stomal recurrence after laryngectomy: interrelated risk factor study. Otolaryngol Head Neck Surg. 1990;103:805-812.

Tong D, Moss WT, Stevens KR. Elective irradiation of the lower cervical region in patients at high risk for recurrent cancer at the tracheal stoma. Radiology. 1977;124:809-811.

Weber RS, Marvel J, Smith P, Hankins P, Wolf P, Goepfert H. Paratracheal lymph node dissection for carcinoma of the larynx, hypopharynx, and cervical esophagus. Otolaryngol Head Neck Surg. 1993;108:11-17.

Yotakis J, Davis S, Kontozoglou T, Adamapoulos G. Evaluation of risk factors for stomal recurrence after total laryngectomy. Clin Otolaryngol. 1996;21:135-138.