RESUMO
INTRODUCTION: The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario. METHODS: A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included. RESULTS: A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce. CONCLUSION: We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.
Assuntos
Fístula Cutânea , Neoplasias Laríngeas , Doenças Faríngeas , Procedimentos de Cirurgia Plástica , Humanos , Fístula Cutânea/prevenção & controle , Fístula Cutânea/complicações , Neoplasias Laríngeas/cirurgia , Laringectomia/efeitos adversos , Doenças Faríngeas/etiologia , Doenças Faríngeas/prevenção & controle , Doenças Faríngeas/cirurgia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.
Assuntos
Fragilidade , Neoplasias de Cabeça e Pescoço , Humanos , Idoso , Neoplasias de Cabeça e Pescoço/terapia , Fragilidade/complicações , ComorbidadeRESUMO
The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for patients with cancer. For those who are working with COVID-19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID-19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.
Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Otolaringologia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , COVID-19 , Infecções por Coronavirus/epidemiologia , Humanos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , SARS-CoV-2RESUMO
Abstract Introduction: Trans-oral laser microsurgery is an established technique for the treatment of early and moderately advanced laryngeal cancer. Objective: The authors intend to test the usefulness of narrow-band imaging in the intraoperative assessment of the larynx mucosa in terms of specifying surgical margins. Methods: Forty-four consecutive T1-T2 glottic cancers treated with trans-oral laser microsurgery Type I-VI cordectomy were presented. Suspected areas (90 samples/44 patients) were biopsied under the guidance of narrow-band imaging and white light and sent for frozen section. Results: Our study revealed that 75 of 90 (83.3%) white light and narrow-band imaging-guided samples were histopathologically positive: 30 (40%) were confirmed as carcinoma in situ or invasive carcinoma and 45 (60%) as moderate to severe dysplasia. In 6 patients mucosa was suspected only in narrow-band imaging, with no suspicion under white light. Thus, in these 6 patients 18/90 (20%) samples were taken. In 5/6 patients 16/18 (88.8%) samples were positive in frozen section: in 6/18 (33.3%) carcinoma (2 patients), 10/18 (66.6%) severe dysplasia was confirmed (3 patients). In 1 patient 2/18 (11.1%) samples were negative in frozen section. Presented analysis showed, that sensitivity, specificity and accuracy of white light was 79.5%, 20% and 71.1% respectively, while narrow-band imaging was 100%, 0.0% and 85.7%, respectively. Conclusion: The intraoperative use of narrow-band imaging proved to be valuable in the visualization of suspect areas of the mucosa. Narrow-band imaging confirms the suspicions undertaken in white light and importantly, it showed microlesions beyond the scope of white light.
Resumo Introdução: A microcirurgia transoral a laser é uma técnica bem estabelecida para o tratamento de câncer de laringe inicial e moderadamente avançado. Objetivo: Verificar a utilidade da imagem de banda estreita na avaliação intraoperatória da mucosa laríngea na especificação das margens cirúrgicas. Método: Foram avaliados 44 cânceres glóticos T1-T2 consecutivos, tratados com cordectomia Tipo I-VI, por microcirurgia transoral a laser. As áreas suspeitas (90 amostras/44 pacientes) foram submetidas a biopsia e avaliadas através de imagens de banda estreita e luz branca e enviadas para cortes por congelação. Resultados: Nosso estudo revelou que 75 (83,3%) das 90 amostras apresentaram histopatologia positiva na análise com luz branca e imagens de banda estreita: 30 (40%) foram confirmadas como carcinoma in situ ou carcinoma invasivo e 45 (60%) como displasia moderada a grave. Em seis pacientes, a mucosa apresentou-se suspeita apenas na imagem de banda estreita, sem suspeita sob luz branca. Assim, nesses seis pacientes 18/90 (20%) amostras foram colhidas. Em 5/6 pacientes, 16/18 (88,8%) amostras mostraram resultado positivo na análise de congelação: em 6/18 (33,3%) amostras foi confirmado carcinoma (dois pacientes) e em 10/18 (66,6%) foi confirmada displasia grave (três pacientes). Em um paciente, 2/18 (11,1%) as amostras mostraram resultado negativo na congelação. A análise apresentada mostrou que a sensibilidade, a especificidade e a acurácia da luz branca foram de 79,5%, 20% e 71,1%, respectivamente, enquanto a imagem de banda estreita apresentou como resultados 100%, 0,0% e 85,7%, respectivamente. Conclusão: O uso intraoperatório de imagem de banda estreita provou ser valioso na identificação de áreas suspeitas da mucosa, confirmou as suspeitas verificadas na análise com luz branca e, o que é mais importante, identificou microlesões além do alcance da luz branca.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Carcinoma/cirurgia , Carcinoma/diagnóstico por imagem , Neoplasias Laríngeas/cirurgia , Neoplasias Laríngeas/diagnóstico por imagem , Terapia a Laser/métodos , Imagem de Banda Estreita/métodos , Microcirurgia/métodos , Prega Vocal/cirurgia , Prega Vocal/diagnóstico por imagem , Carcinoma/patologia , Neoplasias Laríngeas/patologia , Reprodutibilidade dos Testes , Análise de Variância , Estatísticas não Paramétricas , Intervalo Livre de Doença , Cirurgia Endoscópica por Orifício Natural/métodos , Margens de Excisão , Período IntraoperatórioRESUMO
INTRODUCTION: Trans-oral laser microsurgery is an established technique for the treatment of early and moderately advanced laryngeal cancer. OBJECTIVE: The authors intend to test the usefulness of narrow-band imaging in the intraoperative assessment of the larynx mucosa in terms of specifying surgical margins. METHODS: Forty-four consecutive T1-T2 glottic cancers treated with trans-oral laser microsurgery Type I-VI cordectomy were presented. Suspected areas (90 samples/44 patients) were biopsied under the guidance of narrow-band imaging and white light and sent for frozen section. RESULTS: Our study revealed that 75 of 90 (83.3%) white light and narrow-band imaging-guided samples were histopathologically positive: 30 (40%) were confirmed as carcinoma in situ or invasive carcinoma and 45 (60%) as moderate to severe dysplasia. In 6 patients mucosa was suspected only in narrow-band imaging, with no suspicion under white light. Thus, in these 6 patients 18/90 (20%) samples were taken. In 5/6 patients 16/18 (88.8%) samples were positive in frozen section: in 6/18 (33.3%) carcinoma (2 patients), 10/18 (66.6%) severe dysplasia was confirmed (3 patients). In 1 patient 2/18 (11.1%) samples were negative in frozen section. Presented analysis showed, that sensitivity, specificity and accuracy of white light was 79.5%, 20% and 71.1% respectively, while narrow-band imaging was 100%, 0.0% and 85.7%, respectively. CONCLUSION: The intraoperative use of narrow-band imaging proved to be valuable in the visualization of suspect areas of the mucosa. Narrow-band imaging confirms the suspicions undertaken in white light and importantly, it showed microlesions beyond the scope of white light.