Postoperative complications and Its management after total laryngectomy

Objectives: To find out the pattern of complications, frequency, risk factors and the management after total laryngectomy. Methods: It was a cross sectional study done in the Department of Otolaryngology & HeadNeck Surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka from July 2007 to Dec 2009. 15 patients undergoing total laryngectomy for histologically proven Carcinoma larynx were included in this study. Patients were reviewed after surgery and any complication that occurred was recorded. The presentation, diagnosis and management of these complications were discussed after total laryngectomy. Results: There were 15 male patients, 3 non radiated cases and 12 post irradiated cases. Age of patients ranged from 35-75 years. Complications included wound infection (04), pharyngocutaneous fistula (03), flap necrosis (01), pharyngeal stenosis (01), stomal stenosis (01) and stomal recurrence (01). Conclusions: Wound infection and pharyngocutaneous fistula are most common complications after total laryngectomy. Preoperative radiotherapy is an important risk factor for development of pharyngocutaneous fistula in total laryngectomy patients.


Introduction
Cancer of the larynx is neither common nor rare 1 .A higher incidence of laryngeal carcinoma has been reported from Asian population.In Bangladesh, it is the most common malignancy in men 2 .Laryngeal cancer is an important malignancy in head and neck region.It represents 1% of all malignancies. 1Over 95% of laryngeal carcinoma is treatable 3 .
There are many therapeutic options available for the treatment of laryngeal cancer.These include LASER surgery, partial laryngectomy, total laryngectomy and radiation therapy 1 .
Total laryngectomy is a radical procedure which involves removal of whole of the larynx.This procedure is useful in the treatment of advanced laryngeal cancer 4 and as a salvage procedure when previous partial laryngeal surgery or radiotherapy has failed.
Complications following total laryngectomy can cause serious implications on the final outcome of the treatment.Severe infection with flap necrosis resulting in carotid blow out can be life threatening.Pharyngocutaneous fistula can prolong hospitalization and increase morbidity. 5Fistula formation has an important effect on patient morbidity and mortality postoperatively.Similarly late complications like pharyngeal stenosis can result in swallowing difficulty, 6 while stomal recurrence may render the tumour incurable thus adversely affecting the prognosis. 7It is therefore important to diagnose these complications early so that timely intervention can be done.
To find out various complications after total laryngectomy with respect to their presentation, diagnosis and management, this study was conducted on fifteen patients who had undergone total laryngectomy.Exclusion criteria: All patients who underwent total laryngectomy along with additional surgical procedure like radical or functional neck dissection.Patients undergoing partial laryngectomy were also excluded from this study.

Methods
Every patient was assessed pre-operatively by thorough clinical examination and direct Laryngoscopy under general anesthesia to see the primary site and extension and biopsy was taken for histological confirmation of diagnosis.Nodal status was confirmed by CT scan of neck.The nature of the operation and its consequences were explained in details to the patient and to his family members.All patients were observed for any post operative complications during their stay in the hospital and after discharge from hospital a regular follow up visit record was maintained.The patients were examined at regular intervals monthly for three months.Later on patients were called for follow up after every six months for one year.During each follow up visit a thorough clinical examination was done in all patients and appropriate investigations were carried out where indicated.A complete record of complications, their diagnosis and treatment was maintained during this period.

Results
In these series 15 male patients were studied.Out of them 12 (80%) patients received preoperative full dose curative radiotherapy.
The age of the patient ranged from 35 to 75 years.The mean age was 50 years.Most of the cases are supraglottic carcinoma 12(80%), Glottic carcinoma in 3(20%) and no subglottic carcinoma.In this study out of 12 supraglottic cases, 6 patients presented in stage II and 6 in stage III.Among the glottic cases 1 patient presented in stage II and 2 in stage III.Histologically all 15(100%) were squamous cell carcinoma.Tracheostomy was done pre operatively in 6(40%) patients and in the remaining 9(60%) during the time of operation.

Discussion
Carcinoma of larynx is an important malignancy in head and neck region.It accounts for 40% of all head and neck malignancies 8 .In Bangladesh the cancer of larynx and hypo pharynx comprised around 21% of all cancer in males 2 .In this study age distribution of laryngeal carcinoma was in between 35-75 years.This finding is almost consistent with the study of Aslam MJ et al 8 .
In this series, among 15 male patients.12(80%) had supraglottic growth and 3(20%) had glottic growth The incidence of supraglottic growth is higher in this country.
In the present study, pharyngocutaneous fistula developed in 20% patients.This rate is consistent with work of Parikh SR et al 9 , who in large series of 125 patients of laryngectomy reported 22% incidence of fistula 9 .The highest incidence of pharyngocutaneous fistula was reported as 66% by Bresson K et al 10 .The lowest incidence of pharyngocutaneous fistula was 2% 11 .
Out of three patients developed pharyngocutaneous fistula in the post operative period two had pre operative radiotherapy and two had pre operative tracheostomy.This is consistent with the observation of a previous study that patient requiring preoperative tracheostomy had a higher fistula rate 12 .In Memorial Sloan-Kettering Cancer Center in New York, Weingrad DN and Spiro RH analyzed that multiple factors are responsible to fistula formation.The only significant association was the extent of surgery.In their series, out of 48 patients who had undergone laryngectomy, pharyngocutaneous fistula developed in only 2 (4%) 13 .
Three patients developed pharyngocutaneous fistula in this series were managed conservatively which is similar with the statement of SS Qureshi et al 14 .But the pattern of fistula management by Weingrad DN and Spiro RH was different which included simple closure and flap repair 13 .
Here, wound infection was developed in 26.6% of total laryngectomy.This rate is in accordance with the finding of Aslam MJ et al 8 .The factors probably responsible are absence of well trained and well oriented nursing staff, inability to maintain absolute sterilization in the post operative period especially during repeated suction and also because of the contamination from the visitors.Among 4 cases of wound infection, one developed partial flap necrosis.
In the follow up period 1 (6%) patient developed pharyngeal stenosis.However, incidence is 12% in the series of Aslam MJ et al 8 .
Here, one patient (6.6%) developed tracheostomal stenosis.Subsequently he developed stomal recurrence.A lower rate of 5% was evident in the series of Mantravadi R et al 15 .
In our study, no patient developed nodal metastasis.Aslam MJ et al 8 opines that postoperative radiotherapy to the neck reduces the risk of nodal metastasis after total laryngectomy.

Conclusion
To comment on post operative complications of total laryngectomy, it demands further elaborate and extensive study to come to a decisive opinion.The present study reflects that complication rate is higher in radiation failure cases.Complication is almost equal to most comparable published series.The most frequent, troublesome immediate complication is pharyngocutaneous fistula all of which have been treated conservatively with satisfactory result.Preoperative radiotherapy is an important risk factor for development of

Table - I
Site of growth (n-15)