Complications in CO2 Laser Transoral Microsurgery for Larynx Carcinomas

F.A Betances Reinoso, C.M Chiesa Estomba, L.A. Dominguez Collazo, J.L. Rodriguez Fernandez, J.L. Fariña Conde, C. Santidrian

Department of Otorhinolaryngology – Head and Neck Surgery. University Hospital of Vigo

Introduction

During the seventy´s, Strong and Jako proposed the use of endoscopic laser surgery in the treatment of laryngeal lesions.

Since then, the transoral laser microsurgery (TLM) has been gaining ground in the world of laryngeal oncology, and has established itself as an effective option in the management of malignant tumors of the glottis, supraglottis and hypopharynx.

Advantages, such as the magnification generated by the microscope, allow us to make limited resections, to be able to differentiate healthy tissue from the affected tissue, thus achieving to preserve disease-free adjacent areas.

It decreases the number of tracheostomies and the use of nasogastric tubes.

Besides, it is possible to achieve similar oncological benefits from those obtained by open surgery with relatively low rates of complications according to the results reported in the literature.

Material and methods

Retrospective analysis of those patients diagnosed with squamous cell carcinoma (SCC) of the glottis and supraglottis for all stages (T1, T2, T3, T4), N -/+, M -/+ was performed according to the criteria of the Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC) in a tertiary hospital.

Patients treated with TLM between January 2009 and March 2012 were included.

Demographic data (age, gender).

Medical history.

Tumoral stage.

Diagnostic tests information.

Histological findings

Complications.

Type of surgery.

For the final analysis only those complications strictly associated with surgical technique were included.

The type of complications was classified in stages according to the time of presentation: intra-operative, post-operative, immediate and delayed.

Before surgery, all cases were discussed in an interdisciplinary committee of head and neck tumors. Patients with lesions suspicious of malignancy were scheduled for laryngeal microsurgery with biopsy. Those patients who had positive biopsy were followed by a glottic or supraglottic CO2 laser resection. After surgery, the pTNM was presented in the committee and the need for reoperation or complementary treatment with radiotherapy (RT) was assessed.

Results

Patients

4

94

Male Female Interventions

33

98

Primary Reoperations

0

25

50

75

100

Diabetics Hypertensive Smokers Consumed alcoholic beverages

41

93

40

22

N0 N1 N2 M Total

pT1 44 1 0 0 45

pT2 28 2 2 0 32

pT3 9 3 3 0 15

pT4 6 0 0 0 6

Total 87 6 5 0 98

Pathological tumoral stage, regional lymph nodes and distant metastases

Type of cordectomy

pT1 pT2 pT3 pT4 Total (%)

GLS Type III 2 0 0 0 2 (2,04%)

GLG Type IV 27 1 0 0 28 (28,57%)

GLS Type Va 14 8 0 0 22 (22,44%)

GLS Type Vb 0 3 3 1 7 (7,14%)

GLS Type Vc 0 5 1 2 8 (8,16%)

GLS Type Vd 0 1 0 1 2 (2,04%)

SGL Type IIa 1 2 0 0 3 (3,06%)

SGL Type IIb 0 1 1 0 2 (2,04%)

SGL Type IIIa 0 5 0 1 6 (6,12%)

SGL Type IIIb 0 1 3 0 4 (4,08%)

SGL Type IVa 0 3 2 0 5 (5,10%)

SGL Type IVb 1 2 8 1 12 (12,2%)

Total 45 18 4 4 98 (100%)

Glottic and supraglottic cordectomy practiced as rated by the ELSOC

Complicaciones N % Tipo

Intraoperative 2 2,04% One patient loss of tooth and another suffer ignition of the airway.

Inmediate post

operative

6 6,1% 5 episodes of post-surgical bleeding and 1 episode of dyspnea

secundary to airway edema.

Delayed post-

operative

13 13,2% 8 patients suffer aspiration pneumonia. 2 patients had cervical

abscess (One of them complicated with mediastinitis). 2 patients had

stenosis of the laryngeal vestibule. 1 patient had thyroid cartilage

chondritis.

Total 19 19,38%

Intraoperative, immediate and delayed postoperative complications associated with laser surgery

Glottic Supraglottic Transglottic p

Mean hospital stay3,6 days (±8,3

= Min: 1/Max:

66)

13,2 days (±25,5

= Min: 2/Max:

149)

38 days (±54,8 =

Min: 2/Max: 116)

<0,0001

NFT20,6% 80,6% 100% <0,0001

NFT mean duration 0,9 days (± 2,2

days = Min: 0/

Max: 13)

6 days (± 5,7

days = Min: 0/

Max: 29)

15,5 days (± 19,2

days = Min: 2/

Max: 44

<0,0001

The mean of hospital stay, percentage of placement and duration of NFT according to tumor location

Discussion

In this retrospective study we analyzed the results of a group of 98 patients and 131 CO2 laser interventions (98 primary, 33 reoperations) due to laryngeal tumors (pT1, pT2, pT3 and pT4), treated by primary intention with TLM.

The presence of intraoperative complications was low, affecting 2% of patients. The immediate postoperative complications occurred in 6.1% of the cases and the delayed ones up to 13.2% of patients.

Any of these complications were fatal.

In our series this complication represented the 5.1% of the immediate post-surgical complications, affecting 6.4% of patients in the STG, 3.2% in the GTG and 25% in the TTG, findings in relation to those found in the literature.

Vilaseca et al 3 reported an 8% of bleeding in a serie of 275 patients, 6.9% were in the group of supraglottic tumors and 2.9% in the glottic tumors.

Steiner and Ambrosch 8 reported a bleeding rate of 7% in supraglottic tumors and 0% in glottic tumors.

8.1% of patients in our study suffered aspiration pneumonia after surgery, it was lower than the result described by Roh et al 14 who reported an incidence of 11.5% of aspiration pneumonia after TLM, and was higher with respect to those described by Vilaseca et al3 who reported a rate of 6.1% of pneumonias in the treatment of glottic, supraglottic and hypopharyngeal tumors.

Regarding the cervical complications, 2 (2%) patients had cervical abscess formation, one was complicated with mediastinitis. No case of emphysema or cervical fistula was evident.

However Vilaseca et al 3 reported in their study the development of cervical emphysema in 3 patients and cervical fistula in one, while Peretti et al 9 described other 2 cases of persistent cervical fistula after performing temporary tracheotomy in their patients.

42% of patients in our study required NFT, 20.6% of these in the GTG, 80.6% in the STG and 100% of the patients treated in the TTG. But it is important to note that in most cases, the placement of NFT was due to a principle of security because of the wide resection.

During the admission, the swallowing was evaluated and the NFT was removing after achieving an adequate swallowing.

In our sample, ignition of the air was evident in one case, who was able to treat immediately without further consequences for the patient. This complication happened despite using special orotracheal tube for laser surgery, the invaluable collaboration of the anaesthetists to reduce the levels of O2 and the decision-surgical precautions such as placing cottonoid sponge with saline.

These facts suggest that even taking all the precautions, ignition risk is always present.

TLM showed good oncologic results and a low complication rate compared to traditional open surgery during the intervention, the immediate and the delayed postoperative period.

Conclusion

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Bibliography

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