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PubMed1985

Stomal recurrence--etiologic factors and prevention.

Out of a total of 340 laryngectomies performed in the Department of Otorhinolaryngology at Kobe University Hospital from 1969 to 1982, there were 20 stomal recurrences. In the preoperative tracheostomy group, 6 out of 52 patients (11.5%) developed stomal recurrence compared to 14 out of 288 (4.9%) in the operative tracheostomy group. Of these 20 stomal recurrences, 7 were supraglottic with 1 subglottic extension, 9 were glottic with 8 subglottic extensions, and 4 were primary subglottic cancers. The mean interval between the laryngectomy and stomal recurrence was 16 months and ranged from 20 days to 55 months after laryngectomy. We analyzed our series together with recent material which had been subjected to pretracheal and paratracheal lymphatic dissection. Reports from the literature were also used. Tumor cell inoculation in the tracheostomy wound and persistent pretracheal and paratracheal lymph node lesion are the two most likely major etiologic factors. The above evaluation leads us to propose the following preventive measures: 1) thorough irrigation of the wound following the removal of the larynx, 2) complete excision of the tracheostomy tract for preoperatively tracheostomized patients, 3) pretracheal and paratracheal lymphatic dissection for subglottic lesion, 4) in the above cases, laryngectomy should be followed by peristomal radiotherapy.

Adult↗
PubMedDate not supplied

Thorascopic staging of stomal recurrence.

BACKGROUND: Squamous cell carcinoma of the low cervical area may be secondary to stomal recurrence following laryngectomy, low cervical esophageal disease, or peritracheal metastasis. Most often patients with disease in this area have already received both surgery and radiotherapy. Prior to Sisson's description of the trans-sternal radical neck dissection or mediastinal dissection the management and prognosis was uniformly poor. Since then, a number of authors have reported their experience with mediastinal dissection. Survival remains poor but palliation has been acceptable. Unfortunately, resectability of the disease cannot often be determined prior to the actual surgical procedure. A number of patients are explored only to have the procedure terminated. Thoracoscopy is a procedure that involves insertion of two or three trocars into the right thoracic cavity with collapse of the right lung. A form of endoscopic surgery, it permits visualization and dissection of the important structures of the mediastinum. Tracheal, esophageal, and great vessel invasion by tumor can be evaluated. METHODS: Prospectively, all patients initially seen with stomal recurrence from 1991 to 1994 were evaluated. CT scans, MRIs as well as thoracoscopy were performed when indicated. RESULTS: One patient required conversion to a minithoracotomy involving a 7-cm chest incision. The patient was found to have unresectable disease with tumor involving the great vessels of the mediastinum. A second patient was found to have unresectable disease with tumor encasing the subclavian artery. The third patient was found to have no mediastinum involvement. The patient with no mediastinum involvement underwent a stomal resection with mediastinal dissection. Reconstruction with a pectoralis major myogenous flap was performed. The patient has remained disease free to date. The remaining two patients were judged to have unresectable disease and were offered palliative treatment. Both of these patients died of the disease within 6 months. CONCLUSIONS: Thoracoscopy provides important information in judging the surgical resectability of patients with stomal recurrence. This procedure has not been previously described in the otolaryngologic literature. We provide some suggestions for its use in the evaluation of the mediastinal extent of disease.

Aged↗
PubMed1984

Inhibition of stomal recurrence in laryngectomy with preoperative far therapy. A statistical evaluation.

FAR therapy is effective for cancers of the head and neck, in particular laryngeal cancer. This combined chemoradiotherapy consists of 5-FU, vitamin A and radiation. We found 10% stomal recurrences in reviewing 112 patients who had been treated with total laryngectomy. Stomal recurrences after total laryngectomy occur frequently in patients undergoing an emergency tracheotomy. We studied 33 such patients divided into 2 groups, on the basis of whether laryngectomy had been carried out after the emergency tracheotomy plus preoperative FAR therapy, or whether laryngectomy had been carried out without preoperative FAR therapy. The incidence of stomal recurrence was less among those given preoperative FAR therapy and was statistically significant. Such being the case, preoperative FAR therapy seems to e prophylactically effective against stomal recurrence after emergency tracheotomy.

Combined Modality Therapy↗
PubMedDate not supplied

Long-term results of concurrent polychemotherapy and radiotherapy in patients with stomal recurrence after total laryngectomy.

From 1978 through 1985, eight patients with stomal recurrence after total laryngectomy were treated with a combination of a cytotoxic regimen (vincristin sulfate, bleomycin, and methotrexate [VBM]) and radiotherapy. The essential feature of this combination is the synchronous administration of pulses of VBM and fractionated doses of external radiotherapy in order to achieve potentiation of radiotherapy. On average, four to five pulses of VBM were given. Severe mucositis is the main problem during treatment. Two patients needed nasogastric tube feeding, and treatment was carried out as an inpatient procedure. Five patients are alive with complete local remission at 7 years, 3 years, 2 1/2 years, 14 months, and 8 months after treatment. These results appear to be spectacular, even though the number of patients is small. Of the three patients who died, only one had recurrent disease around the tracheostoma. The two other patients were free of disease in the neck when they died 6 and 16 months after treatment of, respectively, lung metastases and a second primary tumor in the lung. Patients with stomal recurrence after total laryngectomy are now routinely treated with synchronous VBM and radiotherapy.

Aged↗
PubMedDate not supplied

Stomal recurrence following laryngectomy: a critical evaluation.

Recurrent tumor in or around the tracheal stoma following laryngectomy almost always terminates in a fatal outcome. Several investigators have attempted to determine the factors that predispose a patient to stomal recurrence, but their conclusions are not entirely in agreement. The records of 251 consecutive laryngectomy patients treated at the UCLA Hospital between 1955 and 1977 were reviewed. The variables evaluated included type of operation, preoperative tracheostomy, interval from operation to recurrence, presence of neck metastases, performance of thyroidectomy, site of lesion, and control of tumor margins. While certain events, such as preoperative tracheostomy, appeared more frequently than others in the stomal recurrence patients, no single factor or group of factors could explain all the recurrences. It appears that stomal recurrences arise from heterogeneous causes. Good planning and utilization of the principles outlined should reduce the incidence of this dreaded complication.

Adult↗
PubMed1981

Pectoral myocutaneous island flap for reconstruction of stomal recurrence.

In 1962, one of us (G.A.S.) reported six mediastinal dissections for stomal recurrence after laryngectomy. Reconstruction of the superior mediastinum depended on the use of several regional flaps. Adequate soft-tissue and muscle coverage is mandatory to avoid major complications in this (usually) previously radiated and/or surgical field. Seven cases in which the greater pectoral myocutaneous island flap was successfully used for a one-stage reconstruction after ablative surgery for stomal recurrence have been reported in the literature. Our series of six patients supports the use of this flap in reconstruction after mediastinal dissection. Partial skin sloughing occurred in two patients. In one patient, a major complication of necrosis of the flap and an innominate artery rupture occurred. A review of this last case reinforces the necessity of adequate artery coverage in reconstruction.

Carcinoma, Squamous Cell↗
PubMed1991

Post-laryngectomy stomal recurrence: tumour implantation or paratracheal lymphatic metastasis?

In the treatment of obstructing laryngeal cancer, an association has often been noted between emergency tracheotomy for airway relief and subsequent post-laryngectomy stomal recurrence. It is however unclear whether this is due to tumour implantation in the tracheotomy track, or paratracheal lymph node metastasis. To investigate the pathophysiology of stomal recurrence, the recurrence rate and clinical outcome of 26 cases of T3N0M0 glottic cancer treated with emergency tracheotomy and subsequent laryngectomy were analysed, and compared with 65 stage-matched cases treated with laryngectomy alone. Analysis shows the 'emergency tracheotomy' group to have a very poor prognosis with a higher incidence of recurrence at the stoma, and also in the regional lymph nodes. These findings suggest that paratracheal lymph node metastasis is an important mechanism in the development of stomal recurrence and thus has considerable implications for the prevention of such a recurrence following laryngectomy in the patient presenting with malignant airway obstruction.

Carcinoma, Squamous Cell↗
PubMedDate not supplied

[Stomal recurrence after laryngectomy. An inevitable late complication].

Postlaryngectomy tumoral recurrence on the stoma is a terrible late complication that has a fatal outcome. In spite of advances in laryngeal surgery and modern reconstructive techniques, it is still a major cause of death in patients with laryngeal cancer. In a review of 500 patients who underwent surgery for laryngeal cancer in 1981-86 and 1995-97, we found no changes in the frequency of stomal recurrence between periods (4% in both periods). Stomal recurrence was associated in our study with subglottic extension and with transglottic lesions. Previous tracheotomy was not a decisive factor in the appearance of stomal recurrence in our patients.

Carcinoma, Squamous Cell↗
PubMed1999

Stomal recurrence invading the cervicothoracic esophagus and upper mediastinum: resectability and the creation of a safe anterior mediastinal tracheostoma.

Surgical salvage for stomal recurrence is a for midable problem for head and neck surgeons. The two factors of considerable significance are resectability and establishment of a safe anterior mediastinal tracheostoma. A case of stomal recurrence invading the cervicothoracic esophagus and upper mediastinum is presented. Total esophagectomy and upper mediastinal dissection was performed. The esophagus was reconstructed immediately with a pedicled gastric flap. The omentum on the gastric pedicle was wrapped around the trachea to reduce the likelihood of erosion into the great vessels and to supplement the lateral blood supply to the trachea. No serious postoperative complications were observed. We believe that the total esophagectomy improved the resectability, and that the bulk of the gastric pedicle and the use of the omentum prevented significant postoperative complications associated with an anterior mediastinal tracheostoma.

Anastomosis, Surgical↗
PubMedDate not supplied

Prevention of stomal recurrence.

BACKGROUND: The authors reviewed the incidence of stomal recurrence (SR) in a population of laryngectomized patients to study associated risk factors and determine the usefulness of certain preventive procedures. METHODS: A retrospective study was performed in 296 patients with larynx and hypopharynx carcinoma treated by total laryngectomy. RESULTS: Of the 296 patients, 6 (2%) were initially seen with SR. In all cases, a risk factor was found to be involved: subglottic extension (5 cases), tracheotomy prior to laryngectomy (1 case). Since 1989, when preventive measures were systematically introduced in patients presenting risk factors, there have been no further cases of SR. The surgical measures in tumors with subglottic extension consisted of hemithyroidectomies, paratracheal lymph node dissection, and extensive tracheal resection; in the case of a tracheotomy prior to the laryngectomy, extensive resections of the tracheal stoma were carried out. CONCLUSIONS: The systematic use of preventive surgical measures together with postoperative radiotherapy to the stoma and superior mediastinum have led to a decrease in the appearance of SR.

Aged↗
PubMed1988

Prevention of stomal recurrence in patients requiring emergency tracheostomy for advanced laryngeal and pharyngeal tumors.

Since 1976, patients requiring emergency tracheostomy for advanced laryngeal and hypopharyngeal cancer at the University of Cincinnati have been treated with a short course of prelaryngectomy radiation in an attempt to decrease the incidence of stomal recurrence. Twenty-one patients were treated after emergency tracheostomy with a course of radiation that usually consisted of 20 Gy in five fractions followed by laryngectomy 1 or 2 days later. Most patients also received postoperative radiotherapy of some type. The follow-up of 18 evaluable patients revealed only two (11%) stomal recurrences--a quite acceptable rate for this high-risk population. Overall, however, local recurrences were seen in ten patients (56%), which is higher than reported in most series of similar tumors. The most likely explanation for this seems to be that the short course preoperative radiation prevented the administration of adequate postoperative radiation for residual disease, which was usually present. An alternative treatment policy would be a planned course of moderate- to high-dose postoperative radiation, which could sterilize tumor in the entire locoregional area including the stoma.

Aged↗
PubMedDate not supplied

A one-stage flap reconstruction following resection for stomal recurrence.

The pectoralis major myocutaneous island flap has been used for a one-stage reconstruction following ablative surgery for stomal recurrence. The skin island of this flap is supplied by the perforating musculature vessels of the thoracicoacromial artery. The flap can be elevated primarily and is used in a one-stage reconstruction. The new stoma is created in the center of the skin island, and the great vessels are covered by the pectoralis major muscle pedicle. The surgical technique as performed in seven successful cases is presented.

Humans↗
PubMed1988

Mesh fixation of the mesentery for treatment of volvulus and recurrent stomal prolapse.

Mesenteric mesh-pexy is indicated for permanent and quick-clean fixation of the intestine. It is applicable to the treatment of recurrent stomal prolapse and intestinal volvulus when the intestine is viable, but resection, less definitive treatment or an additional operation would pose increased risks to the patient. Mesenteric mesh-pexy may also be considered prophylactically for floppy cecum and severely redundant loops of sigmoid colon.

Aged↗
PubMed1979

Stomal recurrences: a clinicopathological analysis and protocol for future management.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St. Louis, Mo. During this period, 33 stomal recurrences were diagnosed. These are clinicopathologically analyzed with regard to tumor size, site, histopathology and original surgical procedure. An association with transglottic tumors, emergency tracheotomy and, surprisingly, hemilaryngectomy is noted. Three theories of etiology are discussed. Since treatment to date is disappointing, several proposed methods of prophylaxis are presented. These include emergency laryngectomy, recurrent laryngeal lymphatic dissection and postoperative radiotherapy. The role of wide local excision and mediastinal dissection is also examined. Based upon the analysis and the proposed methods of prophylaxis, a protocol is suggested for the future management of this dreaded complication.

Aged↗
PubMed2003

Stomal recurrence following total laryngectomy: clinical and molecular analysis of a series.

The aim of the present study was to analyze the risk features and to discuss the preventive measures and treatment of stomal recurrence (SR) after total laryngectomy (TL), and to investigate the clonal relationship between the primary and recurrent lesions. We reviewed a series of 25 patients affected by SR after TL for laryngeal squamous cell carcinoma. A subset of 7 coupled primary and recurrent carcinomas were examined for microsatellite alterations that were used as a marker of genetic lineage. The incidence of SR was higher in patients with initial subglottic lesions (subglottic, transglottic, or glottic-subglottic tumors) than in those with other locations of laryngeal cancer (p = .013). In addition, the frequency of SR was significantly higher in patients who underwent preoperative tracheotomy, performed 48 hours or more before the TL, than in the group of patients who did not receive preoperative tracheotomy (23.3% versus 0.46%, p < .001). According to microsatellite analysis, of the 5 informative patients, 2 demonstrated discordant alterations in the recurrent tumor indicative of clonal heterogeneity, 2 demonstrated identical alterations, and 1 showed an additional alteration in the recurrent tumor. Our analysis supports the hypothesis that a subset of SRs after TL may be second primary tumors, genetically unrelated to the primary laryngeal lesion.

Adult↗
PubMed1987

Surgical salvage for stomal recurrence: a multi-institutional experience.

Recurrence of squamous cell cancer following total laryngectomy constitutes an extremely difficult therapeutic problem. Satisfactory management is elusive and frustrating to the head and neck oncologist. Various recommended therapeutic regimens include symptomatic treatment, palliation with chemotherapy and radiation, and aggressive surgical salvage. While surgery offers the only realistic chance at cure, this procedure is fraught with significant morbidity and a poor success rate. In an attempt to clarify the role of surgical salvage in these patients, experience with 57 patients with stomal recurrence presenting to three head and neck surgical groups will be presented. Forty-one of these patients subsequently underwent definitive surgery. The overall 2-year survival for operated patients was 16% with a 24% determinate survival. Further analysis revealed a 45% 5-year survival with type 1 and 2 lesions and 9% survival with types 3 and 4. Recommendations regarding indications for surgery are made based on this experience.

Carcinoma, Squamous Cell↗
PubMed1998

[Recurrent stomal hemorrhage treated by transjugular intrahepatic portosystemic anastomosis and embolization of stomal varices].

Bleeding stomal varices is a rare complication of portal hypertension. We report the case of a cirrhotic patient, with a history of colonic adenocarcinoma, who had recurrent bleeding stomal varices. Treatment with transjugular intrahepatic portosystemic shunt and stomal varice embolization was performed because failure of medical treatment of portal hypertension and sclerotherapy. Twenty six months later only one stomal hemorrhage was noted. This suggests that transjugular intrahepatic portosystemic shunt and stomal varice embolization is effective in case of recurrent bleeding of stomal varices.

Aged↗