Chapters authored
Prosthetic Reconstruction of the Upper Digestive Tract
In cases of locally advanced cancers involving the junction between the hypopharynx and cervical oesophagus, the curative surgical treatment is total circular laryngo-pharyngectomy with resection of the upper cervical oesophagus, coupled with modified radical neck dissection. Techniques used to re-establish the continuity of the digestive tract have been pectoral transposition flap, gastric pull-up, jejunum or colon transposition and free pedicled fascial-cutaneous flap reconstruction. Prosthetic reconstruction was thought of and used only as a temporary solution. In our clinic, we adapted the Montgomery oesophageal prosthesis as more than just a temporary solution and used it in 63 patients operated from 2004 to 2014 with advanced (stages III and IV) cancer involving most of the hypopharynx or extending towards the upper cervical oesophagus. Following total circular laryngo-pharyngectomy with bilateral modified radical neck dissection, prosthetic reconstruction was performed using the Montgomery oesophageal tube. Patients were followed up on, and their status was monitored. Favourable results encouraged the authors to further develop a new active prosthesis, with advanced design and materials that better mimic the anatomy and physiology of the replaced segment. Prosthetic reconstruction of the upper digestive tract following radical oncologic surgery is a viable option, with advantages compared to other laborious plastic techniques. The new active model is under development, hopefully offering soon a safe and more cost-effective alternative to the other techniques.
Part of the book: Gastrointestinal Surgery
HPV-Positive Oral Squamous Cell Carcinoma
Head and neck malignancies represent the sixth most frequent type of cancer currently in worldwide statistics. Of these, oral and pharyngeal cancers have steadily increased, being linked with the increase in HPV infection pandemic. This rise is not due to one cause, but rather multiple factors such as lifestyle and sexual behavior pattern changes and globalization. Because of the anatomy of the oral cavity and oropharynx, the proper diagnosis is easily delayed, and patients present with advanced stage disease, which requires aggressive and extensive surgery along with neck dissection and chemoradiotherapy. Patients with advanced stage disease have a high recurrence risk with a low 5-year survival rate. Preventing the HPV infection is of course desirable, but right now, for adults which already are infected and have a higher risk of developing HPV-related neoplasias, as well as for our head and neck cancer patients, alternative treatment algorithms are necessary.
Part of the book: Human Papillomavirus
Pharyngocutaneous Fistulas Following Total Laryngectomy
Total laryngectomy is still the final therapeutic solution in cases of locally advanced laryngeal cancer, as well as in cases of therapeutic failure of organ-sparing surgery or radiation therapy. Following excision of the larynx, the remaining pharynx is reconstructed to obtain continuity of the upper digestive tract. One of the most common complications in these patients, despite constant refinement of the procedure, is the development of a pharyngo-cutaneous fistula. These fistulas prolong hospital stay and often require a second surgical procedure, increasing morbidity and cost for the patient, while diminishing his quality of life. Some risk-factors have been identified, but only some may be corrected before surgery to lower this risk. Managing the fistula once present depends on multiple factors, essential being the size of the fistula as well as the position and concomitant factors, with options ranging from conservative measures to aggressive reconstructive surgery with local miocutaneous flaps. Modern vocal rehabilitation with T.E.P. (tracheo-esophageal puncture) and vocal prosthesis placement presents a new challenge – because of the risk of developing a tracheo-esophageal fistula, with an even higher risk for the patient because of tracheal aspiration. Understanding healing mechanisms of these structures is key to proper management of this complication.
Part of the book: Recent Advances in Wound Healing
Pharynx Reconstruction and Quality of Life
Patients who are diagnosed with squamous cell carcinoma of the pharynx have a first delayed presentation, with advanced stages of the disease. Therefore, they frequently require a multimodal approach—by surgery, radio, and chemotherapy. Due to anatomic spatial limits and particularities, therapy can imply large organ resection with difficulties in reconstruction. Nowadays, there is a paradigm shift in the management of this pathology, with significant first referral to oncology departments and initiation as the first line of treatment of radio/radio-chemotherapy. As a consequence, salvage surgery may be mandatory in some selected cases. The proposed chapter will address the oncological particularities of the pharynx, with a focus on the oro- and hypopharynx, ways of reconstruction after oncological ablative surgery of these segments, and impact on quality of life (QoL) index. Speech, respiratory, and deglutition rehabilitation of these patients is essential and will be a distinct topic. This paper will have the structure of a literature review with clinical examples of reconstruction from ENT and Head and Neck Surgery Department of Coltea Clinical Hospital, Bucharest. Reconstruction methods used in our clinic are regional flaps and biocompatible prostheses in advanced stages. QoL index in our clinic is assessed with questionnaires developed by the European Organization for Research and Treatment of Cancer – EORTC QLQ C30.
Part of the book: Pharynx