Management of
Pharyngocutaneous Fistulization
in Transoral Robotic Surgery
Eliot J. Martin, PA-C; Eric J. Moore, MD; Kerry D. Olsen, MD.
Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN.
Abstract
Objectives: 1. To determine the incidence
of pharyngocutaneous fistula associated
with transoral robotic oropharyngectomy
with concurrent neck dissection.
2. To discuss the prevention and treatment
of pharnyngocutaneous fistulization as a
consequence of transoral oropharyngeal
surgery with simultaneous neck dissection.
Methods: A retrospective, single
institution chart review of sixty-six
consecutive patients who underwent
transoral robotic surgery with synchronous
neck dissection for oropharyngeal neoplasia
between April 2007 and February 2009.
Results: Nineteen out of 66, or 28.8% of
patients were identified as having an
orocervical communication intraoperatively.
All were managed with some combination
of primary closure, local tissue
advancement, fibrin glue saturation, and
cervical drain placement. Of these patients
only 3, or 4.5%, went on to develop a
persistent salivary leak requiring post
operative management via controlled
incision and drainage with daily packing
placement.
All of these patients had aesthetic and
functional results comparable to those
patients that did not have/develop an
orocervical communication. No patients
experienced a delay from their operative
treatment that prevented them from
initiating recommended adjuvant therapy on
schedule.
Conclusion: Transoral robotic surgery is
emerging as a primary treatment modality
for oropharyngeal malignancies.
Postoperative pharyngocutaneous fistula is
an uncommon, preventable, but potentially
problematic complication resulting from
this operative technique when combined
with concurrent neck dissection. Prompt
recognition and intervention are of
paramount importance in preventing both
acute and long term functional
impairment.
Introduction
Transoral resection of oropharyngeal malignancies provides
exceptional local/regional disease control and survival benefit while
optimizing function, minimizing complications and limiting treatment
to that which is essential to maximize results1. Previous approaches to
oropharyngeal tumors via the transoral route, however, have been
technically challenging and fraught with a limited operative field of
view. With the emergence of reports advocating the ease, safety and
efficacy of transoral robotic surgery (TORS), it seems probable that a
paradigm shift to primary surgery in reference to oropharyngeal
carcinoma will ensue2-9. The majority of these reports advocate robotic
oropharyngectomy, followed by surgical addressment of the neck in a
delayed fashion. The proposed rationale for secondary neck dissection
in lieu of TORS with synchronous neck dissection is in effort to avoid
pharyngeal entry, as well as to avoid additional laryngopharyngeal
swelling that may result in the need for tracheostomy2.
The obvious downside to this algorithm is prolonged treatment with
multi operational therapy, a delay in recommended adjuvant therapy
when clinically necessary, and increased overall medical costs
associated with the staggered operative course. We in turn have
chosen to manage the neck and the primary tumor during the same
operative setting.
With these statements/presumptions in mind we wanted to
evaluate our institutions data regarding robotic assisted
oropharyngectomy with simultaneous neck dissection to see if
orocervical fistulization would be a deterrent for single setting
operative therapy.
Patients and Methods
Patient Inclusion
After obtaining approval from the Mayo Clinic Institutional
Review Board, we used the Mayo Clinic tumor registry to identify
patients who underwent daVinci assisted oropharyngectomy with
synchronous neck dissection from April 2007 to February 2009 at
Mayo Clinic, Rochester, Minnesota. We retrospectively reviewed the
electronic medical records of sixty-six consecutive patients that
underwent TORS with simultaneous neck dissection within the
aforementioned timeframe in effort to identify the actual incidence of
intra and postoperative pharyngocervical communications. Patient
data was retrieved from operative dictations, final pathology reports,
hospital progress notes, and all subsequent visit documentation via the
head and neck multidisciplinary team. All reviewed medical records
had appropriate documentation regarding the presence, absence or
development of a pharyngocervical connection.
Operative Procedure
All included tumors were located within the confines of the
oropharynx and were exposed with the aid of the FeyhKastenbauer (FK) retractor (Gyrus ACMI, Southborough, MA).
Utilization of the da Vinci surgical robot (Intuitive Surgical Inc.,
Sunnyvale, CA) aided in oropharyngeal tumor extirpation via
techniques described previously by Weinstein et al.2, Holsinger et
al10, and Moore et al.4 When oncologically feasible the
buccopharyngeal fascia was not disrupted. Negative margins were
confirmed in all patients via frozen section analysis, and no
attempts at transoral robotic resection were aborted in favor of
alternative approaches. The robotic resected tonsillar primary
tumors and unilateral tongue base tumors were coupled with
ipsilateral level I – IV neck dissections. Base of tongue
malignancies extending across the midline were paired with
bilateral level I – IV neck dissections. Patients were pathologically
staged according to the American Join Committee on Cancer
Criteria11, and standard descriptive statistics are used to summarize
the data.
Results
Sixty-six consecutive patients with oropharyngeal carcinoma
who underwent TORS with concomitant neck dissection by the
contributing authors comprised the subjects of this review. Nineteen
(28.8%) of the subjects were identified intraoperatively as having an
iatrogenic orocervical communication. All defects were detected via
direct visualization, and or intraoral irrigation flooding that revealed a
pharyngeal breach. Of the 19 patients identified as having an operative
fistula, 15 had tumor removal from the tonsillar fossa, and 4 had
resection of tongue base primaries. The pathology confirmed TNM
staging of the 19 patients is as follows: 8 stage T1 tumors, 9 stage T2
tumors, 1 stage T3 tumor, and 1 stage T4a tumor. Despite the fact that
17 of the 19 were low T stage malignancies, all 19 collectively
suffered from advanced stage disease: 4 stage III, 14 stage IVa, and 1
stage IVb.
The pharyngocervical defects ranged from 5mm in diameter, up
to 4cm in diameter. All defects less than 1 cm in diameter were
managed via transoral or transcervical primary closure of the
pharyngeal constrictors, followed by transcervical application of 4ml
of Tisseel (Baxter Bioscience, Deerfield, IL) fibrin sealant and suction
drain placement. This patient subset resumed clear liquid oral intake
on post operative day 1, and retained their cervical drains until the
output dropped to 10ml in a continuous 24 hour time period.
Defects greater than one centimeter underwent suction drain
placement, were closed primarily when feasible, reenforced with
muscular coverage and bathed with Tisseel. In all cases of muscular
introduction, the digastric and mylohyoid muscles were utilized. In 3
cases a sternocleidomastoid myofascial flap was employed. The
patients with defects greater than 1 cm underwent nasogastric feeding
tube placement intraoperatively, and were made NPO for 24 – 48
hours. Cervical drains were managed mirroring those of the first
group. On post operative day 2 a clear liquid diet was employed if
there was no clinical suspicion for fistula formation.
Regardless of defect diameter, intravenous antimicrobial
coverage was initiated with either Cefazolin/Metronidazole or
Clindamycin.
Of the 19 patients identified as having a communication, 3 went
on to develop a delayed pharyngocutaneous fistula after hospital
dismissal. Two of the patients had T2 tumors (1 tonsil and 1 tongue
base), and the third subject had a T1 tonsillar primary. They all varied
in their nodal staging: N1, N2a, and N2b, and their intraoperative
fistula size ranged anywhere from 5mm to 2cm in greatest dimension.
Time until clinical presentation ranged from post operative day 7 to
POD 12. Interestingly these patients had not been treated with prior
operative or non operative therapy for their carcinoma.
Patients with pharyngocutaneous fistulae were treated with non
operative, aggressive clinical therapy. All underwent controlled
incision and drainage via way of their neck dissection surgical site in
an outpatient setting. Rigorous debridement of necrotic tissue was
followed by wound packing with half inch Iodoform gauze. Initial
local wound care was followed by application of a Barton pressure
dressing. These patients were restarted on antibiotics, made NPO and
underwent indirect placement of a nasogastric feeding tube for
alimentary support. Patient/caregiver education was provided in
regards to wound care and enteral nutrition in an outpatient setting, and
none of the patients required hospital readmission.
.
Fistula closure was documented within two weeks in all three
cases via clinical inspection and dynamic video swallowing evaluation.
None of the patients required reoperation with local or free tissue
reconstruction. Once fistula resolution was ascertained, the feeding
tubes were removed and an oral diet was resumed. All three patients
were able to implement adjuvant therapy four weeks post operatively.
None of the 47 patients who lacked an orocervical
communication intraoperatively developed delayed fistulization.
Further, none of the sixty-six subjects comprising this entire review
required reintubation or unplanned tracheostomy.
Discussion
Squamous cell carcinoma of the oropharynx will affect 9,000
new patients in the United States in 2009, and will be responsible for
upwards of 70,000 deaths worldwide during the same calendar year1213. A retrospective analysis of the National Cancer data base has
indicated that upfront surgical ablation of oropharyngeal neoplasia
followed by radiation therapy affords a survival benefit compared to
chemoradiation or radiation alone 14. Several reported series from
multiple institutions have shown superior local control and five year
survival rates employing this aforementioned treatment algorithm15-16.
Though the benefit of initial surgical resection is recognized,
traditional operative approaches to the oropharynx have left patients
with significant functional and cosmetic impairments, resulting in a
trend towards nonoperative therapy3.
The recent evolution of transoral laser microsurgery (TLM) has
revived enthusiasm for surgical therapy as a primary treatment
modality for oropharyngeal carcinoma. This technique, however, has
a steep learning curve, a laryngoscope limited view of the disease
involved field, and challenges with both tissue manipulation and
vascular control.
In pursuit of a universal user friendly transoral approach to
oropharyngeal neoplasia several authors have recently reported on the
operative advantages associated with transoral robotic surgery
(TORS)2-4,6-9. The daVinci robotic system allows for an up close, three
dimensional view of the tumor field, wristed 6 degree motion, tremor
filtration, and it affords users a shorter learning curve when compared
to TLM2,3,8,17. Weinstein et al.2 demonstrated acceptable oropharyngeal
competency with TORS for squamous cell carcinoma of the tonsil, but
with staged neck dissection 1-3 weeks later.
.
Advocates for delayed neck dissection site a primary worry of
fistulization, increased laryngopharyngeal edema resulting in acute
functional impairment, and the ability to pursue additional tissue
resection should permanent pathology reveal tumor involved margins.
Though these arguments are defendable, delayed treatment of the neck
is likely associated with increased cost (multi operation therapy, multi
hospitalization), longer convalescence, a delay in recommended
adjuvant therapy after primary tumor resection, and one could
theoretically question patient compliance/acceptance due to drawn out
treatment course.
The literature is scarce regarding TORS with simultaneous neck
dissection. Genden et al.6 were the first to report on 15 patients
treated for squamous cell carcinoma with TORS and concomitant
neck dissection. They documented one intraoperative orocervical
fistula that responded to local musculomucosal flap coverage. None
of their patients required tracheostomy. Boudreaux et al. reported
nine cases of robotic assisted oropharyngectomy with synchronous
neck dissection, with no subjects sustaining intra/postoperative
orocervical communications.
Our results showed that intraoperative pharyngocervical defects
were not uncommon (28.8% of patients), but that when identified and
meticulously managed, seldomly (15.8%) resulted in delayed
pharyngocutaneous fistulization. When pharyngocervical breakdowns
ensued, aggressive non operative management was associated with
rapid healing, resulted in no hospital readmissions/reoperation,
precluded a delay in postoperative therapy, and was not associated
with prolonged oropharyngeal dysfunction. Although communications
ensued regardless of tumor T staging, all defects were associated with
advanced stage disease. This correlation should alert the surgical
oncologist to an increased probability of an orocervical communication
when treating stage III and IV oropharyngeal disease.
Based on our clinical experience we feel that TORS with
simultaneous neck dissection is a safe effective primary treatment
modality for select patients with oropharyngeal malignancies.
TORS with synchronous neck dissection
Intra operative orocervical communication
No communication
-Neck drain (output <10ml in 24 hrs.)
-NO dressing
-NO feeding tube
-Clear liquid diet,
advance as tolerated
< 1cm
-Primary closure
-Tisseel
-Neck drain (output <10ml in 24 hrs.)
-Clear liquid diet POD1
>1 cm
-Primary closure if feasible
-Muscle coverage (mylohyoid, digastric, SCM)
-Tisseel
-Neck drain (output <10ml in 24 hrs.)
-Feeding tube
-NPO 24-48hrs. If no leak start clear liquid diet (ADAT)
Pharyngocutaneous fistula
-Controlled incision and drainage, necrotic tissue debridement
-Iodoform packing (changed bid) +/- barton dressing, NPO with feeding tube placement
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