Risk factors for total laryngectomy associated proximal esophageal stricture formation in head and neck cancer patients

Abstract

Background Development of esophageal strictures is common after the total laryngectomy of head and neck cancer patients. While endoscopic techniques like dilatation by balloon or Salvary bougies are well established, risk factors and pathophysiology for development of refractory strictures are less well understood.

Objective To evaluate risk factors associated with occurrence and recurrence of total-laryngectomy-associated esophageal strictures in head and neck cancer patients.

Methods We analyzed retrospectively a cohort of 170 head and neck squamous cell carcinoma patients, who underwent total laryngectomy between 2007 and 2017. The outcome measure was laryngectomy-associated proximal esophageal stricture needing an endoscopic dilatation by using a balloon or Savary dilators.

Results Of the 170 patients in the cohort, 32 (18.8%) developed strictures. Mean time between surgery and first endoscopic intervention was 24.4 months. Significant predictive factors were age ≥ 65 (p=0.017), nodal status N> 1 (p=0.003), continued alcohol abuse after surgery (p=0.005) and diabetes mellitus (p=0.005). In a subgroup, 17 of 32 patients developed refractory strictures and needed more than three dilatations to relieve dysphagia. Postoperative mean (p=0.016) and maximum (p=0.015) C-reactive protein (CRP) were predictive for refractory strictures.

Conclusion Symptomatic strictures occurred in 18.8% of the cases. Age, nodal status N>1, continued alcohol abuse and diabetes mellitus were predictive factors. For refractory stenosis (>3 dilatations needed) mean and maximum postoperative CRP were predictive. This may indicate that systemic inflammatory response post-surgery is involved in the stricture formation process.

Zusammenfassung

Hintergrund Die Entwicklung von Ösophagusstenosen tritt nach einer totalen Laryngektomie bei Patienten mit Kopf-Hals-Krebs häufig auf. Während endoskopische Techniken wie die Dilatation mittels Ballon oder Salvary-Bougies gut etabliert sind, sind die Risikofaktoren und die Pathophysiologie für die Entwicklung von refraktären Strikturen weniger gut bekannt.

Zielsetzung Evaluierung von Risikofaktoren, die mit dem Auftreten und Wiederauftreten von Ösophagusstrikturen nach totaler Laryngektomie bei Patienten mit Kopf-Hals-Tumoren assoziiert sind.

Methoden Wir analysierten retrospektiv eine Kohorte von 170 Patienten mit Plattenepithelkarzinom des Kopfes und Halses, die sich zwischen 2007 und 2017 einer totalen Laryngektomie unterzogen. Weiter untersucht wurden Patienten die eine laryngektomieassoziierte proximale Ösophagusstenose entwickelten, welche eine endoskopische Dilatation mit einem Ballon oder Savary-Dilatatoren erforderte.

Ergebnisse Von den 170 Patienten in der Kohorte entwickelten 32 (18,8 %) behandlungswürdige Strikturen. Die durchschnittliche Zeit zwischen der Operation und dem ersten endoskopischen Eingriff betrug 24,4 Monate. Signifikante prädiktive Faktoren waren Alter ≥ 65 (p=0,017), Nodalstatus N> 1 (p=0,003), fortgesetzter Alkoholmissbrauch nach der Operation (p=0,005) und Diabetes mellitus (p= 0,005). In einer Untergruppe entwickelten 17 von 32 Patienten refraktäre Strikturen und benötigten mehr als drei Dilatationen zur Behebung der Dysphagie. Das postoperative mittlere (p=0,016) und maximale (p=0,015) C-reaktive Protein (CRP) war prädiktiv für refraktäre Strikturen.

Schlussfolgerung Symptomatische Strikturen traten in 18,8 % der Fälle auf. Alter, Nodalstatus N>1, anhaltender Alkoholmissbrauch und Diabetes mellitus waren prädiktive Faktoren. Für refraktäre Stenosen (>3 Dilatationen erforderlich) waren das mittlere und maximale postoperative CRP prädiktiv. Dies könnte darauf hinweisen, dass die systemische Entzündungsreaktion nach der Operation an der Strikturbildung beteiligt ist.

Keywords

HNSCC - esophageal stricture - risk factors - dilatation

Schlüsselwörter

HNSCC - Ösophagusstenose - Risikofaktoren - Bougierung

Publication History

Received: 20 October 2022

Accepted after revision: 03 August 2023

Article published online:
27 September 2023

• Literatur

• 1 Francis DO, Weymuller EA, Parvathaneni U. et al. Dysphagia, Stricture, and Pneumonia in Head and Neck Cancer Patients: Does Treatment Modality Matter?. Annals of Otology, Rhinology & Laryngology 2010; 119 (06) 391-397
• 2 Paleri V, Roe JWG, Strojan P. et al. Strategies to reduce long-term postchemoradiation dysphagia in patients with head and neck cancer: An evidence-based review. Head & Neck 2014; 36 (03) 431-443
• 3 Pezdirec M, Strojan P, Boltezar IH. Swallowing disorders after treatment for head and neck cancer. Radiol Oncol 2019; 53 (02) 225-230
• 4 Lepke RA, Libshitz HI. Radiation-induced injury of the esophagus. Radiology 1983; 148 (02) 375-378
• 5 Forastiere AA, Goepfert H, Maor M. et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. The New England journal of medicine 2003; 349 (22) 2091-2098
• 6 de Almeida JR, Byrd JK, Wu R. et al. A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review. The Laryngoscope 2014; 124 (09) 2096-2102
• 7 van Boeckel PGA, Siersema PD. Refractory esophageal strictures: what to do when dilation fails. Curr Treat Options Gastroenterol 2015; 13 (01) 47-58
• 8 Patterson DJ, Graham DY, Smith JL. et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983; 85 (02) 346-350
• 9 Maclean J, Cotton S, Perry A. Post-laryngectomy: it’s hard to swallow. Dysphagia 2009; 24 (02) 172-179
• 10 Sweeny L, Golden JB, White HN. et al. Incidence and Outcomes of Stricture Formation Postlaryngectomy. Otolaryngology–Head and Neck Surgery 2012; 146 (03) 395-402
• 11 Sgonc R, Gruber J. Age-Related Aspects of Cutaneous Wound Healing: A Mini-Review. Gerontology 2013; 59 (02) 159-164
• 12 Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest 2007; 117 (05) 1219-1222
• 13 Xiang J, Wang S, He Y. et al. Reasonable Glycemic Control Would Help Wound Healing During the Treatment of Diabetic Foot Ulcers. Diabetes Ther 2019; 10 (01) 95-105
• 14 Park JH, Kim KY, Song HY. et al. Radiation-induced esophageal strictures treated with fluoroscopic balloon dilation: clinical outcomes and factors influencing recurrence in 62 patients. Acta Radiologica 2017; 59 (03) 313-321
• 15 Nguyen N, Moltz C, Frank C. et al. Dysphagia following chemoradiation for locally advanced head and neck cancer. Annals of Oncology 2004; 15 (03) 383-388
• 16 de Kort WWB, Maas SLN, Van Es RJJ. et al. Prognostic value of the nodal yield in head and neck squamous cell carcinoma: A systematic review. Head & Neck 2019; 41 (08) 2801-2810
• 17 Zhang Y, Wang R, Miao L. et al. Different levels in alcohol and tobacco consumption in head and neck cancer patients from 1957 to 2013. PLoS One 2015; 10 (04) e0124045
• 18 Vu KN, Day TA, Gillespie MB. et al. Proximal esophageal stenosis in head and neck cancer patients after total laryngectomy and radiation. ORL; journal for oto-rhino-laryngology and its related specialties 2008; 70 (04) 229-235
• 19 Pereira-Lima JC, Ramires RP, Zamin Jr. I. et al. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. The American journal of gastroenterology 1999; 94 (06) 1497-1501
• 20 Shi P, Ding X. Progress on the Prevention of Esophageal Stricture after Endoscopic Submucosal Dissection. Gastroenterol Res Pract 2018; 2018: 1696849
• 21 Nonaka K, Miyazawa M, Ban S. et al. Different healing process of esophageal large mucosal defects by endoscopic mucosal dissection between with and without steroid injection in an animal model. BMC gastroenterology 2013; 13: 72