Chirurgisches Management der persistierenden Speichelfistel nach Salvage-Laryngektomie

Zusammenfassung

Hintergrund:

Die Salvage-Laryngektomie (SLE) hat im Vergleich zu einer Primäroperation ein deutlich erhöhtes Komplikationsrisiko. Insbesondere die Ausbildung von postoperativen Speichelfisteln, für die in der Literatur Inzidenzraten zwischen 3 und 65% angegeben sind, stellt ein Problem dar.

Material und Methoden:

Im Rahmen dieser Studie wurden im Zeitraum von 2004–2011 Pa­tienten nachuntersucht, bei denen ein T4a-Larynx- oder T4a-Hypopharynx-Karzinom im Sinne eines Rezidiv- oder Zweittumors auftrat und die mit einer SLE behandelt wurden: Von 16 Pa­tienten hatten sieben (44%) ein Hypopharynx-Karzinom und neun (56%) ein Larynx-Karzinom. Wir untersuchten bei diesen Patienten das postoperative Risiko zur Ausbildung einer Speichelfistel und evaluierten ein chirurgisches Konzept zum Fistelverschluss.

Ergebnisse:

Bei 6 Patienten (38%) zeigte sich postoperativ eine persistierende Speichelfistel, die sekundär operativ verschlossen werden musste. Hier kam in allen Fällen ein sog. „Sandwich“-Prinzip zur Anwendung, bei dem wir die Pharynxrekonstruktion und somit den eigentlichen Fistelverschluss mittels M. pectoralis-major-Lappen vornahmen und die plastische Defektdeckung der kutanen Halsregion mit einem zweiten gestielten Fernlappen, wie dem Deltopectorallappen oder dem M. latissimus-dorsi-Lappen, durchführten. Hierdurch konnten wir alle 6 Fisteln nach SLE erfolgreich verschließen.

Schlussfolgerung:

Durch die Anwendung unseres „Sandwich“-Prinzips gewährleisten wir einen mehrschichtigen Fistelverschluss mit Einbringen von vitalem Muskelgewebe und einer doppelten Epithelschicht. Hierdurch entsteht eine sichere Barriere für den Speichel, sodass Rezidivfisteln effektiv verhindert werden können.

Abstract

Surgical Management of Persisting Fistulas after Salvage-laryngectomy

Background:

The salvage-laryngectomy (SLE) has compared to the laryngectomy a high risk for complications. The salivary fistula is the most frequent complication with an incidence range from 3% to 65% according to the literature.

Material and methods:

From 2004–2011 we included in this study 16 patients with a recurrent or secondary T4a-squamous cell carcinoma (HNSCC) of the larynx or pyriform sinus undergoing a SLE. 6 HNSCC were located at the pyriform sinus (44%) and 9 at the larynx (56%). The aim of this retrospective study was to analyze the risk of developing a postoperative fistula after SLE as well as to present our surgical concept of persisting fistula treatment.

Results:

6 out of these 16 patients (38%) had a persisting fistula which needed a secondary surgical closure. In all of these cases we used a “sandwich”-concept which included a reconstruction of the pharynx by the pectoralis myofascial flap and another regional rotation flap as the deltopectoral flap or the latissimus dorsi flap for skin reconstruction of the neck. With this concept we were able to successfully close the fistula after the SLE in all 6 cases.

Conclusion:

By using our “sandwich”-concept we provide a multi-layered fistula closure with insertion of vital muscle tissue and a double epithelium. This guarantees a secure barrier to the saliva and prevents effectively a further fistula.

Schlüsselwörter

Salvage-Laryngektomie - tracheopharyngeale ­Speichelfistel - M. pectoralis-major-Lappen - M. latissimus-dorsi-Lappen - Deltopectorallappen

Key words

salvage-laryngectomy - tracheopharyngeal fistula - pectoralis myofascial flap - latissimus dorsi flap - deltopectoral flap

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