Artigo Original
Há indicação para a realização da cirurgia de separação
laringotraqueal para a prevenção de aspiração pulmonar
em pacientes com tumores de cabeça e pescoço?
Is there indication to make laryngotracheal separation
surgery for the prevention of pulmonary aspiration in
patients with head and neck tumors?
Resumo
Objetivo: Avaliar os resultados obtidos em pacientes com câncer
de cabeça e pescoço submetidos à extensas ressecções das
vias aéreas e digestivas superiores associada à cirurgia de
separação laringotraqueal (SLT). Esta tinha o objetivo de prevenir
potencial aspiração pós-operatória. Desenho do Estudo:
Análise retrospectiva. Estabelecimentos: Hospital das Clínicas
da Universidade Federal de Minas Gerais (UFMG) e o Hospital
Biocor. Método: Análise dos prontuários médicos de 30 pacientes
com câncer de cabeça e pescoço, cuja exérese tem, sabidamente,
grande potencial de causar aspiração pulmonar no pós-operatória.
Eles foram submetidos à que se submeteram à realização da SLT
juntamente com a ressecção do tumor, no período de 1991 a 2008.
As seguintes variáveis foram avaliadas: prevenção de potencial
e grave aspiração pulmonar pós-operatória, morbidade e taxa
de reversibilidade da LTS. Resultados: A cirurgia foi eficaz em
100,0% dos casos. Seis (20,0%) pacientes tiveram complicações
pós-operatórias, ou seja, edema, estenose de traqueostomia e
fístula traqueocutânea do coto proximal da traqueia. A cirurgia
para reversão LTS foi realizada em 11 (36,7%) pacientes, sendo
eficaz em nove (81,8%); cinco (45,5%) tiveram complicações
pós-operatórias. Conclusões: A SLT impediu a ocorrência de
aspiração pulmonar pós-operatória em pacientes submetidos à
extensas ressecções das vias aéreas e digestivas superiores. O
procedimento é potencialmente reversível e tem uma alta taxa de
eficácia. No entanto, a frequência de complicações para ambas
LTS e, especialmente sua reversão, não pode ser negligenciada.
Descritores: separação laringotraqueal, prevenção de aspiração
pulmonar, câncer de cabeça e pescoço, deglutição, desordens de
deglutição.
Orlando Barreto Zocratto 1
Daniel Xavier Lima 2
Iure Kalinine F Souza 3
Lauro Nogueira Lopes 4
Vinicius Nogueira Toledo 5
Abstract
Objective: To evaluate the results obtained in patients with
head and neck cancer undergoing extensive resections of upper
aerodigestive tract associated with laryngotracheal separation
(LTS) surgery. The latter had the objective of preventing potential
postoperative aspiration. Study design: retrospective analysis.
Setting: Clinical Hospital of the Federal University of Minas
Gerais (UFMG) and Biocor hospital. Method: Thirty patients with
head and neck tumors, whose resections has great potential to
cause postoperatively pulmonary aspiration. They were submitted
to resection of the tumor and the LTS. The following variables
were evaluated: prevention of potential and severe pulmonary
postoperative aspiration, morbidity and rate of LTS reversibility.
Results: The surgery was effective in 100.0% of cases. Six
(20.0%) patients had postoperative complications, namely edema,
tracheostoma stenosis and tracheocutaneous fistula of the
proximal tracheal stump. Surgery for LTS reversal was performed
in 11 (36.7%) patients, being effective in nine (81.8%); five (45.5%)
had postoperative complications. Conclusion: LTS prevented
the occurrence of postoperative pulmonary aspiration in patients
undergoing extensive resections of the upper aerodigestive tract.
The procedure is potentially reversible and has a high efficacy rate.
However, the frequency of complications for the LTS cannot to be
neglected. Descriptors: laryngotracheal separation, preventing
pulmonary aspiration, head and neck cancer, deglutition,
deglutition disorders.
Key words: Deglutition Disorders; Respiratory Aspiration;
Deglutition.
Descritores: Neoplasias de Cabeça e Pescoço; Deglutição;
Transtornos de Deglutição.
Introduction
Surgical treatment of patients with advanced mouth
tumors, usually, implies extensive resection of the upper
aerodigestive tract (UADT) segments. Not infrequently,
these patients develop pulmonary aspiration in the postoperative period, resulting in potentially fatal pulmonary
complications. Moreover, other disadvantages may be
1 - Doutorado em Medicina. Professor Adjunto de Cirurgia da UFOP Professor Titular de Cirurgia e Anatomia do IMES.
2 - Doutorado em Medicina. Professor Adjunto do Departamento de Cirurgia da Universidade Federal de Minas Gerais - UFMG.
3 - Doutorado em Medicina. Professor Adjunto de Cirurgia da Universidade Federal de Ouro Preto - UFOP.
4 - Médico Veterinário. Acadêmico de Medicina no IMES.
5 - Acadêmico de Medicina no IMES. Acadêmico de Medicina no IMES.
Instituição: Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG) e o Hospital Biocor.
Belo Horizonte / MG – Brasil.
Correspondência: Orlando Barreto Zocratto, MD - Rua Tenente Anastácio de Moura, 740, apto 202 - Santa Efigênia - Belo Horizonte / MG – Brasil - CEP: 30240-390 – E-mail:
Artigo recebido em 08/05/2013; aceito para publicação em 16/07/2013; publicado online em 23/09/2013.
Conflito de interesse: não há. Fonte de fomento: não há.
Rev. Bras. Cir. Cabeça Pescoço, v.42, nº 3, p. 131-135, julho / agosto / setembro 2013 – ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 131
Há indicação para a realização da cirurgia de separação laringotraqueal para a prevenção de aspiração pulmonar em pacientes com tumores de
cabeça e pescoço? highlighted: an increase in hospital permanence, a delay
in starting radiotherapy and an increase in the cost of
treatment.1,2
Total laryngectomy (TL) has classically been indicated in some patients undergoing the resection of advanced UADT tumors, such as: total glossectomy, resection
of tongue base, pharyngolaryngectomy and partial laryngectomy in patients with low pulmonary reserve. In these situations, the objective is not to provide an adequate safety margin for the control of primary tumors, but a
means to prevent potential postoperative aspiration. The
TL eliminates any possibility of reversing the procedure (rehabilitation of laryngeal voice), besides presenting
a potential risk for developing postoperative complications.3-5 The replacement of this procedure by another
one that doesn’t compromise the oncologic principles of
the tumoral resection besides being effective in preventing aspiration and being reversible would benefit these
patients.
Several techniques were proposed to replace TL,
such as: epiglottis flap sutured in arytenoids, glottic closure through laryngofissure, and subperichondreal cricoidectomy.6 The glottic closure procedure was modified
by Sasaki et al (1980)7 by the addition of a sternohyoid
muscle flap to provide an additional layer of laryngeal
closure. All these procedures have not been successful
in controlling aspiration, besides being technically complex and altering the laryngeal anatomy, compromising
its potential for reversibility. The vertical laryngoplasty
was described by Biller et al (1983)8 for the prevention
of aspiration in patients who required total glossectomy
for advanced carcinoma of the tongue. This procedure
permits retention of the larynx with the preservation of
swallowing and speech.
Lindeman (1975)9 reported a procedure of tracheoesophageal diversion and in the following year described
variations of this procedure, which was called laryngotracheal separation (LTS)10. It results in the separation
of the digestive and respiratory tracts, preserving at the
same time both the motor and structural integrity as well
as sensory innervations of the larynx, a fact that turns this
procedure potentially reversible.10 LTS has become the
standard procedure at many institutions, mainly because
it is reliable, technically simple and presents low morbidity, also preserving the ability to swallow and enabling
reversibility. However, it does not preserve vocal function. It has been indicated particularly in the treatment of
clinically intractable aspiration.1,11-13 The main conditions
that motivate more indication of the LTS are serious and
degenerative neurological diseases.11,12
Chronic pulmonary aspiration is frequently observed
in subjects with an altered anatomy of the UADT because of a tumor or its resection.1,2 In these cases, LTS is
indicated for preventing the installation of pulmonary aspiration in the postoperative period. The use of LTS for
potential postoperative aspiration prevention was first
reported by Eibling et al (1995)11 (two patients) and subsequently by Lombard and Carrau (2001)14 (one patient).
Zocratto et al.
The latter proposed its use instead of TL in patients with
pharyngolaryngeal tumors (supraglottic region, vallecula
and tongue base).15 Thus, the LTS was indicated in patients that would be subject to a high risk of severe aspiration, especially those with a clinical status indicative of
low tolerance for this complication. The purpose of this
statement is to evaluate the results of LTS in 30 patients
with head and neck tumors, who underwent extensive
UADT resection.
Objective
Evaluate LTS in 30 patients with head and neck tumors, who underwent the extensive resection of UADT
segments regarding: prevention of postoperative pulmonary aspiration, morbidity and reversibility rate.
Methods
Retrospective analysis of the hospital records of 30
patients with head and neck tumors, who underwent LTS
in a period from 1991 to 2008 collected from two Brazilian institutions: the Clinical Hospital of the Federal University of Minas Gerais (UFMG) and the Biocor Hospital.
All operations were performed by the same surgical team
(members of head and neck surgery at the Clinical Hospital - UFMG). The study was approved by the Research
Ethics Committee of UFMG (process nº. ETIC 080/03).
Twenty patients were male and 10 female (male/female
ratio was 2:1). The age ranged from 36 to 77 years, with
an average of 52.4 ± 8.3 years and median of 56 years.
The indication for the use of LTS was to prevent aspiration after extensive UADT resection.
All patients had advanced squamous-cell carcinoma in UADT segments. The locations of the tumors
are shown in Table 1. Twenty-five (83.3%) patients were
classified as stage IV and five (16.6%) classified as stage
III. The classification used for tumor staging in patients
with pharyngolaryngeal tumors was TNM (American
Joint Committee on Cancer: Manual for Staging of Cancer. Philadelphia, JB Lippincott, 1992).
The operations performed for the resection of a primary tumor are listed in Table 2. In all cases, except
one, bilateral neck dissection was also performed. In 16
(53.3%) patients, we used the flap of the pectoralis major muscle for reconstruction of the surgical defect. The
other patients (46.7%) did not require the rotation flap
to close the wound. LTS was performed during surgery
resection of the primary tumor. It had the objective of preventing potential postoperative aspiration. Radiotherapy
was used in all patients in the postoperative period. No
patient had a tracheostomy or had a previous tracheostomy scar at the time of the LTS procedure. Also, no patient
died during the early postoperative period.
Infection of the surgical site was not considered as a
complication of LTS. This is because the patients were
submitted to LTS during resection of the primary tumor
(contaminated operations); a fact that did not permit a
132 e�� Rev. Bras. Cir. Cabeça Pescoço, v.42, nº 3, p. 131-135, julho / agosto / setembro 2013
Há indicação para a realização da cirurgia de separação laringotraqueal para a prevenção de aspiração pulmonar em pacientes com tumores de
cabeça e pescoço? Table 1. Location of squamous cell carcinomas of
patients undergoing laryngotracheal separation (n = 30).
Tumor location
Base of tongue, with extension to the vallecula
and/or tonsillar pillar
Floor of the mouth extending to tongue
Supraglottic larynx
Amygdala extending to the tongue and floor of
the mouth
Floor of the mouth extending to jaw
Hypopharynx
Total
n
%
Table 2. Operations performed for resection of primary
tumor in patients undergoing laryngotracheal separation
(n = 30).
Type of operation
12 40.0
8 26.7
5 16.6
2
6.7
2
6.7
1
3.3
30 100.0
Extensive resection of the mouth with total or
partial glossectomy
Resection of the mouth and tongue associated
with mandibulectomy
Total or partial glossectomy associated with
supraglottic laryngectomy
Supraglottic laryngectomy
Supracricoid laryngectomy with cricohiodopexia
Supraglottic pharyngolaryngectomy
Total
clear differentiation between infection at the site of tumor
resection and infection at the operative site of LTS.
Results
The surgery (LTS) was effective in preventing aspiration in all patients. Oral feeding was reestablished in
23 (76.7%) patients. In three (13.0%) of these patients, a
nasoenteral catheter was used until the swallow function
recuperated, and the oral diet was introduced at two, four
and ten months respectfully, after the operation. The exclusive enteral nutrition was employed in seven (23.3%)
patients (five (71.4%) of them through a nasoenteral catheter and two (28.6%) by gastrostomy).
Six (20.0%) patients developed postoperative complications. These, two (33.3%) presented tracheostomal
edema; both were treated by the temporary introduction
of a tracheostomy cannula until its regression. Other two
(33.3%) developed a tracheocutaneous fistula of the proximal tracheal stump; both were treated conservatively
(antibiotic, fasting and enteral nutrition). Tracheostomal
stenosis was observed in one (16.7%) patient and was
treated by the placement of a definitive tracheostomy
cannula. Tracheocutaneous fistula of the proximal tracheal stump followed by stenosis of the tracheostoma
occurred in one (16.7%) patient; he was submitted to a
suturing of the dehiscent tracheal stump followed by surgical correction of the stenosis by a tracheoplasty.
One patient had a surgical site infection associated
with the wound dehiscence related to resection of primary tumor. The dehiscence was treated by a rotation flap of
the pectoralis major muscle and the surgical site infection
treated with antibiotics for 14 days. It was not possible
to establish a surgical site infection as a complication of
LTS. The reversal of LTS was performed in 11 (36.7%)
patients. The mean maintenance of LTS to reversal was
14.2 months. The criteria used to make the reversal were
based mainly on clinical and subjective parameters. All
11 patients were followed by specialist speech therapy
for voice rehabilitation. The reversion surgery was suc-
Zocratto et al.
n
%
9
30.0
8
26.7
7
3
2
1
23.3
10.0
6.7
3.3
30 100.0
cessful (ability of oral feeding in the absence of pulmonary aspiration and presence of intelligible speech) in nine
(81.8%) patients. Two of them patients underwent videofluoroscopy and seven patients, indirect laryngoscopy.
In the other two (18.2%) patients, it was ineffective and
resulted in the development of tracheal stenosis at the
suture line, treated with tracheostomy (one patient), and
severe and clinically intractable aspiration with subsequent progression to tracheal stenosis at the suture line,
which was treated with a TL (one patient). Five (45.5%)
of the eleven patients showed postoperative complications, including mild to moderate aspiration (transient),
which was overcome by compensatory mechanisms
(three patients).
Discussion
Patients with head and neck tumors who are submitted to extensive resection of the UADT segments show
a higher risk of developing severe aspiration during the
postoperative period. This fact can be more important in
patients with low pulmonary reserve. These patients may
benefit from a procedure that prevents aspiration and
that is potentially reversible. Opinions are divided over
the validity of total glossectomy without associated TL for
advanced carcinoma of the tongue. Total glossectomy
without TL should only be undertaken in motivated and
well supported patients able to accomplish the difficult
rehabilitation process.15 The total glossectomy with laryngeal preservation in properly selected patients provides
local and regional control and preserves the quality of
life, as demonstrated by Tiwari et al (1993)16.
The use of LTS in order to prevent potential aspiration
postoperative was first reported by Eibling et al (1995)11,
with LTS being effective in preventing aspiration in both
patients. Later, Lombard and Carrau (2001)14 proposed
its use in a patient instead of TL with intent to prevent
aspiration. This patient had a pharyngolaryngeal tumor
(supraglottic region, vallecula and tongue base). The LTS
procedure was effective in preventing postoperative as-
Rev. Bras. Cir. Cabeça Pescoço, v.42, nº 3, p. 131-135, julho / agosto / setembro 2013 – ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 133
Há indicação para a realização da cirurgia de separação laringotraqueal para a prevenção de aspiração pulmonar em pacientes com tumores de
cabeça e pescoço? piration in all patients. LTS has been indicated in these
circumstances because it is effective in preventing aspiration, is potentially reversible, and can be performed
during the same surgical intervention.
LTS was performed in 30 patients with the aim of preventing potential postoperative aspiration, resulting from
extensive resection of UADT segments. The series presented is expressive, especially when faced with a shortage of publications on the subject and the small number
of patients in other previously reported series.11,14 The
LTS procedure is technically simple to perform and represents a technical variation of the tracheoesophageal
diversion.9 The surgical technique of LTS, originally described by Lindeman et al (1976)10, recommend closure of
the proximal tracheal stump in the anteroposterior direction. Side-to-side suture of the proximal tracheal stump
represents a variation of the original technique that was
used in all patients of the present series.6 The time taken
to perform the LTS surgery has not been evaluated in our
research because most of the operative reports did not
record this information.
The present results showed a total efficacy (100.0%)
in preventing pulmonary aspiration. Other investigators
also reported expressive rates of efficacy with LTS.6,11,14
However, it should be noted that most patients in those
series underwent LTS with the purpose of treating already installed pulmonary aspiration and not its prevention.
Six (20.0%) patients developed postoperative complications. Those that were considered less serious were
treated successfully, conservatively. The major complications were tracheocutaneous fistula of the proximal
tracheal stump and tracheostomal stenosis. This complication has also been reported in other studies, being
observed in in 38.0% in the study of Eibling et al (1995)11,
in 21.2% of patients in the series of Zocratto et al (2012)17
and in 22.0% in the series of Yamana et al (2001)18. Francis et al (2012)19 suggests the use of a muscle flap-reinforced closure of the proximal tracheal stump after LTS
surgery that would allow a low incidence of postoperative
fistula formation.
The tracheocutaneous fistula can often result in LTS
failure, requiring surgical treatment in some cases.17,19
The possibility of using diet orally without aspiration is
related to the effectiveness of LTS.17 The oral diet was
not possible in seven (23.3%) cases because of the great extension of the resections performed. Some patients
had already been on an enteral diet before the operation
because of the nature of the base disease, which did not
permit oral feeding, a fact also previouslly reported.11,17
Patients who are intolerant to a diet by natural means
are nourished by the enteral route, primarily through the
nasoenteral catheter, and less frequently by gastrostomy.
Many clinicians and surgeons have adopted, at first, gastrostomy for nutrition in patients with aspiration. With the
use of LTS for aspiration treatment, gastrostomy is reserved for a small number of patients.
The main disadvantage of LTS refers to loss of the larynx function, which eliminates the ability to speak, either
Zocratto et al.
temporarily or permanently. However, this characteristic
is common to all procedures that separate the digestive
and respiratory tracts. Another restriction for LTS refers
to the possible harmful effects (squamous metaplasia
and/or reabsorption of the tracheal cartilage) of food and
secretions accumulated in the blind fund arising from
the subglottic tracheal proximal stump suture.18,20 This,
however, does not seem to be relevant because, until
now, there is no record of late complications, such as
infections, arising from this fact.9,19,20 The potential risk
of complications caused by pooling in the tracheal blind
pouch in laryngotracheal separation is prevented presumably due to the slow but continuous turnover of pooling
material.18,20
LTS results in the separation of the digestive and respiratory tracts, preserving at the same time the integrity
of both the structural integrity and motor and sensory innervations of the larynx; a fact that makes this procedure
potentially reversible, as reported by other authors.1,3,6,11,14
In the present study, eleven (36.7%) patients were submitted to LTS reversal. The criteria used for the decision
to reverse were mainly based on the clinical assessment
of the patient (recovery of nutritional status, adaptation to
the new conditions of swallowing after extensive resection of UADT segments, absence of pulmonary complications and motivation of the patient for a new surgery).
The possibility of LTS reversal is evaluated after complete postoperative recovery and post-radiotherapy of the
patient. This occurs about three to six months after the
operation when the clinical conditions of the patients are
most often much more favorable. At this moment, the patient is already recovered from a nutritional standpoint
and adapted to the new conditions for swallowing. In the
series under study, the average time between the LTS to
the reversal surgery was 14.2 months.
The success of reversal (tracheal re-anastomosis
of the stumps) is achieved with the restoration of the
physiological airway and satisfactory laryngeal function
(ability to feed orally without aspiration and the restoration of intelligible speech). The patients whose reversion
surgery is effective usually maintain oral feeding and
comprehensible speech for an indefinite period of time.
However, the frequency of complications and inefficacy
of LTS reversal should not be overlooked.21 The success
rate in the series under study was 76.7%. However, the
complication rate was high (45.5%). This fact is similar
to previous studies described in the literature.6,21 The 11
patients who underwent reversal of LTS were accompanied with specialist speech therapy for rehabilitation
of laryngeal voice, once the completion of the LTS does
not interfere with the structural integrity (anatomical) of
the larynx. In the remaining 19 patients, the persistence
of LTS prevented the laryngeal vocal rehabilitation, given the fact that the larynx remained defunctionalized.
In such cases, the vocal rehabilitation was proceeded in
the same manner as in laryngectomized patient.
The introduction of the diet by mouth can be done
in the first days after surgical reversal. However, some
134 e�� Rev. Bras. Cir. Cabeça Pescoço, v.42, nº 3, p. 131-135, julho / agosto / setembro 2013
Há indicação para a realização da cirurgia de separação laringotraqueal para a prevenção de aspiração pulmonar em pacientes com tumores de
cabeça e pescoço? patients may present mild to moderate post-prandial aspiration, which can be overcome by compensatory mechanisms. It allows the restoration of oral feeding over a
period of weeks to months. However, the reversal may
be ineffective and result, mainly, from the development of
tracheal stenosis at the suture line, a fact which occurred
in two (18.2%) of the 11 patients. Despite the advantage
of LTS reversion, it should not be indicated because this
background but because it prevents the pulmonary aspiration.6,21
Conclusion
LTS surgery is effective in preventing pulmonary aspiration in patients undergoing extensive resections of
UADT segments. It can be indicated as an alternative to
TL. LTS is more advantageous because of its potential
reversibility. However, the frequency of complications for
both LTS and, especially, its reversion operation cannot
be neglected.
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