INTRODUCTION
Partial surgeries have been more frequently used in the treatment of laryngeal cancer, showing better results concerning quality of life and similar results in relation to local control of the disease 1, 2. The conduction of tracheostomy in patients submitted to laryngectomy is a safety measure to maintain permeability of upper airways. However, it may be related to greater morbidity, such as creation of a contamination source and delay to introduce oral diet, in addition to increasing the surgical time. In view of these hypotheses, we started to perform in our service partial laryngectomy without conducting tracheostomy, and we had no difficulties concerning airway control. The purpose of the present study was to compare the results of partial laryngectomy with and without tracheostomy, defining advantages and disadvantages of not performing the procedure.
MATERIAL AND METHOD
From January 2001 to May 2002 we surgically treated 11 cases of glottic tumors, with clinical pathologic diagnosis of squamous cell carcinoma, in the Service of Larynx, Department of Otorhinolaryngology, Santa Casa de Sao Paulo. The patients were submitted to frontal-lateral vertical laryngectomy, without intraoperative tracheostomy and reconstruction of sternohyoid muscle. Some patients with glottic tumors T2 and T3 were submitted to extended frontal-lateral laryngectomy with removal of supraglottic or arytenoid tissues. In the present study, these cases were assessed concerning surgical clinical follow-up and data were collected retrospectively through analysis of medical charts, which were under the care of the Filing Department of Santa Casa de Sao Paulo. We filled out a follow-up protocol of all cases and collected the important data according to the joint analysis of the group and the discussion of literature data.
In order to define comparison, we looked for 11 cases of patients with glottic tumors with diagnosis of squamous cell carcinoma. These patients were submitted to frontal-lateral vertical laryngectomy, with intraoperative tracheostomy and reconstructed with the same technique, with sternohyoid muscle. Frontal-lateral laryngectomy was expanded in cases of T2 and T3. This control group was admitted to the service in March 1998 up to November 2000 and they were randomly selected according to the first medical charts available for the analysis. The cases submitted to preoperative tracheostomy were excluded from the study. Group A (control) was formed by patients submitted to tracheostomy, and group B (case study) comprised patients that were not submitted to tracheostomy.
The data analyzed were surgical time, length of hospital stay, number of days with nasogastric tube, and affection of tumor margins detected in frozen biopsy. The margins we considered were the final ones, after the removal of the piece, being considered positive-margin if at least one margin was involved. The cases with positive margin were submitted to resection of complementary margin at the same surgical time, and the result of the complementary margin was not considered in the comparison of the two groups. Complications during the hospitalization period were also described.
In Group A (11 patients), mean age was 60 years and 3 months being minimum age of 31 years and maximum of 76 years. We selected 10 male and 1 female cases. Staging (TNM) of patients was T1b for 4 cases, T2 for 4 cases, T3 for 3 cases and no T4, being all N0Mx. It is important to highlight that the mean time of tracheostomy in group B was 23.45 days between 9 patients that had temporary tracheostomy, being the minimum of 14 days. Two patients of the group maintained permanent tracheostomy.
In group B (11 patients) mean age was 59 years and 7 months, ranging from 51 years to 77 years. As to gender, we assessed 9 male patients and 2 female patients, defining a proportion of 4.5 male to 1 female subject. Staging TNM was T1b for 3 cases, T2 for 3 cases, T3 for 4 cases and T4 for 1 case, all of them N0Mx.
RESULTS
Group A (with tracheostomy):
Mean hospitalization time of 9 days, ranging from 4 days to 14 days;
Mean permanence of nasoenteral tube was 9,27 days, ranging from 4 days to a maximum time of 30 days.
Mean surgical time was 3 hours and 48 minutes, ranging from 1 hour and 45 minutes to 4 hours and 40 minutes;
Concerning surgical margins, two patients presented at least one positive margin and 9 had free margins;
We did not observe any complication during hospitalization in this group.
Group B (without tracheostomy):
Mean hospitalization time was 6.2 days ranging from 3 to 15 days;
Mean duration of nasoenteral tube was 4 days, ranging from 1 day to maximum 7 months (one single patient). This case, however, involved an isolated problem, in which other factors interacted to maintain the tube.
Mean surgical time was 2 hours and 49 minutes, being that the shortest time was 1 hour and 55 minutes and the longest was 5 hours.
Concerning surgical margins, three patients presented at least one positive margin in frozen analysis and 8 presented free margins. Positive margins were submitted to resection of complementary margin at the same surgical time.
We observed 5 patients with subcutaneous emphysema, which started on the second postoperative day. These patients presented glottic staging T1b (1 case), T2 (2 cases), T3 (1 case) and T4 (1 case).
DISCUSSION
The option of conservative surgery with partial preservation of larynx has been the treatment of choice in our service, since it allows effective control of lesion site and better functional results 3. Some authors advocate laryngeal partial surgeries only in cases staged T1 and T2 4. In our sample of 22 analyzed patients, we conducted partial surgeries in 7 cases with staging T3 and in 1 with staging T4.
As to hospitalization time, patients in group B (without tracheostomy) presented an average of 6.2 days and in group A, 9 days. Reduction in hospitalization time is an important factor to be considered in view of cost and small number of beds available in the public service. The patients in group B had longer length of stay in some cases owing to subcutaneous emphysema, which happened in 5 patients on the second postoperative day. All cases had spontaneous resolution, being controlled with rest and cervical compressive dressing. This complication shows the importance of careful closure of the anterior wall of the larynx, use of cervical compressive dressing and rest. This complication was observed in patients staged T1b, T2, T3 and T4, showing there is no evident correlation between level of resection and presence of the complication. None of the patients in the group with tracheostomy had this complication. Tracheostomy allows air escape though the orifice, preventing occurrence of subcutaneous emphysema.
Group B had average time with nasoenteral tube of 4 days against 9.27 days in group A. Tracheostomy prevents laryngeal elevation, hindering opening of the upper esophageal sphincter and causing less effective closure of epiglottis' laryngeal vestibule, exposing the patient to higher risk of aspiration. At the same time in which tracheostomy allows better lung hygiene, it exposes the lung to higher risk of aspiration. Early removal of cannula facilitates tracheoesophageal movement, more quickly reestablishing normal swallowing 5, 6.
Mean surgical time was reduced in one hour. Group A, since it was not submitted to tracheostomy, did not require ligation of the thyroid isthmus, allowing surgical time saving. This group of patients in general presents lung limitations associated with laryngeal disorder, so by reducing the surgical time we reduce the exposure of the patients to higher surgical morbidity. Patients with higher surgical risk should be considered for this technique.
As to lesion margins, we observed three positive margins in patients without tracheostomy and two in patients with tracheostomy. In view of a positive margin, it is important to consider the possibility of complementing the resection of the margins in order to have controlled exeresis of the lesion 7. In our clinical practice, the main difficulty was manipulation of the area to be resected in cases without tracheostomy, which is an important factor to be considered in view of oncological surgery. The presence of orotracheal cannula limits the visualization of the posterior portion of the lesion, which can lead to difficulties to define tumor margins. In our study we observed similar results between the two groups in positive tumor margins. Patients with positive margins have the worst oncological prognosis 8, 9. This procedure is more work-demanding, but it does not interfere in the final outcome. The difficulty to define the affection of the margins does not show correlation with the technique used. However, in cases of tumor extension into the interarytenoid region, this technique should be carefully used, since the orotracheal cannula can hinder the manipulation of the area and interfere in the prognosis of the patient.
Failure to perform tracheostomy is an alternative in partial laryngectomy. The cases to undergo the technique without tracheostomy should be well selected.
Patients with lesions on the posterior portion of the larynx require greater manipulation of the tumor area because of the orotracheal cannula in the surgical filed. We believe that these cases can benefit the most from tracheostomy. Patients that have lesions that do not affect the vocal process or interarytenoid region should be considered candidates for the technique without tracheostomy. Reduction in surgical time and length of stay and easy swallowing rehabilitation, can bring benefits to these patients, especially those with higher clinical morbidity. However, longer follow-up time is required in these cases so as to allow the real oncological control of the patients.
CONCLUSION
Partial laryngectomy using sternohyoid muscle for reconstruction without conduction of tracheostomy is a procedure that allows reduction of hospital stay as well as of nasoenteral tube use, which does not interfere in positive tumor margins. Studies with longer follow-up period are required to define the effectiveness of tumor control with this technique.
REFERENCES
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2. Muller R. Quality of life of patients with laryngeal carcinoma: post treatment study. Eur Arch Otorhinolaryngol 2001; 258(6):276-80.
3. Costa H et al. Cirurgia conservadora da laringe em tumores glóticos T3 e T4. Experiência de 10 anos. Rev Bras Otorrin 2001; 67:357-62.
4. Giovanni A et al. Partial frontolateral laryngectomie with epiglottis reconstruction for management of early stage glottic carcinoma. Laryngoscope 2001; 11(4):663-8.
5. Shenoy AM, Kumar SS, Nanjundappa, Prasad S, Premalatha BS. Supracricoid laryngectomy with cricohyoidopexy: a clinico oncological and functional experience. Indian J Cancer 2000; 37(2-3):67-73.
6. Sulikowski M. The assessment of compensatory mechanisms improving pharyngeal phase of deglutition after partial laryngectomy. Otolaryngol Pol 2001; 55(2):153-9.
7. Apostolopoulos K, Samaan R, Labropoulou E. Experience with vertical partial laryngectomy with special reference to laryngeal reconstruction with cervical fascia. J Laryngol Otol 2002;116(1):19-23.
8. Cooley M et al. Discrepancies in frozen sectional mucosal margin tissue in laryngeal squamous cell carcinoma. Head Neck 2002; 24(3):262-7.
9. Yilmaz T, Turan E, Gürsel B, Onerci M, Kaya S. Positive surgical margins in cancer of the larynx. Eur Arch Othorhinolaryngol 2001; 258(4):188-91.
1 Ph.D., Professor, Department of Otorhinolaryngology, Santa Casa de Sao Paulo. Joint Professor in Otorhinolaryngology, Medical School, Santa Casa de Sao Paulo.
2 Ph.D., Professor, Department of Otorhinolaryngology, Santa Casa de Sao Paulo. Instructor, Department of Otorhinolaryngology, Medical School, Santa Casa de Sao Paulo.
3 Ph.D., Professor, Department of Otorhinolaryngology, Santa Casa de Sao Paulo. Assistant Professor, Department of Otorhinolaryngology, Medical School, Santa Casa de Sao Paulo.
4 Resident physician, Department of Otorhinolaryngology, Santa Casa de Sao Paulo.
5 Resident physician, Department of Otorhinolaryngology, Santa Casa de Sao Paulo.
Study conducted at Department of Otorhinolaryngology, Santa Casa de Sao Paulo.
Address correspondence to: André de Campos Duprat - Av. 9 de Julho 5519 7º andar Itaim Bibi Sao Paulo SP 01407-200
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