الفهرس 
TREATMENT OF PRIMARY LARYNGEAL CARCINOMA
SurgicalOnly 14 pages are availabe for public view
 |  | from | 171 |  |  |
| | | from | 171 | | |
Abstract
Laryngeal carcinoma is considered as a very common cancer among head and neck cancers. There are many risk factors for it, the most important one of which is smoking.
According to the site of the primary tumor and it’s stage, the treatment is established. The general conditions of the patients, The economic status, the equipments available and the expert doctors availability also contributes in the choice of treatment.
Surgical and non surgical management of the tumor are always available. Surgical management ranges from simple stripping of the vocal cords to partial and total laryngectomy.
Non surgical management includes all the regimens of radiotherapy being alone or concomitant with chemotherapy especially in early stage of tumor or for the advanced laryngeal cancer.
Nowadays, people all over the world are looking forward to better quality of life. and according to this idea the conservational non surgical treatment of cancer increasingly is applied.
As a result the number of patients in need to a salvage laryngectomy after failure of primary treatment increases and also the side effects of salvage laryngectomy became common. One of the complications of the salvage laryngectomy is the PCF. It was documented that radiotherapy is an independent risk factor of PCF after salvage laryngectomy.
All attempts were tried to prevent the formation of PCF. Primary flap reconstruction of the neopharynx after salvage laryngectomy was one of them.
Reconstruction was done in several studies. Either with pedicled flaps like pectoralis major or free flaps as radial forearm flap, anterolateral thigh flap and rectus abdominus flap.
A systematic review was done to compare between fistula incidence in primary flap reconstruction with salvage laryngectomy and it’s incidence in salvage laryngectomy with primary closure of the neopharynx.
Search was done in pub med where 85 articles were found, 48 of them were irrelevant to our study and 37 articles were relevant.According to the inclusion criteria 23 article were excluded. And our study included 14 article
In our meta-analysis the results showed that flap reconstruction of pharynx is favoured than the primary closure of it. As fistula rate for patients with flap reconstruction is 17.8% while it’s rate for those with primary closed pharynx is 35.4% with P-value <0.001
So the primary flap reconstruction of pharynx after salvage laryngectomy decreases incidence of fistula from 35.4% to 17.8%.in acceptance with the recent meta-analysis of Paleri et al., 2014 which was conducted on 9 studies with 591 patients with fistula incidence in flap group 22.2% and 31.2% in non flap group with p value <0.02
Our result came different to the study of Sayles et al., 2014, there is no significant difference in PCF incidence between patients receiving a reinforcing flap and those without 46.2% to 36.2%.
This difference could be reasoned by the inclusion of population to the patients who underwent resection more than laryngectomy in paleri study.
Free flap primary reconstruction of pharynx is also favoured over primary pharynx closure after SL as free flap reconstruction decreased incidence of fistula to 23.1% from 35.6% in primary closure group.
This result is in acceptance with the study of Tsou et al., 2010, Fistula incidence in primary closure group was 76% and 14% in flap group.
We were able to compare between pectoralis flap and free flaps which reaveled that fistula incidence in pectoralis group was 13.5% while in free flap group was 23.1%. in contrast to study of sayles that mentioned no significant difference between fistula incidence in flap group than other and that could be reasoned for that his population including patients who were previously untreated and their resection was more than laryngectomy. The result of our study favors pectoralis over other flap. but recently the issue is not which flap is better in all situation but the most suitable flap for each case according to many factors as general condition, type of the pharyngeal defect, cost, hospital tools and expertise of the surgeons.
In our study we concluded that not only primary flap reconstruction in salvage laryngectomy lowers fistula incidence but also lowers need to second surgical intervention for fistula which was formed.
Prophylactic tissue flaps placed over the pharyngeal suture at the time of STL following failed organ preservation protocols reduce the risk of PCF.. This reduction in fistula incidence prevents the associated morbidity and mortality from exposed major vessels in the neck.
Chemoradiotherapy increases fistula incidence more than radiotherapy. Notwithstanding the limitations of the meta-analyses, prophylactic flaps are recommended to aid pharyngeal closure in STL after failed chemo-radiotherapy. Prophylactic flaps may have a role after failed radiotherapy alone, but the benefits may be smaller in comparison to the failed chemoradiotherapy group.
But more studies are needed for confirmation of the effect of the mentioned risk factors on fistula formation. No guidelines published for the usage of flap reconstruction after salvage laryngectomy. So more studies are needed to precisely detect the indications for primary flap reconstruction after salvage laryngectomy. And when to it routinely.