Thomas Lequeux

The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy

Pharyngocutaneous fistula after total laryngectomy remains a hardly inevitable complication. The predisposing factors are not clearly identified, but prior radiotherapy seems to increase the risk of fistulae. The purpose of this retrospective study was to determine the value of the pectoralis myofascial flap in pharyngeal reconstruction in post-radiotherapy total laryngectomy in order to decrease the risk of fistula formation. The charts of 60 consecutive patients who had undergone total laryngectomy or pharyngolaryngectomy after radiotherapy were analyzed. Twenty-one variables were recorded for each patient. The overall rate of fistula formation was 38% (23% when a pectoralis myofascial flap was used to cover the pharynx and 50% when no flap was used, P=0.06). The flap-related complications were exceptional. In the subgroup of patients with diabetes mellitus, a history of vascular disease or a poor nutritional status, the use of a flap reduced the fistula formation from 73 to 13% (P=0.018). The pectoralis myofascial flap covering the pharyngeal sutures in postradiotherapy laryngectomy is particularly useful in a selected group of patients (with diabetes mellitus, history of vascular disease or poor nutritional status).

Determination of the Levels of Expression of Sarcolectin and Calcyclin and of the Percentages of Apoptotic But Not Proliferating Cells to Enable Distinction Between Recurrent and Nonrecurrent Cholesteatomas

Objectives: To investigate in a series of cholesteatomas 1. whether subgroups of cholesteatomas with specific proliferative/apoptotic features exhibit distinct differentiation markers and 2. whether these different subgroups identified at the biological level relate to specific groups of clinically identified cholesteatomas.

Reconstruction of circumferential oro- and hypopharyngeal defects with U-shaped pectoralis major myocutaneous flap

OBJECTIVE: The purpose of the study was to evaluate the effectiveness of a U-shaped pectoralis major myocutaneous flap (PMMF) to reconstruct a large circumferential defect involving the oro- and hypopharynx. STUDY DESIGN AND SETTING: Retrospective case series. RESULTS: Twelve patients with advanced oro- and hypopharyngeal cancer (stage IV) underwent surgery resulting in a circumferential defect of pharyngoesophageal segment (PES). Those defects were reconstructed using a U-shaped PMMF. Four pharyngocutaneous fistulas were observed postoperatively and healed spontaneously within 3 to 7 weeks. Eight patients were able to resume a regular diet. A voice prosthesis was functional in 5 patients. CONCLUSION: This preliminary study shows that this technique is a simple and effective method with acceptable morbidity rate and satisfactory functional results. We demonstrate that this procedure allows the reconstruction of large defects involving the oro- and hypopharynx in irradiated patients. This technique could be an interesting alternative for surgical teams suffering from the absence of a microsurgical team. EBM rating: C-4

A comparison of survival lifetime of the Provox and the Provox2 voice prosthesis.

The Provox (Atos Medical AB, Hörby, Sweden) voice prosthesis was developed between 1988 and 1990 and has been used at our centre with regular success since 1993. Since 1996, a second generation of Provox (Provox2) has been used, which can be inserted by an anterograde technique. The aim of this study is to compare the survival lifetime of both voice prostheses. The survival time of the two voice prostheses were compared retrospectively in 152 devices placed in 38 patients. A Kaplan-Meier analysis was performed to determine the survival lifetimes and a log rank test was performed to compare the two curves. Clinical factors affecting the lifetime were also analysed with a Kaplan-Meier plot. The median survival lifetime of the Provox and Provox2 were 303 and 144 days respectively. The Kaplan-Meier estimation shows that this difference is statistically significant (p=0.02). It is considered an early failure if it occurs within the first three months. There was a larger number of early failures with the Provox2 than with the Provox (p=0.04). Neither the gender nor the age affected the lifetime of the devices. Radiotherapy seemed to lengthen the lifetime of the first valve. The survival lifetime of the second generation Provox2 valve is shorter than the lifetime of the first generation Provox. This could be due to the difference in elasticity of these valves that could lead to a different level of colonization and invasion of the valves by micro-organisms.

Physiotherapy in obstructive sleep apnea syndrome: preliminary results

Apneic patients have hypotonia of the lingual and supra-hyoid muscles. The dysfunction of theses muscles leading to a collapse of the upper airway is responsible for the apnea. The goal of this study, designed as a before-after trial, is to determine the effect of lingual and supra-hyoid muscle strengthening on obstructive sleep apnea. Thirty-four patients with obstructive sleep apnea were included (consecutive sample). Only 16 patients completed the study. The treatment consisted of 30 sessions of transcutaneous neuromuscular stimulation administered to the submental region associated with muscular exercises. The effect on apneic events was analyzed with a polysomnography before and after the treatment. Thirteen patients could be analyzed for the statistical studies. The mean apnea-hypopnea index (AHI) decreased from 32.9 to 20.6 (Wilcoxon rank test: P=0.017). Seven patients ended the study with an AHI of less than 10, and three more patients decreased their AHI by more than 50%. This treatment significantly decreased the AHI in most of the patients. A larger study with more patients and with a long-term follow-up is necessary to determine the place of physiotherapy in the treatment of obstructive sleep apnea.

Mediastinal tracheostomy: unilateral resection of the anterior chest wall.

Since the first reliable mediastinal tracheostomy described by Grillo et al. in 1966, many new techniques have been described in order to reduce the number of complications. We here report the case of a 55-year-old man who was referred for surgery with post-radiochemotherapy recurrence of a double neoplasm of the pharyngolarynx extending to the proximal trachea and the medial part of the oesophagus. Through a median sternotomy, a pharyngolaryngoesophagectomy was performed with an extended tracheal resection. The reconstruction of the upper digestive tract was performed with a gastric pull-up. The mediastinal tracheostomy was performed with a pectoralis major muscular flap through a right unilateral resection of the manubrium, the right clavicular head and the right first and second costal cartilages. Historically, the mediastinal tracheostomy was performed through a large bilateral resection of the anterior chest wall, in order to prevent the tension on the tracheocutaneous sutures. Nowadays, with the possibility of various pedicled flaps, bilateral resection no longer seems to be necessary. This unilateral resection leads to a reduction in post-operative sequelae.