Inserción del tubo de derivación salival de montgomery con anestesia local en pacientes con fístula faringocutánea tras laringectomía totalInsertion of montgomery salivary bypass tube under local anesthesia in patients with pharyngocutaneous fistula following total laryngectomy
Resumen
El tubo de derivación salival de Montgomery ha demostrado ser eficaz en el tratamiento de las fístulas faringocutáneas tras laringectomía total. La técnica original de inserción del mismo requiere la realización de una anestesia general para colocarlo mediante visualización directa de la hipofaringe. En este trabajo se presenta un método de inserción basado en la técnica de Seldinger que permite su colocación con anestesia local de forma rápida y bien tolerada por los pacientes
Abstract
Montgomery salivary bypass tube is an effective therapeutic option in the treatment of the pharyngocutaneous fistulas following laryngectomy. The original insertion technique requires general anesthesia to introduce the tube with direct vision of the hypopharynx. In this paper we present an insertion method based in the Seldinger technique that allows the placement of the tube under local anesthesia in a rapid fashion and well tolerated by the patients
Referencias (4)
- W.H. Warren et al.
Clinical experience with Montgomery Salivary Bypass Stent in the esophagus
Ann Thorac Surg
(1994) - W.W. Montgomery
Salivary bypass tube
Ann Otol Rhinol Laryngol
(1978)
Cited by (15)
Pharyngocutaneous fistula following total laryngectomy. A case-control study of risk factors implicated in its onset
2008, Acta Otorrinolaringologica EspanolaLa fístula faringocutánea es la complicación postoperatoria más frecuente de la laringectomía total. Los factores implicados en su aparición han sido estudiados por numerosos autores sin obtener resultados concluyentes. El principal objetivo de este estudio es conocer los factores de riesgo implicados en la aparición de fístulas en nuestro medio.
Diseñamos un estudio retrospectivo de casos y controles. Incluimos en ambos grupos a 33 pacientes a los que se practicó laringectomía total con el mismo protocolo en todos los casos. Excluimos a los pacientes en que se realizó una reconstrucción compleja para evitar sesgos.
Observamos que la extensión de la cirugía a la faringe es el único factor asociado significativamente (p = 0,04) a la aparición de fístulas en nuestro medio (odds ratio [OR] = 2,83). La asociación de radioterapia previa y vaciamientos cervicales muestra una tendencia importante (OR = 3,2), no significativa (p = 0,099). Otros factores como la edad del paciente, la radioterapia previa, los vaciamientos cervicales, la traqueotomía previa o la hemoglobina postoperatoria no se asocian estadísticamente a la aparición de esta complicación. La mayoría de las fístulas se cierran con medidas conservadoras (72,7 %), pero en pacientes irradiados previamente requieren reparación quirúrgica con mayor frecuencia que en los no irradiados (p <0,01).
En nuestro medio el factor más asociado a la aparición de fístulas tras laringectomía es la extensión de la cirugía a la faringe. Las fístulas en pacientes irradiados tienen menor tendencia a la reparación conservadora y requieren cirugías más agresivas para solucionarlas.
Pharyngocutaneous fistula is the most frequent complication after total laryngectomy. Risk factors involved in its appearance have been studied by many authors without conclusive results. Our main objective is to identify the risk factors involved in the onset of fistulae at our institution.
A retrospective case-control study was designed. Thirty-three patients subjected to total laryngectomy with the same protocol were included in both groups. Patients who required a complex surgical reconstruction were excluded in order to avoid biases.
The only risk factor with statistical significance (P=.04) for the onset of fistulae in our setting is the extension of the surgery to the pharynx (OR=2.83). The association of prior radiotherapy and concurrent neck dissection displayed a notable trend (OR=0.32) but without significance (P=.099). Patient age, prior radiotherapy, concurrent neck dissection, prior tracheotomy and post-operative haemoglobin level did not predispose to this complication in our study. Non-surgical closure of the pharyngocutaneous fistula was achieved in most cases (72.7 %) but patients who had pre-operative radiotherapy required surgical closure more frequently (P<.01) than those not irradiated.
At our centre the main risk factor associated with post-laryngectomy fistulae is the extension of surgery to the pharynx. In previously-irradiated patients, fistulae have a lower incidence of non-surgical closure and require more aggressive surgery to resolve them.
Self-Expanding Stents in Benign Esophageal Strictures
2008, Techniques in Gastrointestinal EndoscopyCitation Excerpt :Palliation can be attempted by placing a MSBT. These endoprostheses have been used as temporary treatment in patients with pharyngocutaneous fistula following total laryngectomy.15 However, the proximal funnel is too wide and could cause a foreign body sensation.
Self-expanding metal stents (SEMS) have gained a wide consensus in the treatment of malignant dysphagia. The small diameter of the delivery system has reduced the morbidity related to their placement. These stents could be a reasonable option also in patients with benign refractory esophageal strictures. Two types of stents have been used: self-expandable plastic stent (SEPS; Polyflex®) and SEMS. Fluoroscopy is recommended, and predeployment dilation should be performed when a SEPS is placed. SEMS should be completely covered with a silicone layer that opposes the granulomatous ingrowth through the meshes, which prevents imbedding and allows easy retrieval. Migration represents the most frequent complication and is due to the lack of imbedding of these stents. The techniques of stent placement are similar to those when stents are placed for malignant disease. Dilation is not advisable before placing a SEMS, but may be performed after its release. The prolonged and stable dilation of the endoprosthesis is believed to work in some patients by prevention of the scarring process and avoiding the adhesion of damaged areas (such as after extensive endoscopic mucosal resection). Remodeling of scar tissue by the indwelling stent is believed to occur in chronic strictures but is difficult to obtain in patients with refractory hypopharyngeal strictures following radiation therapy. Stents need to be removed, the timing of which is variable but usually more than 4 to 8 weeks after placement. Prolonged placement may lead to complications such as reactive overgrowth and result in a new stricture. This review analyses the risk and benefits of self-expandable stents in the management of dysphagia for benign esophageal strictures.
Aorto-oesophageal fistula in patient with Montgomery salivary bypass tube
2008, Acta Otorrinolaringologica EspanolaLas fístulas aortoesofágicas son afecciones sobradamente descritas y con múltiples etiologías. No obstante, es excepcional que se presenten por la utilización del tubo de derivación salival de Montgomery (TBSM), algo descrito en la literatura médica en una sola ocasión. Presentamos el caso clínico correspondiente a un paciente de 81 años que portaba un TBSM y falleció por una hemorragia masiva del tracto digestivo superior causada por una fístula aortoesofágica en la localización del TBSM. Se revisa la literatura sobre este tema.
Aorto-oesophageal fistula is a well-reported pathology with several known causes. The co-existence of this pathology associated with the use of a Montgomery salivary bypass tube (MSBT) is exceptional and only one case is described in the literature. We present here a case report about an 81-year-old patient with an MSBT who died because of a massive upper gastrointestinal bleeding caused by an aortooesophageal fistula at the site of the MSBT. The literature on this pathology will also be reviewed.
A modified self-expanding Niti-S stent for the management of benign hypopharyngeal strictures
2007, Gastrointestinal EndoscopyCitation Excerpt :We placed a Montgomery stent. Montgomery stents have been used as temporary treatment in patients with pharyngocutaneous fistula.35 They are proven to be effective in patients with malignancies at the same location.36
The management of patients with refractory hypopharyngeal strictures after surgery in combination with radiation therapy is disappointing, and nutrition through feeding tubes is often required.
To evaluate the efficacy and safety of a modified self-expanding Niti-S metal stent in the treatment of hypopharyngeal strictures after combined therapy for laryngeal cancer.
Case series.
A general hospital and a university hospital.
Seven consecutive patients were included. One of them did not have laryngectomy.
All patients received a modified Niti-S stent.
Improvement of dysphagia, avoiding periodic bougienage, and enteral nutrition through feeding tubes.
After placement of the first stent, dysphagia improved in all patients. Six of 7 patients developed stent migration and/or granulomatous tissue ingrowth or overgrowth. Additional stents were placed in all patients after a median of 3 months after the previous stent placement. One patient developed an esophagorespiratory fistula caused by a Polyflex stent. Two patients died of causes unrelated to the stent. The remaining 5 patients remained alive and asymptomatic after a median follow-up of 10 months.
Periodic stent exchange. Stent placement did not resolve the stricture definitively. We had a limited number of patients and have no long-term outcome data yet.
The use of this modified Niti-S stent avoids both enteral nutrition through feeding tubes and the need for periodic bougienage in patients with difficult-to-treat benign hypopharyngeal strictures.
Montgomery salivary bypass tube: A simple solution for pharyngocutaneous fistulas
2006, Acta Otorrinolaringologica EspanolaUna de las complicaciones más temidas por los cirujanos y el personal de enfermería en el paciente sometido a una laringectomía son las fístulas faringocutáneas (FFC) por su complejidad en prevenirlas y/o curarlas. El tubo de derivación salival de Montogomery ha demostrado ser eficaz en el tratamiento de las mismas. Se describe nuestra experiencia en el uso del bypass salival en el tratamiento de la FFC.
Se realizó un estudio retrospectivo de 21 casos de pacientes intervenidos de laringectomía total por carcinoma epidermoide de laringe e hipofaringe entre 1999 y 2005, los cuales desarrollan una FFC y en los que se empleó el by-pass salival. Se evaluó la eficacia del by-pass en la solución de la fístula.
Las FFC aparecieron entre el 2º y 20º día (media: 7º día tras la cirugía) y como tratamiento de la misma se les colocó un by-pass salival, con anestesia local a 12 y con anestesia general a 9 pacientes. En todos los casos, excepto en uno, la fístula se cerró en una mediana de 26 días con el by-pass, no requiriendo otro tratamiento. El caso en que la fístula persistió tras la retirada del by-pass, ésta se cerró de forma espontánea posteriormente.
El by-pass salival es una importante ayuda en el tratamiento de las FFC pues ningún paciente requirió tratamiento quirúrgico.
The pharyngocutaneous fistulas (PCF) are among the complications surgeons and nursing personnel fear the most due to their complexity to prevent and/or cure them. Montgomery salivary bypass tube is an effective therapeutic option in the treatment of the PCF following laryngectomy. The aim of our study was to describe our experience with salivary bypass in the treatment of the PCF.
This was a retrospective analysis of pharyngocutaneous fistulas in 21 patients in whom total laryngectomy was performed for squamous cell carcinoma of the larynx or hypopharynx (January 1999-December 2005). We determinate the overall efficacy of the Montgomery salivary bypass tube in the treatment of the PCF.
A pharyngocutaneous fistula developed within a mean time of 7 days from surgery (from 2nd to 20th day). Montgomery salivary bypass tube was the therapeutic option in all these PCF.12 patients required local anesthesia to introduce the tube and in 9 patients the insertion method was with general anesthesia with direct vision of the hypopharynx. The mean healing time was 26 days, except in one case. This PCF achieved spontaneous closure with local wound care after the bypass was removed.
The observed results corroborated the relevance of Montgomery salivary bypass tube as an important therapeutic option in the treatment of the PCF. There was no need of surgical treatment.
Predictive biochemical indicators of a postlaryngectomy pharyngocutaneous fistula: A clinical study
2006, Acta Otorrinolaringologica EspanolaEl objetivo de este trabajo será identificar posibles indicadores bioquímicos predictores de la aparición de fístula faringocutánea tras laringuectomía y revisar el tratamiento quirúrgico de este problema
Se seleccionaron 100 pacientes con carcinoma epidermoide T2-4 de laringe y seno piriforme clasificados como ASA 2-4 tratados mediante cirugía. Las variables estudiadas fueron la albúmina plasmática, las proteínas totales, el colesterol sérico y el número total de linfocitos. Se realizó estudio estadístico mediante Chi-cuadrado
El 19% de los pacientes laringuectomizados presentaron fístula faringocutánea en el postoperatorio, con una estancia media hospitalaria de 25 días frente a 10 días en postoperatorio sin fístula postlaringuectomía. Fue necesario tratamiento quirúrgico del faringostoma en 7 de los 19 pacientes, que se realizó a los 25 días de la laringuectomía de media. Se identificó como marcadores bioquímcos predictivos de faringostoma proteínas totales <6,5 g/dL y albúmina plasmática <3,5 g/dL (p < 0,05). El 45% de los enfermos presentaban un colesterol sérico <180
Nuestros resultados sugieren qué identificación prequirúrgica hipoproteinemia e hipoalbuminemia se asocian a alto riesgo de aparición de fístula faringocutánea tras laringuectomía
The aim of this clinical study was to determinate biochemical predictor indicators of postlaryngectomy pharyngocutaneous fistula
We have studied 100 patients with T2- 4 a laryngeal and piryform sinus carcinoma who underwent a laryngectomy. All patients were ASA 2-3. We studied serum albumin, protein serum level, cholesterol and lymphocites in each patient. These variables underwent statistical analysis (p < 0.05)
19% of the patients developed a postlaryngectomy pharyngocutaneous fistula, with a long-stay of 25 days vs. 10 days of stay in patients without postlaryngectomy pharyngocutaneous fistula. 7 postlaryngectomy pharyngocutaneous fistula needed surgical repair. Low serum albumin (< 3.5 g/dL) and a low level of serum proteins (< 6.5 g/dL) were predictive indicators of postlaryngectomy pharyngocutaneous fistula (p < 0.05)
Our results suggest that a low-level of serum proteins and albumin are predictive clinical parameters of postlaryngeal pharyngocutaneous fistula