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Total Laryngopharyngectomy

A total laryngopharyngectomy is the removal of the entire voice box and the pharynx. Mostly, this involves removal of the hypopharynx, but part of the oropharynx may need to be removed as well, depending on the extent of the tumor. A modification of this procedure is a partial pharyngectomy, with preservation of the larynx. All of this depends on the location of the tumor.

After removal of the voice box and pharynx, the trachea will be sewn to the skin above your sternum, which will create a permanent breathing hole in that area. This is just like a total laryngectomy. However, because the pharynx is also removed, there will be no direct connection between your mouth and esophagus. To eat again, a reconstructive procedure will be required to recreate the tube connecting your mouth to your esophagus.

There are a number of ways to speak after the larynx has been removed (this is called alaryngeal speech—speech without a larynx). Some possible techniques include a tracheoesophageal puncture, esophageal speech or an electrolarynx. See voice rehabilitation after laryngectomy to learn more about options to speak after your voice box has been removed.

Reconstruction can be done several ways, including either free tissue transfer or a gastric pull-up (in which the stomach is pulled up through the chest and sewn to the throat). In some cases, a regional flap, such as a pectoralis major muscle/skin flap, might be used. The free flaps most commonly used for this purpose include the radial forearm free flap and the anterolateral thigh free flap, in which the skin is turned into a tube to recreate the pharynx. In select cases, part of the small intestines (the jejunum) can be used as a free tissue transfer as well. Even if a free flap is used, your reconstructive surgeon may still additionally do a pectoralis major muscle flap.

Additional procedures performed during a laryngopharyngectomy might include neck dissections, removal of at least one lobe of the thyroid gland and/or feeding tube placement. A tracheoesophageal puncture might be performed at the same time in anticipation of giving you a voice eventually.

After the larynx is removed, there are a number of ways to speak (this is called alaryngeal speech; that is speech with a larynx). Some possible techniques include a tracheoesophageal puncture, esophageal speech or an electrolarynx. See voice rehabilitation after laryngectomy to learn more about options to speak after your voice box has been removed.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

If you are undergoing a total laryngopharyngectomy, you should have had a discussion with a speech and swallow therapist prior to surgery.

What to expect

You will be put completely to sleep with general anesthesia.

For a total laryngopharyngectomy, the incision is placed in the central neck, extending to perform neck dissections on both sides. Once the larynx and pharynx are removed, your surgeon might send some frozen section margins to see if there is any obvious cancer left behind to be removed.

Once the ablative part of the surgery is complete, the reconstructive part of the surgery will begin. In some cases, the reconstructive surgeon might start working while the ablative surgeon is still working. This can speed up the total surgical time in some cases.

The reconstructive part of the surgery involves harvesting the flap, insetting the flap to recreate the tube of the pharynx and sewing the blood vessels together to give the flap a blood supply. A salivary bypass tube might be placed into the tube that your surgeon creates. In theory, this can limit the amount of saliva coming in contact with the sutures of the new pharynx. Some surgeons do not use salivary bypass tubes.

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At the end of the procedure, your surgeon will likely place a few small drains coming out of your skin to drain any blood and/or fluid that might accumulate in the space that is created by removing the larynx and pharynx as well as any fat and lymph nodes from the neck dissections. When the time is right—after a few days—the drains will be removed by your surgical team. This only takes a few seconds, and you can think of it as removing a bandage. There will be a little discomfort, but it will go by quickly.

You will have a feeding tube inserted either through the nose, directly in the stomach or through the tracheoesophageal puncture, unless a gastric tube was placed directly into your stomach. At first, all your nutrition will be provided through the tube. You will start eating after one or two weeks, depending on your surgeon’s preference and prior treatment you might have received.

It is important to check your calcium level immediately post-operatively, because the blood supply to the parathyroid glands could become compromised after this surgery. By saving one half of the thyroid lobe, it should protect two of the parathyroid glands that are responsible for regulating calcium levels in your blood.

Recovery and aftercare

After the surgery you will probably be in a closely monitored setting such as a post-anesthesia care unit or an intensive care unit. You will slowly be awakened and will return to breathing on your own by the next day. Your pain will be controlled with medication.

If everything goes well, you should start to get out of bed after a couple of days and start walking as soon as possible. You should expect to be in the hospital for approximately one to two weeks. A stay longer than two weeks is usually due to a post-operative complication that your doctors are working to improve.

The recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks in undergoing a total laryngopharyngectomy:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Seroma: This is a collection of normal body fluid in the neck after removal of the drain. This can be treated with observation, as the body will eventually resorb it, or repeated needle aspirations. The risk of leaving seroma is that it could become infected.
  • Infection: Total laryngectomy is often done with both sided neck dissections, therefore, in theory, joining saliva and mucous with the sterile neck contents. Interestingly, infections of the neck are quite rare. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Salivary fistula: This means that saliva is leaking from the pharynx into the neck. The chances of this increase if you have had previous treatment, including radiation and/or chemotherapy. This is because wound healing might be impaired in these cases. Typical treatment for this is to place a drain to divert the saliva away from critical structures in the neck and later to place packing into that diverted tract and let the body heal it up on its own. In some cases, an additional surgical procedure might be required to close the leak (such as a pectoralis major muscle flap).
  • Chyle fistula: This means that lymphatic fluid is leaking from a lymph vessl to the skin surface. It can happen if the thoracic duct is injured during surgery.
  • Hypocalcemia: Low calcium levels can occur post-operatively if all four parathyroid glands are either removed and not re-implanted (permanent hypocalcemia) or put into a state of shock by affecting their blood supply (temporary hypocalcemia). This is why calcium levels should be followed closely after a total laryngectomy (or total laryngopharyngectomy) with adequate calcium replacement as needed.
  • Hypothyroidism: This can happen if both lobes of the thyroid gland are removed, if only one lobe is removed but the other lobe cannot make enough thyroid hormone to keep up with the body’s needs or regardless of how much thyroid is removed but radiation treatment has affected the function of the thyroid gland. In any case, thyroid hormone level can be measured with some blood tests and a once-daily pill can replace the function of thyroid hormone.
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood thinning-medication) to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might itself cause another complication, such as bleeding, especially immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.