Complicaçoes Pulmonares Laringe

ORIGINAL ARTICLE

Factors That Predict PostoperativePulmonary Complications AfterSupracricoid Partial LaryngectomyYoung-Hoon Joo, MD; Dong-Il Sun, MD, PhD; Jung-Hae Cho, MD;Kwang-Jae Cho, MD, PhD; Min-Sik Kim, MD, PhD

Objective: To determine the risk factors related to post-operative pulmonary complications in patients who un-dergo supracricoid partial laryngectomy.

Design: Retrospective analysis of medical records.

Setting: Tertiary care referral center.

Patients: One hundred eleven patients who under-went supracricoid partial laryngectomy from January 1,1993, through December 31, 2008.

Main Outcome Measures: Relationship between post-operative pulmonary complications and perioperative riskfactors, such as age, sex, chronic lung disease, smokingstatus, tumor site, tumor stage, preoperative irradia-tion, extent of surgery, reconstruction method, and pul-monary function tests.

Results:Thirty-sixpatients (32.4%)developedpostopera-tivepulmonarycomplications.Significantcorrelationswerefoundamongage(P=.002),chronic lungdisease(P=.005),smokingstatus(P=.02),andpostoperativepulmonarycom-plications. Cricohyoidopexy (P=.008) and ipsilateral ary-tenoidectomy (P=.03) were associated with postoperativepulmonarycomplications.Themultivariateanalysisshowedasignificantassociationofthepostoperativepulmonarycom-plications with age (odds ratio [OR],3.8; 95% confidenceinterval [CI], 1.2-11.7 in patients 60 to 69 years old; andOR,7.1;95%CI,1.3-37.6 inpatients70 to79yearsold)andcricohyoidopexy (OR, 4.4; 95% CI, 1.1-18.1).

Conclusion: Patients 60 years or older and patients withcricohyoidopexy are at high risk of having postopera-tive pulmonary complications after supracricoid partiallaryngectomy.

ArchOtolaryngolHeadNeckSurg.2009;135(11):1154-1157

S UPRACRICOID PARTIAL LARYN-gectomy (SCPL) is a surgicaltechnique used for en bloc re-section of the thyroid carti-lage, paraglottic space, and

pre-epiglottic space with an oncologic out-come comparable to a total laryngec-tomy.1,2 Supracricoid partial laryngec-tomy allows for the cricoarytenoid unit tobe spared and enables physiologic phona-tion and deglutination without a perma-nent tracheostomy. However, because of theoccurrence of aspiration in virtually allpatients who undergo this procedure, pre-operative assessment of the pulmonary sta-tus and prevention of postoperative pul-monary complications are necessary.Postoperative pulmonary complicationscontribute significantly to the morbidity,mortality, and length of hospitalization af-ter this procedure. The most important andmorbid postoperative pulmonary compli-cations are atelectasis, pneumonia, respi-ratory failure, and exacerbation of under-lying chronic lung disease.3 However, there

has been no report with regard to the fre-quency of postoperative pulmonary com-plications associated with perioperative riskfactors in patients who undergo SCPL. Theaims of this study were to retrospectivelyevaluate the pulmonary complication ratesand the clinical and laboratory predictorsof postoperative pulmonary complica-tions in patients who undergo SCPL andto provide guidance to reduce the postop-erative pulmonary complications.

METHODS

PATIENTS

The clinical and pathologic data of 111 pa-tients who were diagnosed as having laryn-geal carcinoma and underwent SCPL at the De-partment of Otolaryngology–Head and NeckSurgery, The Catholic University of Korea, fromJanuary 1, 1993, through December 31, 2008,were reviewed. The decision to perform SCPLdepended on strict oncologic selection crite-ria. For patients with stage T1 disease that wassuspected to involve anterior commissure or

Author Affiliations:Department ofOtolaryngology–Head and NeckSurgery, College of Medicine,Kangnam St Mary’s Hospital,The Catholic Universityof Korea, Seoul.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 135 (NO. 11), NOV 2009 WWW.ARCHOTO.COM1154

©2009 American Medical Association. All rights reserved. on February 21, 2012 www.archoto.comDownloaded from

http://www.archoto.com

thyroid cartilage, impaired vocal cord mobility, or paraglottic spaceinvasion in accordance with preoperative imaging, SCPL was con-sidered first. We examined the relationship between postopera-tive pulmonary complications and preoperative risk factors, suchas age, sex, chronic lung disease, smoking status, tumor site,tumor stage, preoperative irradiation, extent of surgery, recon-struction method, and pulmonary function tests (PFTs).

Preoperative evaluations included a complete medical his-tory and physical examination. Forced expiratory volume in1 second (FEV1), forced vital capacity (FVC), and FEV1/FVCwere the specific PFTs examined in each patient included inthis study. Each result was placed into 1 of 3 categories basedon the FEV1, FVC, and FEV1/FVC (�59%, 60%-79%, and �80%,respectively).4 The postoperative period was defined as the pe-riod that extends from the end of the surgical procedure untilhospital discharge. Diagnosis of postoperative pulmonary com-plications was always supported by chest radiograph and spu-tum culture data. Disease was staged according to the 2002 edi-tion of the TNM classification of the American Joint Committeeon Cancer. The institutional review board of Bandopong Seo-chogu Kangnam St. Mary’s Hospital (Seoul, Korea) approvedthis retrospective review of the medical records and the use ofarchived tumor specimens.

STATISTICAL ANALYSIS

To analyze statistically significant relationships among the dis-tribution of categorical values, the �2 test, Fisher exact test, mul-tiple logistic regression analysis, multiple linear regression analy-sis, and correlation analysis were used, as appropriate. P� .05was considered statistically significant. All calculations wereperformed by means of SPSS statistical software, version 13.0(SPSS Inc, Chicago, Illinois).

RESULTS

PATIENT DEMOGRAPHICS

The mean age of the patients was 60.9 years (range, 40-79years), and the male-to-female ratio was 105:6. As seen inthe Table, we identified 11 patients who had a history ofchronic obstructive pulmonary disease (eg, asthma, em-physema, chronic bronchitis). Smoking habits were re-corded in all patients: 14 never smoked, 10 had stopped atleast 6 months before surgery, and 87 patients currentlysmoked. With regard to their pathologic stages, there were19, 46, 28, and 18 patients with stage T1 through T4 dis-ease, respectively. Concerning the disease stage of the cer-vical lymph nodes, there were 93, 8, 9, and 1 patients withN0 through N3 disease, respectively. The tumor origi-nated from the glottis, supraglottis, and transglottis in84, 14, and 13 patients, respectively. Preoperative radio-therapy was performed in 8 patients, and PFTs wereperformed preoperatively in 90 patients. Ipsilateral aryte-noidectomy was performed in 28 patients. For reconstruc-tion, cricohyoidoepiglottopexy and cricohyoidopexy wereperformed in 78 and 33 patients, respectively.

RISK FACTORS RELATED TO POSTOPERATIVEPULMONARY COMPLICATIONS

Among the 111 patients who underwent SCPL, 36 (32.4%)developed postoperative pulmonary complications. Post-operative pneumonia was identified in 24 patients, pleu-

ral effusion in 5 patients, atelectasis in 4 patients, and pul-monary edema in 3 patients. A significant positivecorrelation was found between age (P=.002), chronic lungdisease (P=.005), and smoking status (P=.02) and post-operative pulmonary complications. However, there wasno relationship between sex (P=.39), preoperative irra-diation (P=.27), tumor sites (P=.19), and primary tumorstage (P=.84) and postoperative pulmonary complica-tions. For the SCPL procedure-related risk factors, crico-hyoidopexy (P=.008) and ipsilateral arytenoidectomy(P=.03) were strongly associated with postoperative pul-monary complications. Among the PFTs, the FEV1/FVC

Table. Demographic Profiles and Association WithIncidence of Postoperative Pulmonary Complicationsin Patients Who Undergo Supracricoid Partial Laryngectomy

Parameter

Patients,No. (%)(N=111)

PostoperativePulmonary

Complications, %P

Value

Age, y�59 49 (44.1) 18.4

.00260-69 48 (43.3) 39.6�70 14 (12.6) 57.1

SexMale 105 (94.6) 31.7

.39Female 6 (5.4) 50.0

Chronic lung diseaseYes 11 (9.9) 72.7

.005No 100 (90.1) 28.0

Smoking statusCurrent smoker 87 (78.4) 37.9

.02Ex-smoker 10 (9.0) 30.0Never smoker 14 (12.6) 0

Tumor siteGlottic 84 (75.7) 27.9

.19Supraglottic 14 (12.6) 50.0Transglottic 13 (11.7) 46.2

T classificationT1 19 (17.1) 31.6

.84T2 46 (41.5) 28.3T3 28 (25.2) 35.7T4 18 (16.2) 32.4

Preoperative irradiationYes 8 (7.2) 12.5

.27No 103 (92.8) 34.0

Reconstruction methodCricohyoidoepiglottopexy 78 (70.3) 24.4

.008Cricohyoidopexy 33 (29.7) 51.5

Arytenoid resectionYes 28 (25.2) 50.0

.03No 83 (74.8) 26.5

PFT, %FEV1 7 (7.8) 42.9

.77�59 11 (12.2) 36.460-79 72 (80.0) 30.6�80

FVC�59 2 (2.2) 100.0

.1260-79 15 (16.7) 33.3�80 73 (81.1) 29.2

FEV1/FVC�59 3 (3.3) 100.0

.0460-79 8 (8.9) 25.0�80 79 (87.8) 30.4

Abbreviations: FEV1, forced expiratory volume in 1 second; FVC, forcedvital capacity; PFT, pulmonary function test.




(P=.04) was significantly correlated with postoperativepulmonary complications, whereas no relationship wasfound between FEV1 (P=.77) and FVC (P=.12) with post-operative pulmonary complications. The multivariateanalysis showed that only age (P=.02) and cricohyoido-pexy (P=.04) were significantly correlated with postop-erative pulmonary complications. The odds ratio (OR)was 3.8 (95% confidence interval [CI], 1.2-11.7; P=.02)for patients 60 to 69 years of age and 7.1 (95% CI, 1.3-37.6; P=.02) for those 70 to 79 years of age comparedwith the younger patients (those �60 years of age). TheOR for cricohyoidopexy was 4.4 (95% CI, 1.1-18.1; P=.02)compared with cricohyoido-epiglottopexy.

COMMENT

Pulmonary complications are common, with significantmorbidity, after partial laryngectomy procedures andsometimes result in the need for a completion total lar-yngectomy. The incidence of pulmonary complicationshas been reported to be 6% to 47% after supraglottic lar-yngectomy and 0% to 13% after vertical hemilaryngec-tomy.4-7 Supracricoid partial laryngectomy results in com-plete and bilateral resection of the paraglottic spaceincluding, when required, 1 arytenoid cartilage on thetumor-bearing side. When compared with the conven-tional vertical partial and supraglottic laryngectomies,SCPL is considered to be a conservative laryngeal pro-cedure that interferes mostly with the sphincteric func-tion of the larynx.8 Lewin et al9 reported that the post-operative complication rate, including pneumonia andsubcutaneous emphysema, was 26% after SCPL. The over-all complication rate was 32.4% in our study, slightlyhigher than with the conventional supraglottic and ver-tical partial laryngectomies reported in the literature.

The present study showed a statistically significant re-lationship between the incidence of postoperative pul-monary complications and the risk factors of old age(P=.02) and cricohyoidopexy (P=.04) after multivari-ate analysis. Age was a significant risk predictor and wasthe second most commonly identified risk factor.10 Ag-ing is associated with impaired oropharyngeal motor com-mands and laryngopharyngeal sensitivity. Modifica-tions of the pulmonary physiologic processes related toaging also greatly increase the risk of atelectasis and pneu-monia during the postoperative period.11 Some authorshave strict age criteria for the performance of partial la-ryngeal surgery. Alajmo et al12 studied 3 elderly patientstreated with SCPL and cricohyoidopexy and found that1 presented with bronchopneumonia from aspiration and1 required completion total laryngectomy; the author con-cluded that SCPL and cricohyoidopexy were not advis-able in elderly patients. However, others have stated thatit is the biological age and overall constitution of the pa-tient that are more important than the chronologic age.5,8

Laccourreye et al8 reported that age by itself should notbe considered as a deterrent to SCPL completion. In thisstudy, the postoperative pulmonary complication rate forpatients 60 to 69 years of age was 39.6%, and for pa-tients older than 70 years the complication rate was 57.1%;however, the postoperative pulmonary complication rate

for patients younger than 59 years was 18.4%. Care shouldbe taken to carefully control the perioperative comor-bid conditions and provide the appropriate medical careneeded in elderly patients who have undergone SCPL.

Classically, SCPL provides 2 types of interventions: cri-cohyoidoepiglottopexy and cricohyoidopexy. Althoughsimilar in surgical concept, they differ in their effects onaspiration and postoperative pulmonary complications.13

For cricohyoidoepiglottopexy, aspiration uniquely oc-curs in patients whose epiglottic dynamics do not returnto a satisfactory level during the recuperation period. Forcricohyoidopexy, aspiration more frequently occurs be-cause of the absence of the epiglottis and faulty neoglotticclosure, most often secondary to the poor adaptation of lin-gual dynamics. Woisard et al13 reported that aspiration wasnot common after cricohyoidoepiglottopexy but was morefrequent with cricohyoidopexy. They found that even if neo-glottic closure was maintained during the pharyngeal swal-low, the persistent stasis between the arytenoids and thelingual base might be aspirated after swallowing in crico-hyoidopexy. Yücetürk et al,14 however, recently reportedexcellent functional results after SCPL and cricohyoido-pexy in 10 patients evaluated by the use of videofluoros-copy. They noted that the preventive precautions for as-piration were preserving of the superior laryngeal nerves,suturing and positioning of the cricoarytenoid unit as an-terosuperiorly as possible, early decannulation, and earlyonset of swallowing rehabilitation. In our series, postop-erative pulmonary complications developed in 51.5% of thecricohyoidopexy patients and in 24.4% of patients after cri-cohyoidoepiglottopexy. Therefore, our findings suggest thatpatients who undergo SCPL and cricohyoidopexy are at in-creased risk for postoperative pulmonary complications.

According to this study, the following risk factors weresignificant predictors of postoperative pulmonary com-plications on univariate analysis: chronic lung disease(P=.005), smoking status (P=.02), ipsilateral arytenoid-ectomy (P=.03), and FEV1/FVC (P=.04). Chronic ob-structive pulmonary disease was the most frequentlyidentified risk factor for postoperative pulmonary com-plications.10 Chronic obstructive pulmonary disease is apreoperative variable that has been identified as signifi-cantly associated with a prolonged length of hospitaliza-tion after major elective head and neck surgery.15 Someinvestigators, however, have reported that a history ofchronic obstructive pulmonary disease could not reliablypredict the development of postoperative pulmonary com-plications after a partial laryngectomy.4 In this series, 8 of11 patients (73%) with chronic obstructive pulmonary dis-ease developed postoperative pulmonary complications,whereas 28 of 100 patients without chronic obstructivepulmonary disease had postoperative complications.

Typically, patients with head and neck cancer are heavysmokers and users of alcohol who may have tumor-induced dysphagia with associated chronic aspiration. vander Voet et al16 reported that 28% of patients with T1 glot-tic cancer who continued smoking had complications at10 years compared with approximately 13% of those whostopped before or after radiotherapy. McCulloch et al17

reported that univariate analysis identified smoking andweight loss as significant factors associated with pulmo-nary complications postoperatively after head and neck




surgery. The multivariate analysis of 410 patients, whounderwent elective general, orthopedic, urologic, or car-diovascular surgery, showed an adjusted OR of 5.5 (95%CI, 1.9-16.2) for the risk of postoperative pulmonary com-plications in current smokers vs nonsmokers.18 In thisstudy, 14 nonsmokers in our patient group had a zerocomplication rate and 10 ex-smokers had a 30.0% com-plication rate, whereas 87 current smokers had a 37.9%complication rate by the univariate analysis.

During the act of swallowing after SCPL, the tonguebase has to approximate to the arytenoids and also has tocover the neoglottis to protect the airway and prevent as-piration.19 The extent of the arytenoid resection may havean effect on aspiration and postoperative pulmonary com-plications. It was reported that the average feeding tuberemoval time was 16 days when both arytenoids werespared during SCPL, 21 days when 1 arytenoid was sparedduring SCPL, and 63 days when both arytenoids were re-sected during SCPL.20 Lewin et al,9 however, reported thatthe type of SCPL and the presence or absence of aryte-noid resection had no statistically significant effect on theoccurrence of aspiration. However, the number of pa-tients in their study with partial arytenoid resection wastoo few, and their results require confirmation with an ad-equate sample size. In this study, the postoperative pul-monary complication rate was 50.0% with an ipsilateralarytenoid–sparing SCPL, whereas it was 26.5% when botharytenoids were spared during SCPL.

Controversy exists about the usefulness of PFTs to as-sess the ability of patients to undergo partial laryngec-tomy. Although the PFTs diagnose obstructive lung dis-ease, the results do not translate into effective risk predictionfor individual patients. Chow et al4 reported that the PFTsof patients who undergo partial laryngectomy could notreliably predict postoperative complications. In this study,the FEV1/FVC was a statistically significant independentpredictor of postoperative pulmonary complications. OtherPFT parameters, such as FEV1 and an FVC less than 59%,showed a trend toward a greater risk for postoperative pul-monary complications (100%); however, these differ-ences did not reach statistical significance. The PFTs mightnot be needed unless there is a serious impairment of ven-tilation detected in the history or physical examination.

In conclusion, all patients who undergo SCPL shouldbe evaluated for the presence of the significant risk fac-tors of old age (�60 years) and cricohyoidopexy to de-termine their risk for postoperative pulmonary compli-cations. The presence of factors that increase the risk forpostoperative pulmonary complications might help im-prove patient management and outcomes.

Submitted for Publication: April 30, 2009; final revi-sion received April 30, 2009; accepted June 1, 2009.Correspondence: Min-Sik Kim, MD, PhD, Departmentof Otolaryngology–Head and Neck Surgery, 505 Ban-podong Seochogu, Kangnam St Mary’s Hospital,The Catholic University of Korea, Seoul, Korea 137-040([email protected]).Author Contributions: Drs Joo and Kim had full accessto all the data in the study and take responsibility for the

integrity of the data and the accuracy of the data analy-sis. Study concept and design: Joo, J.-H. Cho, and Kim.Acquisition of data: Sun and Kim. Analysis and interpre-tation of data: Joo and K.-J. Cho. Drafting of the manu-script: Joo. Critical revision of the manuscript for impor-tant intellectual content: Joo, Sun, J.-H. Cho, K.-J. Cho,and Kim. Statistical analysis: Joo. Study supervision: Sun,J.-H. Cho, K.-J. Cho, and Kim.Financial Disclosure: None reported.Previous Presentation: This study was presented at theAmerican Head and Neck Society 2009 Annual Meet-ing; May 30, 2009; Phoenix, Arizona.

REFERENCES

1. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoidlaryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure forglottic carcinoma. Ann Otol Rhinol Laryngol. 1990;99(6, pt 1):421-426.

2. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D. Supracricoidlaryngectomy with cricohyoidopexy: a partial laryngeal procedure for selectedsupraglottic and transglottic carcinomas. Laryngoscope. 1990;100(7):735-741.

3. Smetana GW, Lawrence VA, Cornell JE; American College of Physicians. Preopera-tive pulmonary risk stratification for noncardiothoracic surgery: systematic reviewfor the American College of Physicians. Ann Intern Med. 2006;144(8):581-595.

4. Chow JM, Block RM, Friedman M. Preoperative evaluation for partial laryngectomy.Head Neck Surg. 1988;10(5):319-323.

5. Tucker HM. Conservation laryngeal surgery in the elderly patient. Laryngoscope.1977;87(12):1995-1999.

6. Murray GM. Pulmonary complications following supraglottic laryngectomy. ClinOtolaryngol Allied Sci. 1976;1(3):241-247.

7. Maceri DR, Lampe HB, Makielski KH, Passamani PP, Krause CJ. Conservationlaryngeal surgery: a critical analysis. Arch Otolaryngol. 1985;111(6):361-365.

8. Laccourreye O, Brasnu D, Perie S, Muscatello L, Menard M, Weinstein G. Su-pracricoid partial laryngectomies in the elderly: mortality, complications, and func-tional outcome. Laryngoscope. 1998;108(2):237-242.

9. Lewin JS, Hutcheson KA, Barringer DA, et al. Functional analysis of swallowingoutcomes after supracricoid partial laryngectomy. Head Neck. 2008;30(5):559-566.

10. Qaseem A, Snow V, Fitterman N, et al; Clinical Efficacy Assessment Subcom-mittee of the American College of Physicians. Risk assessment for and strate-gies to reduce perioperative pulmonary complications for patients undergoingnoncardiothoracic surgery: a guideline from the American College of Physicians.Ann Intern Med. 2006;144(8):575-580.

11. Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging. Surg ClinNorth Am. 1994;74(1):23-39.

12. Alajmo E, Fini-Storchi O, Agostini V, Polli G. Conservation surgery for cancer ofthe larynx in the elderly. Laryngoscope. 1985;95(2):203-205.

13. Woisard V, Puech M, Yardeni E, Serrano E, Pessey JJ. Deglutition after supra-cricoid laryngectomy: compensatory mechanisms and sequelae. Dysphagia. 1996;11(4):265-269.

14. Yücetürk AV, Tarhan S, Günhan K, Pabuscu Y. Videofluoroscopic evaluation of theswallowing function after supracricoid laryngectomy. Eur Arch Otorhinolaryngol.2005;262(3):198-203.

15. BuSaba NY, Schaumberg DA. Predictors of prolonged length of stay after majorelective head and neck surgery. Laryngoscope. 2007;117(10):1756-1763.

16. van der Voet JCM, Keus RB, Hart AAM, Hilgers FJM, Bartelink H. The impact oftreatment time and smoking on local control and complications in T1 glottic cancer.Int J Radiat Oncol Biol Phys. 1998;42(2):247-255.

17. McCulloch TM, Jensen NF, Girod DA, Tsue TT, Weymuller EA Jr. Risk factors forpulmonary complications in the postoperative head and neck surgery patient.Head Neck. 1997;19(5):372-377.

18. Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits andpostoperative pulmonary complications. Chest. 1998;113(4):883-889.

19. Zacharek MA, Pasha R, Meleca RJ, et al. Functional outcomes after supracricoidlaryngectomy. Laryngoscope. 2001;111(9):1558-1564.

20. Akbas Y, Demireller A. Oncologic and functional results of supracricoid partial lar-yngectomy with cricohyoidopexy. Otolaryngol Head Neck Surg. 2005;132(5):783-787.




Complicaçoes Pulmonares Laringe

Documents

Transcript of Complicaçoes Pulmonares Laringe