1) The document discusses complications in CO2 laser transoral microsurgery for larynx carcinomas. It analyzes 98 patients who underwent the procedure between 2009-2012. 2) Intraoperative complications occurred in 2% of patients. Immediate postoperative complications occurred in 6.1% of patients, while delayed complications occurred in 13.2% of patients. 3) The most common complications were postoperative bleeding (5 cases), aspiration pneumonia (8 cases), and cervical abscess (2 cases). One patient experienced airway ignition during the procedure.

1. Complications in CO2 Laser Transoral
Microsurgery for Larynx Carcinomas
F.A Betances Reinoso, C.M Chiesa Estomba, L.A. Dominguez Collazo, J.L. Rodriguez Fernandez, J.L. Fariña Conde, C. Santidrian
Department of Otorhinolaryngology – Head and Neck Surgery. University Hospital of Vigo

2. Introduction

3. During the seventy´s, Strong and Jako proposed the use
of endoscopic laser surgery in the treatment of
laryngeal lesions.

4. Since then, the transoral laser microsurgery (TLM) has been
gaining ground in the world of laryngeal oncology, and has
established itself as an effective option in the management
of malignant tumors of the glottis, supraglottis and
hypopharynx.

5. Advantages, such as the magnification generated by
the microscope, allow us to make limited resections,
to be able to differentiate healthy tissue from the
affected tissue, thus achieving to preserve disease-
free adjacent areas.
It decreases the number of tracheostomies and the
use of nasogastric tubes.
Besides, it is possible to achieve similar oncological
benefits from those obtained by open surgery with
relatively low rates of complications according to the
results reported in the literature.

6. Material and methods

7. Retrospective analysis of those patients diagnosed
with squamous cell carcinoma (SCC) of the glottis and
supraglottis for all stages (T1, T2, T3, T4), N -/+, M -/+
was performed according to the criteria of the Union
Internationale Contre le Cancer (UICC) and the
American Joint Committee on Cancer (AJCC) in a
tertiary hospital.
Patients treated with TLM between January 2009 and
March 2012 were included.

8. Demographic data (age, gender).
Medical history.
Tumoral stage.
Diagnostic tests information.
Histological findings
Complications.
Type of surgery.
For the final analysis only those complications strictly associated with
surgical technique were included.
The type of complications was classified in stages according to the time of
presentation: intra-operative, post-operative, immediate and delayed.

9. Before surgery, all cases were discussed in an
interdisciplinary committee of head and neck tumors.
Patients with lesions suspicious of malignancy were
scheduled for laryngeal microsurgery with biopsy.
Those patients who had positive biopsy were
followed by a glottic or supraglottic CO2 laser
resection. After surgery, the pTNM was presented in
the committee and the need for reoperation or
complementary treatment with radiotherapy (RT) was
assessed.

10. Results

11. Patients
4
94
Male Female Interventions
33
98
Primary Reoperations

12. 0
25
50
75
100
Diabetics Hypertensive Smokers Consumed alcoholic beverages
41
93
40
22

13. N0 N1 N2 M Total
pT1 44 1 0 0 45
pT2 28 2 2 0 32
pT3 9 3 3 0 15
pT4 6 0 0 0 6
Total 87 6 5 0 98
Pathological tumoral stage, regional lymph nodes
and distant metastases

14. Type of
cordectomy
pT1 pT2 pT3 pT4 Total (%)
GLS Type III 2 0 0 0 2 (2,04%)
GLG Type IV 27 1 0 0 28 (28,57%)
GLS Type Va 14 8 0 0 22 (22,44%)
GLS Type Vb 0 3 3 1 7 (7,14%)
GLS Type Vc 0 5 1 2 8 (8,16%)
GLS Type Vd 0 1 0 1 2 (2,04%)
SGL Type IIa 1 2 0 0 3 (3,06%)
SGL Type IIb 0 1 1 0 2 (2,04%)
SGL Type IIIa 0 5 0 1 6 (6,12%)
SGL Type IIIb 0 1 3 0 4 (4,08%)
SGL Type IVa 0 3 2 0 5 (5,10%)
SGL Type IVb 1 2 8 1 12 (12,2%)
Total 45 18 4 4 98 (100%)
Glottic and supraglottic cordectomy practiced
as rated by the ELSOC

15. Complicaciones N % Tipo
Intraoperative 2 2,04% One patient loss of tooth and another suffer ignition of the airway.
Inmediate post
operative
6 6,1% 5 episodes of post-surgical bleeding and 1 episode of dyspnea
secundary to airway edema.
Delayed post-
operative
13 13,2% 8 patients suffer aspiration pneumonia. 2 patients had cervical
abscess (One of them complicated with mediastinitis). 2 patients had
stenosis of the laryngeal vestibule. 1 patient had thyroid cartilage
chondritis.
Total 19 19,38%
Intraoperative, immediate and delayed postoperative
complications associated with laser surgery

16. Glottic Supraglottic Transglottic p
Mean hospital stay
3,6 days (±8,3
= Min: 1/Max:
66)
13,2 days (±25,5
= Min: 2/Max:
149)
38 days (±54,8 =
Min: 2/Max: 116)
<0,0001
NFT
20,6% 80,6% 100% <0,0001
NFT mean duration
0,9 days (± 2,2
days = Min: 0/
Max: 13)
6 days (± 5,7
days = Min: 0/
Max: 29)
15,5 days (± 19,2
days = Min: 2/
Max: 44
<0,0001
The mean of hospital stay, percentage of placement
and duration of NFT according to tumor location

17. Discussion

18. In this retrospective study we analyzed the results of
a group of 98 patients and 131 CO2 laser
interventions (98 primary, 33 reoperations) due to
laryngeal tumors (pT1, pT2, pT3 and pT4), treated by
primary intention with TLM.
The presence of intraoperative complications was
low, affecting 2% of patients. The immediate
postoperative complications occurred in 6.1% of the
cases and the delayed ones up to 13.2% of patients.
Any of these complications were fatal.

19. In our series this complication represented the 5.1%
of the immediate post-surgical complications,
affecting 6.4% of patients in the STG, 3.2% in the
GTG and 25% in the TTG, findings in relation to
those found in the literature.
Vilaseca et al 3 reported an 8% of bleeding in a serie
of 275 patients, 6.9% were in the group of
supraglottic tumors and 2.9% in the glottic tumors.
Steiner and Ambrosch 8 reported a bleeding rate of
7% in supraglottic tumors and 0% in glottic tumors.

20. 8.1% of patients in our study suffered aspiration
pneumonia after surgery, it was lower than the result
described by Roh et al 14 who reported an incidence
of 11.5% of aspiration pneumonia after TLM, and
was higher with respect to those described by
Vilaseca et al3 who reported a rate of 6.1% of
pneumonias in the treatment of glottic, supraglottic
and hypopharyngeal tumors.

21. Regarding the cervical complications, 2 (2%)
patients had cervical abscess formation, one was
complicated with mediastinitis. No case of
emphysema or cervical fistula was evident.
However Vilaseca et al 3 reported in their study the
development of cervical emphysema in 3 patients
and cervical fistula in one, while Peretti et al 9
described other 2 cases of persistent cervical
fistula after performing temporary tracheotomy in
their patients.

22. 42% of patients in our study required NFT, 20.6% of
these in the GTG, 80.6% in the STG and 100% of
the patients treated in the TTG. But it is important
to note that in most cases, the placement of NFT
was due to a principle of security because of the
wide resection.
During the admission, the swallowing was
evaluated and the NFT was removing after
achieving an adequate swallowing.

23. In our sample, ignition of the air was evident in one
case, who was able to treat immediately without
further consequences for the patient. This
complication happened despite using special
orotracheal tube for laser surgery, the invaluable
collaboration of the anaesthetists to reduce the
levels of O2 and the decision-surgical precautions
such as placing cottonoid sponge with saline.
These facts suggest that even taking all the
precautions, ignition risk is always present.

24. TLM showed good oncologic results and a low
complication rate compared to traditional open
surgery during the intervention, the immediate
and the delayed postoperative period.
Conclusion

25. 1. Strong MS, Jako GJ. Laser surgery in the larynx. Early clinical experience with continuous CO 2 laser. Ann Otol Rhinol Laryngol 1972;81:791–8.
2. Strong MS. Laser excision of carcinoma of the larynx. Laryngoscope 1975;85:1286–9.
3. Vilaseca-González I, Bernal-Sprekelsen M, Blanch-Alejandro JL, Moragas-Lluis M. Complications in transoral CO2 laser surgery for carcinoma of the larynx
and hypopharynx. Head Neck. 2003 May;25(5):382-8.
4. Stoeckli SJ, Schnieper I, Huguenin P, Schmid S. Early glottic carcinoma: treatment according patient's preference? Head Neck. 2003 Dec;25(12):1051-6.
5. Steiner W, Ambrosch P. Advantages of transoral laser microsurgery over standard therapy. In: Endoscopic laser surgery of the upper aerodigestive tract.
Stuttgart : Georg Thieme Verlag; 2000. p 44–45.
6. Remacle M, Van Haverbeke C, Eckel H, Bradley P, Chevalier D, Djukic V, et al. Proposal for revision of the European Laryngological Society classification of
endoscopic cordectomies. Eur Arch Otorhinolaryngol. 2007 Jun;264(6):709.
7. Remacle M, Hantzakos A, Eckel H, Evrard AS, Bradley PJ, Chevalier D, et al. Endoscopic supraglottic laryngectomy: a proposal for a classification by the
working committee on nomenclature, European Laryngological Society. Eur Arch Otorhinolaryngol. 2009 Jul;266(7):993-8.
8. Steiner W, Ambrosch P. Complications. In: Endoscopic laser surgery of the upper aerodigestive tract. Stuttgart: Georg Thieme Verlag; 2000. p 112–113.
9. Peretti G, Piazza C, Ansarin M, De Benedetto L, Cocco D, Cattaneo A, et al. Transoral CO2 laser microsurgery for Tis-T3 supraglottic squamous cell
carcinomas. Eur Arch Otorhinolaryngol. 2010 Nov;267(11):1735-42.
10.Remacle M, Lawson G, Hantzakos A, Jamart J. Endoscopic partial supraglottic laryngectomies: techniques and results. Otolaryngol Head Neck Surg. 2009
Sep;141(3):374-81.
Bibliography

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