Introduction
Tracheoesophageal puncture with siting of a voice prosthesis has become the preferred method of post-laryngectomy voice rehabilitation.Reference Brown, Hilgers, Irish and Balm1, Reference Stafford2 Although a primary tracheoesophageal puncture can be created, many centres prefer to perform the procedure at a second stage, for various reasons.Reference Lau, Wei, Ho and Lam3–Reference Andrews, Mickel, Hanson, Monahan and Ward5 However, performing a secondary tracheoesophageal puncture is not always easy and has a higher complication rate. Prior irradiation or chemoradiation may cause significant fibrosis of the neck, preventing neck extension. In such situations, the conventional, rigid endoscope technique becomes almost impossible.
We describe a simple alternative method for performing secondary tracheoesophageal puncture, using curved intestinal clamps (Kocher's curved intestinal clamp forceps) or right-angled forceps (Mixter forceps).
Surgical technique
In our institute, all patients who have undergone laryngectomy without voice prosthesis siting are offered secondary tracheoesophageal puncture along with voice prosthesis insertion. The procedure is performed under local anaesthesia in an out-patient setting, or under general anaesthesia in select cases.
Either curved intestinal clamps or right-angled forceps are used. Kocher's curved intestinal clamp forceps are long, slender forceps with very long flanges and two gentle reciprocating curves that perfectly match the curve of the oral and oropharyngeal cavity (Figure 1). Mixter forceps are long, slender, right-angled forceps with straight flanges that turn at a right angle near the tip (Figure 1). In a patient whose neck can be extended, right-angled forceps can be used effectively (Figure 2a), whereas in patients whose neck cannot be extended, curved intestinal clamp forceps are more convenient (Figure 2b).
Fig. 1 Kocher's curved intestinal clamp forceps (below) and Mixter right-angled forceps (above).
The patient is placed supine and maximum neck extension is achieved. The procedure can be performed under general anaesthesia or local anaesthesia with equal ease. Where used, general anaesthesia is induced and maintained by a small (number five or six) tracheostomy tube. Alternatively, local anaesthetic is sprayed in the oropharynx and also infiltrated into the proposed tracheoesophageal puncture site.
The mouth is opened fully and the tongue retracted anteriorly out of the mouth. The curved intestinal clamp is passed gently from the mouth into the oesophagus until it reaches the posterior wall of the tracheostoma (Figure 2a). A large bulge is produced in the posterior wall of the trachea, which can be easily seen and felt. The puncture site remains the same as described in the standard technique, i.e. 5 to 8 mm below the mucocutaneous junction on the posterior wall of the tracheostoma. A small stab incision is made on the posterior wall, keeping the bulge as a guide. This delivers the tip of the instrument (Figure 2c and Figure 3). There is no risk of injuring the posterior oesophageal wall with this method, and the puncture is made easily with a single stab. Guide wire (or silk thread) is locked between the tip of the two forceps flanges and is carried in a retrograde fashion out of the mouth (Figure 2d and Figure 4). The prosthesis is fixed to this guide wire and then pulled through the puncture into the tracheostoma (Figure 2d and 2e and Figures 5 and 6).
Fig. 2 Diagram of secondary tracheosophageal puncture technique.
Fig. 3 Intra-operative view showing forceps tip emerging from the posterior wall of the tracheostoma.
Fig. 4 Intra-operative view showing guide wire held between forceps flanges and pulled through mouth.
Fig. 5 Intra-operative view showing guide wire pulled out through the mouth in a retrograde fashion, with the prosthesis attached.
Fig. 6 Intra-operative view showing the prosthesis being pulled with the guide wire through the puncture site.
In patients with pharyngeal stenosis due to irradiation, dilatation is performed first and then tracheoesophageal puncture. In these cases, a Ryle's tube is first passed through the tracheoesophageal puncture. A track is allowed to form, and after 10 days the prosthesis is inserted in an anterograde manner, either with a Provox®2 Single-use insertion tube (ATOS MEDICAL AB, Hörby, Sweden). or a Blom–Singer gel cap® insertion system (INHEALTH®, Carpinteria, United States of America). This obviates the need to pass the guide wire and pull the prosthesis through the stenotic pharyngeal segment.
Results
We performed secondary tracheoesophageal puncture, using the above technique, in five cases. Three of these were referred from elsewhere following laryngectomy and adjuvant radiotherapy. The other two cases had undergone total laryngectomy and partial pharyngectomy with patch pectoralis major muscle flap and adjuvant chemoradiotherapy. None of the patients had a speech valve. All patients had significant neck fibrosis, with only minimal neck extension possible, and conventional tracheoesophageal puncture with a rigid endoscope was not possible.
Tracheoesophageal puncture, using the above method, was successful in all five cases, without any complications. The procedure was performed under local anaesthesia in four cases and general anaesthesia in one case (in which simultaneous pharyngeal dilatation was planned). After tracheoesophageal puncture, valve insertion was easily achieved, and no patient developed post-operative peri-tracheoesophageal puncture leak. All patients underwent speech rehabilitation, resulting in intelligible speech.
Discussion
Tracheoesophageal puncture and the use of a voice prosthesis (such as the Provox or Blom–Singer) has become widely popular for post-laryngectomy voice rehabilitation.Reference Brown, Hilgers, Irish and Balm1, Reference Stafford2 Primary tracheoesophageal puncture is performed at the same time as laryngectomy. It is easy to perform, has very few complications and enables immediate voice rehabilitation, and it has become standard care for patients undergoing laryngectomy. However, some centres still prefer to perform tracheoesophageal puncture as a second stage procedure.Reference Lau, Wei, Ho and Lam3–Reference Andrews, Mickel, Hanson, Monahan and Ward5 We prefer to perform secondary tracheoesophageal puncture in cases in which total laryngopharyngectomy has been performed with free jejunal or free Anterolateral thigh flap (ALT), gastric pull-up, or patch pectoralis major flap. Post-laryngectomy patients referred from elsewhere who do not have a voice prosthesis are also offered secondary tracheoesophageal puncture.
Conventional secondary tracheoesophageal puncture technique involves the use of a rigid oesophagoscope and a trocar-cannula, and may not be possible in all cases. Radiation causes significant fibrosis of the neck in some patients which can restrict neck extension, making use of a rigid endoscope very difficult.Reference Spiro and Spiro6–Reference Görür, Ozcan, Unal and Ozkul8
Few alternative techniques for secondary tracheoesophageal puncture have been described. Most use a flexible endoscope together with various instruments such as a trocar-cannula, dilators, forceps, laser, percutaneous endoscopic gastrostomy set, endotracheal tube and suction cannula.Reference Ng, Lam and Wong7–Reference Padhya, Athavale, Morgan and McCaffrey15 Such techniques are relatively simple and effective but can have their own problems. In cases with pharyngeal stenosis, it is sometimes difficult to visualise the inner oesophageal wall with a flexible endoscope and to protect the posterior wall from injury. It is also difficult to pass the prosthesis through the stenotic segment.
The method described here is simple, safe and effective. The instruments used are easily available and can be used in any setting. The procedure can be performed in an out-patient setting under local anaesthesia, minimalising inconvenience to the patient. The procedure does not require any endoscopic guidance; despite this, there is no risk of injuring the posterior oesophageal wall or creating a false passage. The curved intestinal clamp used has two gentle reciprocating curves which match the curve of the pharynx. It is very easy to insert, even in a flexed neck. Its tip bulges out beneath the posterior wall of the tracheostoma and can be easily seen and felt. The incision is made over the tip of the instrument, so there is no risk of damaging the posterior oesophageal wall. Right-angled forceps are equally easy to use in patients in whom the neck can be extended. In cases of severe stenosis, oesophageal dilatation is performed first and then tracheoesophageal puncture. Both instruments are long and slender and easily pass through the stenotic segment. In this way, anterograde insertion of the valve is possible, avoiding dragging the voice prosthesis through the narrow, stenotic segment.
Conclusion
We describe a simple, safe alternative technique for secondary tracheoesophageal puncture. The technique is quick, easy to perform in any setting (including under local anaesthesia) and gives good results.
