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Interdisziplinäre Defektrekonstruktion bei Fisteln des oberen Aerodigestivtrakts – Fallserie und Behandlungsalgorithmus

Interdisciplinary defect reconstruction of upper aerodigestive fistulas—case series and treatment algorithm

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Zusammenfassung

Hintergrund

Persistierende komplexe Defekte und Funktionsstörungen des oberen Aerodigestivtrakts nach tumorchirurgischen Eingriffen stellen eine große Herausforderung dar. Ziel dieser Studie war es, die Wirksamkeit eines interdisziplinären Ansatzes mit der freien lateralen Oberschenkellappenplastik (ALT) als Rekonstruktionsoption im oberen Aerodigestivtrakt zu evaluieren.

Material und Methoden

Die retrospektive Studie identifizierte zwischen 2017 und 2023 5 Patient*innen mit komplexen Defekten nach Laryngektomie (LE) und multiplen Revisionsoperationen. Die Operationen erfolgten durch ein interdisziplinäres Team aus HNO, Plastischer Chirurgie und Viszeral‑/Thoraxchirurgie. Die Ergebnisse der mikrochirurgischen Rekonstruktion wurden erfasst.

Ergebnisse

Es lagen durchschnittlich 6 Voroperationen vor. Die Defekte umfassten tracheoösophageale Fisteln, pharyngokutane Fisteln, Neopharynxstenosen sowie deren Kombination. Eine erfolgreiche Rekonstruktion konnte in 100 % der Fälle durch den ALT-Lappen erreicht werden. In zwei Fällen wurden ALT-Durchflusslappen mit einem zusätzlichen Jejunuminterponat (JI) und in drei Fällen ein Split-ALT-Lappen durchgeführt. Die Major-Komplikationsrate lag bei 40 % und die Minor-Komplikationsrate bei 20 %.

Schlussfolgerung

Komplexe Defekte des oberen Aerodigestivtrakts mit multiplen Voroperationen können erfolgreich rekonstruiert werden. Aufgrund seiner Vielseitigkeit scheint der ALT-Lappen eine sehr gute Option zu sein. Voraussetzung hierfür ist ein interdisziplinärer Behandlungsansatz mit einer kritischen Abwägung der patienten- und krankheitsspezifischen Faktoren.

Abstract

Background

Persistent complex defects and dysfunctions of the upper aerodigestive tract after tumor surgery represent a major challenge. The aim of this study was to evaluate the effectiveness of an interdisciplinary approach using the free anterolateral thigh flap (ALT) as a reconstruction option in the upper aerodigestive tract.

Materials and methods

The retrospective study identified 5 patients with complex defects after laryngectomy/pharyngolaryngectomy (LE/PLE) and multiple revision surgeries between 2017 and 2023. The operations were performed by an interdisciplinary team from otolaryngology, plastic surgery, and visceral/thoracic surgery. The results of the microsurgical reconstruction were analyzed.

Results

There was an average of six previous operations. The defects included tracheoesophageal fistulas, pharyngocutaneous fistulas, neopharyngeal stenosis, and combinations thereof. Successful reconstruction was achieved in 100% of patients using the ALT flap. In 2 patients, ALT flow-through flaps were used with an additional free jejunal interposition (JI) and in 3 patients split-ALT flaps were used. The major complication rate was 40% and the minor complication rate was 20%.

Conclusion

Complex defects of the upper aerodigestive tract with multiple previous operations can be successfully reconstructed. Because of its versatility, the ALT flap seems to be a very good option. Prerequisite for this is an interdisciplinary treatment approach with a critical assessment of patient- and disease-specific factors.

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Authors and Affiliations

  1. Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Klinik für Hand und Plastische Chirurgie der Universität Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland

    S. Nolte, U. Kneser, A. K. Bigdeli, M. Aman, F. Struebing &  E. Gazyakan MSc

  2. Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland

    S. Nolte & M. Tisch

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Correspondence to E. Gazyakan MSc.

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Interessenkonflikt

S. Nolte, U. Kneser, A.K. Bigdeli, M. Aman, F. Struebing, M. Tisch und E. Gazyakan geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Nolte, S., Kneser, U., Bigdeli, A.K. et al. Interdisziplinäre Defektrekonstruktion bei Fisteln des oberen Aerodigestivtrakts – Fallserie und Behandlungsalgorithmus. HNO 71, 795–801 (2023). https://doi.org/10.1007/s00106-023-01358-y

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