**8. Postoperative management**

#### **8.1 Perioperative management**

Since tracheostomies are not performed in most cases, careful attention should be focused on airway management and postoperative bleeding. Laryngopharyngeal edema may worsen for a few days after surgery, although problems may not arise at the time of extubation. Routine endoscopic observation over time should be performed, and steroid administration should be considered if needed. Postoperative bleeding can occur not only immediately but also for more than 2 weeks after surgery due to crust removal during the wound healing process. Therefore, careful follow-up with a ready for emergency airway management, including tracheostomy, is necessary for more than 2 weeks after surgery.

For nutritional management, resurgence of oral intake is considered according to the extent of resection and the risk factors of dysphagia (such as age, performance status, preoperative swallowing function, and irradiation history). However, in cases with small lesions and low risk of dysphagia, oral intake can be resumed from the next day. In many cases with extensive, muscular layer resection and/or arytenoid resection, nasogastric tubal feeding is needed. Swallowing examinations such as videofluorography and/or videoendoscopy are usually performed within 1 week of surgery. Assessment for oral intake should be judged based on these results, and swallowing rehabilitation (direct or indirect training) by a speech therapist should be performed, if necessary, with being appropriate re-evaluation. In most cases, a normal diet can be resumed within 1 week to 1 month of TOVS.

In cases without any postoperative complications such as airway, bleeding, infection, and dysphagia, the patient can be discharged from the hospital. Patients with small lesions are usually discharged within 1–2 weeks after TOVS.

#### **8.2 Long-term management**

It is important to consider the possibility of pneumonia due to silent aspiration. Only a few percent of patients have long-term dysphagia [5, 10]. If long-term oral intake is difficult, gastrostomy is considered.

Epithelization of the wound healing occurs 1–2 months after TOVS in most cases. However, wound healing is very slow and takes more than 6 months in some previously irradiated cases [8]. In such cases, the risk of infection is high. Serious complications such as cervical spondylitis and mediastinitis can occur after more than 6 months after surgery. Long-term antibiotic administration is required in some cases. In addition, it is difficult to discriminate infection/inflammation from recurrence; therefore, long-term follow-up with careful observation is necessary.

Wound adhesion and scar formation due to wound healing causes fixation of the cricoarytenoid joint in some cases of extensive pyriform sinus resection. In such cases, restriction of vocal fold movement and insufficient glottic closure may occur several months after TOVS. Although there is no problem with laryngeal function immediately after surgery, dysphagia and voice disorder might worsen over a few months after TOVS. Intraoperative local steroid injection (triamcinolone acetonide) is effective; however, its indications should be limited only to new cases with extensive excision of the pyriform sinus, postcricoid, and/or esophageal inlet lesions, as described in Section 5.4 [9].

#### **8.3 Oncological management and additional treatments**

The pathological assessment of surgical margins in the resected permanent specimen is often difficult due to cauterization. Therefore, the margins are uncertain in some cases. In cases with horizontal margins, careful follow-up enables early detection, even in the case of recurrence. However, in cases with deep margins, early detection of recurrent lesions may be difficult after wound healing. In such cases, a second-look operation after 2–3 months of TOVS or postoperative irradiation should be considered.

According to pathological findings, patients might undergo postoperative radiation therapy (RT) or chemoradiation therapy (CRT). Definite positive margins, multiple lymph node metastases, extranodal extension, and perineural invasion are indications for RT or CRT.

#### **9. Representative cases**

#### **9.1 Case 1: 64-year-old male, hypopharynx cancer, pT3N0M0**

The lesion was extended from the left pyriform sinus to the posterior wall and anterior surface of the epiglottis (**Figure 6**).

#### **9.2 Case2: 58 years-old male, hypopharyngeal cancer, rT2N0M0**

Chemoradiotherapy for hypopharyngeal cancer (T3N0M0), was performed 2 years before TOVS. The recurrent lesion was located more than half of the posterior wall to the esophageal inlet (**Figure 7**).

#### **Figure 6.**

*Case 1. a. Pre-operative endoscopic view, b. observation with Normal light: Lesion was extended from left piriform sinus to posterior wall. c. Observation with Normal light: Lesion was extended to the left side of the anterior surface of the epiglottis. d. Observation with NBI, e. observation after iodine staining: Left piriform sinus to the posterior wall, f. observation after iodine staining: Anterior surface of epiglottis, g. resection from the left side of the anterior surface of the epiglottis to the upper side of the piriform sinus. h. Resection of the left piriform sinus to the lateral wall, i. removal of resected en block specimen, j. view after resection: Left piriform sinus to posterior wall, k. view after resection: Resected anterior surface and left edge of epiglottis, l. postoperative endoscopic view (2 months after TOVS).*

#### **Figure 7.**

*Case 2. a. Pre-operative endoscopic view, b. observation with Normal light, c. observation with NBI, d. marking of the mucosal incision line, e. resection from Musclar layer of oral side, f. resection of the whole layer of pharyngeal constrictor muscle, g. view after resection: Ara fascia was preserved. h. View after spraying fibrin grue, i. postoperative endoscopic view (9 months after TOVS).*
