Figure.2. Weighted complication rates for three treatment modalities
undertaken to treat RRP, with straight lines depicting 95% confidence
intervals for individual studies and diamond depicting 95% confidence
intervals for the weigh.
Discussion
This systematic review and meta-analysis is the first to summarize the
existing literature on complication rate of different Treatment
Modalities of RRP. Heterogeneity precluded a direct comparison between
studies within the same surgical techniques.
Benboujja[38] investigated the depth of RRP using
optical coherence tomography and found that the tumor was limited to
above the basement membrane. In other words, removing the upper layer of
the lesion above the surface is sufficient to remove RRP. Such
microsurgery is essential to preserve the layered structure of the vocal
cords, avoid fibrosis or scarring, and restore normal vocal function.
The rate of complications reported for each is variable, the reason can
be explained by the working mechanism of surgical instrument itself. On
the one hand, cold steel instruments (like microdebrider) avoid heat
transfer to the surrounding tissue and thereby the possibility of scar
retraction. On the other hand, hot methods (laser) allow for better
hemostasis and vaporization of the flat superficial lesions while
preserving normal tissue.
Due to the blood-rich nature of RRP, KTP laser, which belongs to the
angiolytic laser, seems has great advantages in RRP
resection[15]. Unlike the CO2 laser, the
angiolytic laser uses the peak in the absorption spectrum of the oxygen
hemoglobin rather than water, which helps to selectively ablate the
vascularized lesion without excessive thermal
damage[39]. In other words, the KTP laser can
better preserve the surrounding tissue and hemostasis
control[40]. Burns[41] also
argues that diseases in the anterior commissure of glottis can be
treated with minimal risk of scarring or adhesions, whether using KTP
lasers alone or as a complement to other surgical modalities, with
minimal preservation of the potential superficial intrinsic layer.
The wavelength of the CO2 laser (10 600 nm) is absorbed by water,
allowing the lesion to evaporate with a high percentage of intracellular
water. CO2 laser was applied to the treatment of RRP as early as the
early 1970s, which replaced the traditional micro-cold device, and
gradually become a recognized treatment method for laryngeal diseases
due to the better hemostasis effect, lesion clearance and other
characteristics[37, 42, 43]. In 2015, Murono
published a questionnaire to the department of otolaryngology at all 80
Chuo University hospitals in Japan with regard to the use of surgical
instruments. A trend was observed towards lasers (50 hospitals) rather
than micro devices (16 hospitals) or cold instruments (20 hospitals).
Among the 50 hospitals that regularly undergo laser surgery, the most
commonly used carbon dioxide (CO2) laser is followed by titanium-based
potassium phosphate laser[44]. In 2016, a Germany
multicenter cohort study reported that CO2 laser remained the most
common surgical modality used alone or in combination with other
treatment modalities[9]. At present, CO2 laser
fiber is available, and outpatient-based CO2 laser surgery provides
great benefits for RRP patients who need multiple surgeries to control
the disease, the time and cost of treatment are greatly reduced, and the
need for general anesthesia is reduced[27].
However, CO2 laser operation is time-consuming, expensive, and
potentially dangerous. If the intraoperative procedure is improper may
lead to serious complications, such as airway combustion, normal tissue
burns and medical staff damaged, which limit its development.
Microdebrider is a dynamic
rotational dissection device with suction assist, was initially used in
plastic surgery and rhinology. In 1999, Myer first reported the use of
microdebrider in the larynx for the treatment of recurrent respiratory
trait tumors[45]. Under the endoscopic auxiliary
support laryngoscopy, microdebrider can easily reach the throat, trachea
and other parts, with its continuous suction cutting effect. Therefore,
it can easily push the mass away from the base and suck up, remove the
mass accurately, and has gradually become the preferred treatment for
handling JO-RRP in recent years[18, 32].
Wenbin[6] retrospectively analyzed the case series
of RRP, microdebrider can quickly remove tumors, with few complications
and satisfactory postoperative short-term sound quality.
El-Bitar[25]conducted a retrospective study of seventy-three operations, the
microdebrider was proved to be less time-consuming than the carbon
dioxide laser when used in patients with juvenile-onset recurrent
respiratory papillomatosis, whit soft tissue complications were
nonexistent. Pasquale[46] was the first to compare
microdebrider with CO2 laser, there was no significant difference in
postoperative pain between the two groups, but this was a short-term
study that provided initial data in a relatively small patient
population. Similarly, in a retrospective study collaborated by
Patel[5], it was noted that since the C02 laser
switched to microdebrider, the operation time was significantly
shortened without affecting the accuracy of the operation, saving
surgical costs, avoiding the risk of airway burns that may occur during
laser surgery and the possibility of vaporization of virus particles.
Rees[34] found no statistically significant
difference in postoperative pain scores between the microdebriders or
CO2 laser treatment groups. Unlike in the case of lasers, microdebrider
has some drawbacks, where hemostasis is an issue with cold techniques,
but due to the suction of the connection, the surgical field could
remains clear most of the time[34].
Rare
complications of microdebrider include mediastinal emphysema and
retroperitoneal air[47] and subglottic
injuries[48]. Granulomas that occur after vocal
cord polyps have also been
reported[49].
Because of these advantages above, microdebrider may replace CO2 lasers,
the preferred method of airway clearance in these patients, and become
the surgical modality of choice for RRP[50].
In addition, since microdebriders
are more effective at removing bulky diseases than lasers alone,
microdebriders may be a more
cost-effective tool for removing tumors [15].
For bulky exogenous trait tumors,
several surgical methods are often combined to learn from each other’s
strengths and improve surgical efficiency. But there is currently
insufficient data to prove whether combined surgery can reduce the
occurrence of surgical complications. Huang[24]notes that the surgeons prefer to use microdebrider for bulky tumors and
use KTP laser peeling technique for near-normal structure. This mixing
mode can help surgeons shorten surgery time and make it easier to
control bleeding, and it may avoid injury to the stratified structure of
the vocal cords.
Improvements in surgical modalities may reduce the complications
associated with surgical treatment of RRP. The recent introduction of
blue laser to office-based laryngology presents potential advantages,
which includes a desirable combination of cutting and photoangiolytic
qualities and a lightweight, shock-resistant design.
Miller[51] present a case series(thirty-six cases)
and overview of office 445 nm blue
laser transnasal flexible laser surgery, which support conclusion that
blue laser is safe and effective in the treatment of RRP and a range of
benign laryngeal lesions. Future research should compare the efficacy
and safety of blue laser with potassium titanyl phosphate laser in
office-based treatment of these conditions. In addition to improving
surgical instruments, the development of imaging technology may also
help. The use of OCT imaging for simultaneous monitoring alongside laser
treatment may provide the best, patient-specific treatment to improve
postoperative prognosis for patients with RRP in the
future[38].
There are several limitations to this systematic review. First, due to
the lack of adequate literature, this study did not conduct a
meta-analysis of other influencing factors of complications. For
example, the location of the lesion, surgeon surgical techniques and the
number of surgeries the patient undergoes may also be the influencing
factors of complications. Huang[24] reported three
patients with RRP developed anterior glottis after continuous KTP laser
surgery in his retrospective case analysis, but all three patients
received RRP treatment near the front at the same time. They then
performed a staging procedure for papillomas of the bilateral vocal
cords, reducing the incidence of anterior commissure web. As mentioned
earlier, the discovery of Benboujja[38] proves
that the upper layer of the lesion above the surface is sufficient to
remove RRP, except whyich requires surgeons to have superb surgical
skills in order to precisely control the depth of resection. Finally, a
higher number of surgeries may be associated with a higher rate of
surgical complications. PAPAIOANNOU [14] believes
that patients who undergo more surgeries are more likely to develop
complications than patients with fewer surgeries.
Scatolini[21] conducted a retrospective analysis
of 74 patients with adolescent RRP and found that patients who had
undergone more than 10 surgeries or who had previously had a history of
surgery in an external institution had a higher frequency of throat
scarring. However, El-Bitar[25] argued that the
incidence of postoperative complications of RRP was related to the
surgical technique used, not to the number of surgeries or the interval
between surgeries. Due to the fact that most of the existing studies are
retrospective studies, made it difficult to control these variables.
Studies in the future would require detailed reporting of disease
burden, so that patients could be risk stratified by group. Pre- and
post-op Derkay scores or other consisten quantitative metrics are
necessary, to accurately stage the bulk and severity of disease to allow
for more standardized reporting of disease. Complications in these
groups could then be compared to help determine the security of
instruments used in the surgical procedures, so that we can provide data
support for patients to make the best choice.
Conclusion
This systematic review summarizes the complications and complication
rate of RRP patients treated by
surgery using three kinds of
surgical modalities as an independent way. Only one study compared
outcomes of those three kinds of surgical modalities simultaneously, two
studies compared microdebrider and CO2 laser, and the remaining studies
focused on only one of three treatments. While definitive conclusions
cannot be drawn from the available literature, it is possible that CO2
lasers in the surgical treatment of RRP may lead to more surgical
complications, and microdebrider and KTP lasers may be safer. However,
the heterogeneous data limits any strong comparison of outcomes of
different treatment of laryngeal papillomas is needed. Future Randomised
controlled trials that directly compare the safety of different
surgical modalities are needed.
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