Rehabilitation Program for Postlaryngectomy Patients Following Ileocolon Flap Transfer for Voice Reconstruction: An Essential Part of Success

• Abstract
• Methods
• Operation procedure
• Rehabilitation Program for Voice Training
• Results
• Discussion
• Conclusion
• References

Abstract

Background Speech restoration is important for communication and social activities after pharyngolaryngectomy in head and neck cancer or corrosive injury. Several techniques of voice restoration have been developed to improve life quality. The aim of this paper was to focus on the microsurgical transfer of ileocolon flap and outcome of further voice rehabilitation.

Patients and Methods From 2010 to 2022, 69 patients had ileocolon flap at our hospital with postoperative speech training and regular follow-up for over 1 year. The patients received deglutition training first, followed by voice rehabilitation. Voice outcomes were evaluated at an interval of 3 months and finally at 12 months of voice training rehabilitation. Among other examinations, the speech function was evaluated using a 4-point Likert scale and senior surgeon (H-c.C.) scoring system.

Results The results showed that speech function reached 13.1% of excellent voice, 65.1% of good voice, 13.1% of fair result, and 8.7% of poor result by Likert scales. Meanwhile, the senior surgeon (H-c.C.) score showed 17.4% of excellent, 63.8% of moderate, and 18.8% of poor results. About voice laboratory results, maximal phonation time was 11.0 seconds, and the average number counted in one breath was 15. Loudness and frequency showed 56.0 dB and 105.0 Hz, respectively.

Conclusion The study showed that after voice reconstruction with ileocolon flap followed by the voice rehabilitation program, the patients would have a better understanding of the altered anatomical structures and practice in a more efficient way. Adequate recommendation by the therapists to plastic surgeons for revision surgeries optimized voice function of the patients.

Head and neck cancer could cause psychosocial problems, not only anxiety and depression but also isolation from friends and even family members due to changes in patients' structural and functional integrity of the head and neck area,[1] [2] especially after total pharyngolaryngectomy which causes a tremendous impact on physiological functions including speech, swallowing, and airway.[1] [3] [4]

Speech function plays an important role for verbal communication and personal characteristics. Loss of voice could affect patients' quality of life (QOL).[5] [6] [7] Voice rehabilitation was first introduced in the 19th century. Voice restoration was the most important tool for patients to maintain social activities and improve their QOL.[6] [7] [8]

The techniques of voice restoration include nonsurgical and surgical methods. The nonsurgical methods include esophageal speech (ES), pneumatic artificial larynx, and electrolarynx. The surgical methods include neoglottis, tracheoesophageal puncture (TEP), fasciocutaneous flap such as anterolateral thigh (ALT) flap, radial forearm free flap (RFFF), intestinal flap such as ilecolon free flap, and jejunal flap.[9] [10] [11] [12] [13]

TEP is widely accepted and used in western countries. In TEP technique, a fistula is created between the posterior wall of the trachea and the anterior wall of the esophagus. Then the one-way valve mechanism is inserted into the fistula. Patients could occlude the tracheostome with finger or thumb to produce the intelligible speech.[10] However, TEP is easily occluded by saliva which needs frequent replacement (even as frequent as every 1–2 months, that is costly). Also, TEP could attrit with the surrounding tissue that enlarged the fistula.

Although fasciocutaneous flaps are easy to harvest, long-term outcomes include stricture, leakage, and voice tube obstruction. Since flap loss and complications are irreversible and could be potentially preventable, there was a study which introduced a modified technique for fasciocutaneous flap using a refined design and inset method to divert toxic drainage and avoid related complications. Delta ALT flap was designed to exceed the dimension of the defect to cover the vulnerable vessels. With the technique, it could minimize fistula and stricture formation.[14] However, there was no discussion for the detailed speech evaluation in Delta ALT flap.

In speech fluency, although the words per minute produced by TEP was more with better intelligibility compared with ES and electrolarynx,[15] [16] [17] several series of voice restoration amendment have been reported. After total pharyngolaryngectomy, reconstruction by using free ileocolon flap allowed simultaneous restoration of swallowing as well as speech.[18] [19] Thus, the rehabilitation program of voice has been developed after voice reconstruction with free ileocolon flap in our hospital. In this study, we introduced our method of rehabilitation for voice reconstruction with ileocolon flap after total pharyngolaryngectomy.

Methods

A retrospective analysis was conducted utilizing patient data obtained from medical records. All the patients underwent voice reconstruction with free ileocolon flap after total laryngectomy and received regular voice rehabilitation between 2010 and 2022 in our hospital.

Operation procedure

The defects of pharynx, cervical esophagus, and upper trachea (including larynx) were measured first. A segment of ileocolon flap was harvested (including 10–20 cm of the terminal ileum with a variable length of ascending colon depending on the length of esophageal defect). It was transferred to the neck with the ascending colon for reconstruction of pharynx and cervical esophagus, and an ileum segment for voice reconstruction ([Fig. 1]).

Rehabilitation Program for Voice Training

The physiotherapy program was provided after restoration of swallowing capacity. Before rehabilitation, the patients were explained regarding their anatomical structures on the diagram. This would give them a better understanding and more incentive to practice. We also showed them the video of other patients who could speak well after training. Thus, the patients would have more confidence when they saw the encouraging results. The steps of voice rehabilitation ([Fig. 2]) were explained by the same therapist. Analysis of patients' voice quality was also done in our voice laboratory ([Table 1]). Revision of voice tube was done if necessary, with regard to the specific problem found by clinical findings and voice laboratory. The speech function was evaluated every 3 months and finally at 1 year after initial voice rehabilitation. The voice function was evaluated with a 4-point Likert scale ([Table 2]) and senior surgeon (H-c.C.) scoring system ([Table 3]). The 4-point Likert scale of score 1 indicated that the patient could not make sound and a score 4 indicated very clear speech understood by everyone including conversation through the phone. In HCC scoring system, patients were required to speak and answer five phrases: “What is your name?,” “Where do you live?,” “Are you hungry?,” “Have you had dinner?” and “Can you help me?” Then two investigators (two authors K.K-Y.L. and H-c.C.) counted the number of sentences that were intelligible. A higher score indicated better speech intelligibility. Two scores were combined to evaluate the degree of intelligibility. Eight to 10 points indicated excellent scores, and 5 to 7 points showed moderate scores, and points that less than 4 meant poor result.

Besides 4-point Likert scale, we also used several ways to assess the speech function including percentage of effective phonation in a sentence, maximal phonation time (MPT), number counted in one breath, breathiness, roughness, and presence of wet voice.

During the course of voice rehabilitation, the therapist would assess and make suggestions to plastic surgeon for revision procedures according to the observation during rehabilitation and the analysis of voice laboratory. Chi-square test was used for statistical analysis.

Results

From 2010 to 2022, there were 69 patients who had ileocolon flap at China Medical University Hospital with postoperative speech training and regular follow-up for over 1 year (cases in 2023 were not included due to the need of follow-up for 1 year). There were 62 (89.9%) male and 7 (10.1%) female. The average age was 54.6 years (ranged from 33 to 78). Most of the patients (63.7%) were aged between 50 and 70 years, which is relevant to the most common onset age of hypopharyngeal carcinoma (HPC) patients. The etiologies for surgery were hypopharyngeal cancer in 55 patients (79.7%), laryngeal cancer in 3 patients (4.4%), thyroid cancer in 3 patients (4.4%), corrosive injury in 4 patients (5.8%), supraglottic squamous cell carcinoma (SCC) in 2 patients (2.9%), nasopharyngeal carcinoma (NPC) postradiotherapy damage in 1 patient (1.4%), and pyriform sinus cancer in 1 patient (1.4%; [Table 4]).

Regarding speech function with the 4-point Likert scale, nine patients (13.1%) had excellent voice which indicated a very clear voice with little or no wetness and could be understood by everyone. Forty-five patients (65.1%) with good voice which could be understood by family members and close friends, nine patients (13.1%) with fair results which means the voice could be understood only by close families, and finally six patients (8.7%) with poor result. Poor result meant the patients could not communicate due to lack of voice training due to inconvenience or without family support, or cancer recurrence and were sent to chemoradiation. Concerning the senior surgeon (H-c.C.) score, 12 patients (17.4%) had excellent results, 44 patients (63.8%) had moderate results, and 13 patients (18.8%) had poor results. About voice laboratory results, MPT was 11.0 seconds, and the average number counted in one breath was 15. Loudness and frequency showed 56.0 dB and 105.0 Hz, respectively.

During voice rehabilitation, we made a diagram to illustrate 10 steps in rehabilitation of voice. In voice rehabilitation, we let patient spit out saliva in the mouth before voice training. After letting the patients review the anatomical structures of esophagus and voice tube in the pictures, patients would start voice rehabilitation by covering the tracheostome with thumb. After evaluation, plastic surgeons would perform surgical revision if needed. Then patients would restart voice rehabilitation again ([Fig. 2]).

At the same time, the patients were divided into two groups. The first group was hypopharyngeal cancer (including HPC and pyriform sinus cancer), and the other group was nonhypopharyngeal cancer (including thyroid cancer, corrosive injury, laryngeal cancer, supraglottic SCC, and NPC postradiotherapy damage). There was no significant difference shown with the 4-point Likert scale ([Table 5]), but a significant difference (p < 0.05) was noted in HCC score between the hypopharyngeal cancer group and nonhypopharyngeal cancer group ([Table 6]).

In addition, 35 patients (50.7%) could speak after voice rehabilitation following first surgery, and 34 patients (49.3%) underwent secondary reconstruction for revision. Among the ones receiving secondary reconstruction for revision, in 18 patients (52.9%) the voice tube had to be shortened, 8 patients (23.5%) patients had revision for tracheostomy, 5 patients (14.7%) had widening of voice tube–tracheal stump (V–T) orifice, and in 3 patients (8.9%) the voice tube–pharynx (V–P) orifice had to be narrowed down.

Discussion

After cancer resection for head and neck cancer, most patients required reconstruction. Especially for those undergoing total pharyngolaryngectomy, the patients were accompanied by loss of voice and swallowing function that remarkably affect patients' social activities and even cause psychiatric disorders. Therefore, several techniques of voice restoration have been developed and widely used globally.[9] [10] [11] [20] For instance, the surgical techniques for voice restoration have been reported by using the tracheo–gastric (T–G) tube shunt in 1984, jejunum flap in 1991, free ileocolic flap in 1992 by Kawahara et al.[21] [22] [23] [24]

The reconstruction with intestinal free flaps transfer may become a good option which is getting more popular and reliable after total pharyngolaryngectomy or severe corrosive injury for simultaneous restoration the speech and swallowing functions.[24] [25] [26] [27] The ileocolon flap is useful in a variety of reconstructions with the ileocecal (Bauthins) valve to prevent reflux of food or fluids into the trachea and create voice.[10] [18] [19] The advantages of ileocolon flap also include low incidence of complications and morbidity as well as a high success rate.[18] [23]

In ileocolon flap, a segment of ascending colon was harvested with the adjacent segment of terminal ileum which included the ileocecal valve. The ascending colon was used to reconstruct the cervical esophagus, and the ileum with ileocecal valve was used for voice reconstruction. Ileocecal valve could prevent from regurgitation with minimal risk of aspiration pneumonia. Ileocecal valve was incorporated in the ileocolon flap.

A counterpart study of cases which underwent voice reconstruction with ileocolon flap after total pharyngolaryngectomy but without training program was reported by Karri et al[19] in 2010. In our recent results, the speech function of 4-point Likert scale showed that 12.8% of patients had excellent voice, 61.5% had good voice; the HCC score revealed that 75.3% patients showed moderate-to-excellent results. While there was no significant difference in 4-point Likert scale, there was significant difference (p < 0.05) in HCC score between the hypopharyngeal and nonhypopharyngeal cancer groups. Possible cause might be that the patients' speech ability was evaluated by the conversation between patients and therapists or with family members then assessed using a 4-point scale. However, in HCC scoring system, the patients must read out the five questions and answer directly, which could help the therapists and senior surgeons to evaluate more about the patient's speech ability. The age group of 30 to 39 years particularly had better speech ability than the other age groups due to their younger age, better learning capacity, work duties, or necessity to maintain a social life leading to more active practice, and resulted in better voice rehabilitation.

TEP is popular in western countries due to simplicity of the procedure and minimal training requirement. Although TEP could reach good speech intelligibility, it has several potential risks including obstruction, tissue maceration, fungus or bacterial growth on voice prosthesis, and aspiration into trachea or esophagus. Frequent attrition of TEP with the surrounding tissue while talking would lead to enlargement of fistula. Enlargement of the fistula requires bigger TEP device to fit in. However, when TEP device is changed to 12 mm size, there is no larger TEP device, then the plastic surgeons should remove the TEP device and close the fistula ([Table 7]).

ALT flap was initially utilized by Song et al[29] in 1984, and this technique soon gained popularity because it was easier to be harvested. ALT flap was especially preferred by surgeons in Asian countries. Harii et al[30] were the earliest to describe the fasciocutaneous flap for reconstruction of pharyngolaryngoesophageal defects with RFFF in 1985. Though skin flaps are easy to harvest, it has potential risks such as leakage, aspiration, and stricture. In 2017, there was a study that reported a novel inset technique based on ALT flap to divert toxic drainage and circumvent complications of HPC patients. In delta ALT flap, the width of flap was dictated by defect length. Flaps were designed as long as possible to facilitate coverage. This technique was designed to exceed the defect to cover the vulnerable vessels. Delta ALT flap indeed could avoid radiation and vascular injury. However, this is a relatively new method which needs evaluation of infection, flap loss, and mortality risk reduction. Moreover, there was no detailed voice reconstruction in the delta ALT flap.[14]

In addition, the length of ileocolon flap is also related to voice quality. In 2016, Tsou et al reported that a longer flap may result in compression of the tracheostome space which increased airflow resistance and impaired vocalization. The ileum segment 10 cm in length was optimal in loudness, maximum phonation time, and sound pressure compared with less than 7 cm, or more than 15 of the ileum segment.³² Our study found that among the 46.2% of patients who underwent secondary revision, 50% of the patients had voice tube (ileum segment of ileocolon flap) too long and had to be shortened; 16.6% of patients had difficulty to apply thumb over the tracheostome and needed revision because the tracheostome was either too large or too small. In 11.1% of patients there was occasional regurgitation of food or saliva and needed narrowing for V–P junction. The remaining 22.2% patients had too small V–T orifice and needed widening.

Conclusion

After voice reconstruction with ileocolon flap, the voice rehabilitation is important. Through voice rehabilitation program, the patients could practice more efficiently to speak better. Adequate recommendations can also be suggested by the therapists during rehabilitation program based on clinical findings and voice laboratory analysis to plastic surgeons for revision to improve voice function of the patients.

Conflict of Interest

None declared.

Acknowledgments

We thank Dr. Zih-Ping Ho's for the statistical support.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Ethics Approval

The study was approved by the Institutional Review Board (or Ethics Committee) of China Medical University Hospital (Protocol number: DMR 101-IRB1-167).

“All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.”

• References

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• 22 Hsiao HT, Leu YS, Chang YC, Yang JC, Tung KY. Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer. Ann Plast Surg 2009; 62 (04) 390-394
  CrossrefPubMedSearch in Google Scholar
• 23 Rampazzo A, Gharb BB, di Spilimbergo SS, Chung KP, Chen HC. Voice reconstruction with free ileocolon flap transfer: implications for the lower respiratory tract. Plast Reconstr Surg 2011; 127 (05) 1916-1924
  CrossrefPubMedSearch in Google Scholar
• 24 Kawahara H, Shiraishi T, Yasugawa H, Okamura K, Shirakusa T. A new surgical technique for voice restoration after laryngopharyngoesophagectomy with a free ileocolic graft: preliminary report. Surgery 1992; 111 (05) 569-575
  PubMedSearch in Google Scholar
• 25 Perrone F, Gharb BB, Rampazzo A, Ngo QD, Chen SH, Chen HC. Evaluation and management of complications or functional problems at the recipient site after esophageal and voice reconstruction with free ileocolon flap. Surgery 2013; 153 (03) 373-382.e2
  CrossrefPubMedSearch in Google Scholar
• 26 Manrique OJ, Sabbagh MD, Kapoor T, Ciudad P, Chen HC. Postoperative management after total pharyngolaryngectomy using the free ileocolon flap: a 5-year surgical intensive care unit experience. Ann Plast Surg 2020; 84 (01) 68-72
  CrossrefPubMedSearch in Google Scholar
• 27 Yang SC, Loh CYY, Tang YB, Chen HC. Using intestinal segments during secondary salvage procedures after failed reconstructions of the cervical oesophagus. Eur J Cardiothorac Surg 2019; 55 (02) 286-291
  CrossrefPubMedSearch in Google Scholar
• 28 Ţiple C, Drugan T, Dinescu FV, Mureşan R, Chirilă M, Cosgarea M. The impact of vocal rehabilitation on quality of life and voice handicap in patients with total laryngectomy. J Res Med Sci 2016; 21: 127
  CrossrefPubMedSearch in Google Scholar
• 29 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
  CrossrefPubMedSearch in Google Scholar
• 30 Harii K, Ebihara S, Ono I, Saito H, Terui S, Takato T. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985; 75 (04) 463-476
  CrossrefPubMedSearch in Google Scholar
• 31 Tsou YA, Li TS, Tsai MH, Chen HC, Belafsky P. Optimal ileocolic flap length for a reconstructed voice tube after laryngopharyngectomy. J Laryngol Otol 2016; 130 (02) 190-193
  CrossrefPubMedSearch in Google Scholar

Address for correspondence

Publication History

Received: 30 October 2023

Accepted: 15 April 2024

Accepted Manuscript online:
06 May 2024

Article published online:
04 June 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

• References

• 1 Thrasyvoulou G, Vlastarakos PV, Thrasyvoulou M, Sismanis A. Horizontal (vs. vertical) closure of the neo-pharynx is associated with superior postoperative swallowing after total laryngectomy. Ear Nose Throat J 2018; 97 (4-5): E31-E35
  CrossrefPubMedSearch in Google Scholar
• 2 Kazi R, De Cordova J, Kanagalingam J. et al. Quality of life following total laryngectomy: assessment using the UW-QOL scale. ORL J Otorhinolaryngol Relat Spec 2007; 69 (02) 100-106
  CrossrefPubMedSearch in Google Scholar
• 3 Elmiyeh B, Dwivedi RC, Jallali N. et al. Surgical voice restoration after total laryngectomy: an overview. Indian J Cancer 2010; 47 (03) 239-247
  CrossrefPubMedSearch in Google Scholar
• 4 Hanna E, Sherman A, Cash D. et al. Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg 2004; 130 (07) 875-879
  CrossrefPubMedSearch in Google Scholar
• 5 Lorenz KJ. Rehabilitation after total laryngectomy-a tribute to the pioneers of voice restoration in the last two centuries. Front Med (Lausanne) 2017; 4 (04) 81
  CrossrefPubMedSearch in Google Scholar
• 6 Jassar P, England RJ, Stafford ND. Restoration of voice after laryngectomy. J R Soc Med 1999; 92 (06) 299-302
  CrossrefPubMedSearch in Google Scholar
• 7 Tang CG, Sinclair CF. Voice restoration after total laryngectomy. Otolaryngol Clin North Am 2015; 48 (04) 687-702
  CrossrefPubMedSearch in Google Scholar
• 8 Kaye R, Tang CG, Sinclair CF. The electrolarynx: voice restoration after total laryngectomy. Med Devices (Auckl) 2017; 10: 133-140
  CrossrefPubMedSearch in Google Scholar
• 9 Galli A, Giordano L, Biafora M, Tulli M, Di Santo D, Bussi M. Voice prosthesis rehabilitation after total laryngectomy: are satisfaction and quality of life maintained over time?. Acta Otorhinolaryngol Ital 2019; 39 (03) 162-168
  CrossrefPubMedSearch in Google Scholar
• 10 Chen HC, Kim Evans KF, Salgado CJ, Mardini S. Methods of voice reconstruction. Semin Plast Surg 2010; 24 (02) 227-232
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Kapila M, Deore N, Palav RS, Kazi RA, Shah RP, Jagade MV. A brief review of voice restoration following total laryngectomy. Indian J Cancer 2011; 48 (01) 99-104
  CrossrefPubMedSearch in Google Scholar
• 12 Deschler DG, Doherty ET, Reed CG, Anthony JP, Singer MI. Tracheoesophageal voice following tubed free radial forearm flap reconstruction of the neopharynx. Ann Otol Rhinol Laryngol 1994; 103 (12) 929-936
  CrossrefPubMedSearch in Google Scholar
• 13 Yang CC, Lee JC, Wu KC, Chang SH. Voice and speech outcomes with radial forearm free flap-accompanied phonation tube after total pharyngolaryngectomy of hypopharyngeal cancer. Acta Otolaryngol 2011; 131 (08) 847-851
  CrossrefPubMedSearch in Google Scholar
• 14 Zelken JA, Kang CJ, Huang SF, Liao CT, Tsao CK. Refinements in flap design and inset for pharyngoesophageal reconstruction with free thigh flaps. Microsurgery 2017; 37 (02) 112-118
  CrossrefPubMedSearch in Google Scholar
• 15 Anton Dev X, Saha S. A study of rehabilitation of speech in post laryngectomy cases, as seen in a tertiary care institution esophageal speech vs speech with tracheoesophageal puncture prosthesis. Int J Phonosurg Laryngol 2019; 9 (02) 36-39
  CrossrefPubMedSearch in Google Scholar
• 16 Merwin GE, Goldstein LP, Rothman HB. A comparison of speech using artificial larynx and tracheoesophageal puncture with valve in the same speaker. Laryngoscope 1985; 95 (06) 730-734
  CrossrefPubMedSearch in Google Scholar
• 17 Cruz S, Viana R, Guimarães JR, Fernandes J, Silva JC, Monteiro E. Tracheoesophageal voice prosthesis outcomes: success or insucess?. International Journal of Otolaryngology and Head & Neck Surgery 2014; 3 (01) 4-22
  PubMedSearch in Google Scholar
• 18 Lo Torto F, Ribuffo D, Manrique OJ. et al. Simultaneous restoration of swallowing and voice function with ileocolon free flap. J Craniofac Surg 2020; 31 (04) 916-918
  CrossrefPubMedSearch in Google Scholar
• 19 Karri V, Yang MC, Chung KP, Chen SH, Mardini S, Chen HC. Total pharyngolaryngectomy and voice reconstruction with ileocolon free flap: functional outcome and quality of life. J Plast Reconstr Aesthet Surg 2011; 64 (07) 911-920
  CrossrefPubMedSearch in Google Scholar
• 20 Massaro N, Verro B, Greco G, Chianetta E, D'Ecclesia A, Saraniti C. Quality of life with voice prosthesis after total laryngectomy. Iran J Otorhinolaryngol 2021; 33 (118) 301-309
  PubMedSearch in Google Scholar
• 21 Sakurai H, Nozaki M. Reconstruction of the pharyngoesophagus with voice restoration. Int J Clin Oncol 2005; 10 (04) 243-246
  CrossrefPubMedSearch in Google Scholar
• 22 Hsiao HT, Leu YS, Chang YC, Yang JC, Tung KY. Voice and swallowing after laryngopharyngectomy and free ileocolic flap reconstruction for hypopharyngeal cancer. Ann Plast Surg 2009; 62 (04) 390-394
  CrossrefPubMedSearch in Google Scholar
• 23 Rampazzo A, Gharb BB, di Spilimbergo SS, Chung KP, Chen HC. Voice reconstruction with free ileocolon flap transfer: implications for the lower respiratory tract. Plast Reconstr Surg 2011; 127 (05) 1916-1924
  CrossrefPubMedSearch in Google Scholar
• 24 Kawahara H, Shiraishi T, Yasugawa H, Okamura K, Shirakusa T. A new surgical technique for voice restoration after laryngopharyngoesophagectomy with a free ileocolic graft: preliminary report. Surgery 1992; 111 (05) 569-575
  PubMedSearch in Google Scholar
• 25 Perrone F, Gharb BB, Rampazzo A, Ngo QD, Chen SH, Chen HC. Evaluation and management of complications or functional problems at the recipient site after esophageal and voice reconstruction with free ileocolon flap. Surgery 2013; 153 (03) 373-382.e2
  CrossrefPubMedSearch in Google Scholar
• 26 Manrique OJ, Sabbagh MD, Kapoor T, Ciudad P, Chen HC. Postoperative management after total pharyngolaryngectomy using the free ileocolon flap: a 5-year surgical intensive care unit experience. Ann Plast Surg 2020; 84 (01) 68-72
  CrossrefPubMedSearch in Google Scholar
• 27 Yang SC, Loh CYY, Tang YB, Chen HC. Using intestinal segments during secondary salvage procedures after failed reconstructions of the cervical oesophagus. Eur J Cardiothorac Surg 2019; 55 (02) 286-291
  CrossrefPubMedSearch in Google Scholar
• 28 Ţiple C, Drugan T, Dinescu FV, Mureşan R, Chirilă M, Cosgarea M. The impact of vocal rehabilitation on quality of life and voice handicap in patients with total laryngectomy. J Res Med Sci 2016; 21: 127
  CrossrefPubMedSearch in Google Scholar
• 29 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
  CrossrefPubMedSearch in Google Scholar
• 30 Harii K, Ebihara S, Ono I, Saito H, Terui S, Takato T. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985; 75 (04) 463-476
  CrossrefPubMedSearch in Google Scholar
• 31 Tsou YA, Li TS, Tsai MH, Chen HC, Belafsky P. Optimal ileocolic flap length for a reconstructed voice tube after laryngopharyngectomy. J Laryngol Otol 2016; 130 (02) 190-193
  CrossrefPubMedSearch in Google Scholar