Use of platelet-rich plasma in irradiated patients to treat and prevent complications of head and neck surgery

Abstract

Nowadays, many patients facing head and neck oncological surgery have a history of tissue irradiation. This represents an important risk factor for postsurgical complications, including dehiscences and fistulas. Platelet-rich plasma (PRP) obtained from the patient’s blood represents an easy, fast and inexpensive method for the prevention and treatment of such complications. We present three cases of previously irradiated patients in which PRP was successfully used to prevent and treat postsurgical complications.

Background

Nowadays, patients facing head and neck surgery are more and more often presenting with comorbidities, such as cardiovascular diseases or diabetes, and have a history of heavy use of tobacco.¹ Also, radiation therapy (RT) plays an increasingly bigger role in head and neck cancer, both as a mean of organ preservation (particularly in laryngeal cancer) and as adjuvant therapy after surgery.² It is well demonstrated that preoperative RT, as well as other risk factors mentioned above, increases the risk of postsurgical complications, such as wound dehiscences and fistulas, as irradiated tissues are chronically hypoxic, hypocellular and hypoperfused, making it more difficult for surgical wounds to heal.³ One strategy that has been widely used in order to prevent complications in these patients is the implementation of free or pedicled flaps.⁴

Platelet-rich plasma (PRP) is a preparation of autologous plasma, with a platelet concentration that is above that of whole blood.⁵ It is usually obtained by centrifugation of the patient’s own whole blood, which makes it possible for its components to separate and for platelets to concentrate. The rationale for its therapeutic use is based on its capacity of supplying high amounts of growth factors and cytokines, which are essential in tissue regeneration and wound healing.⁵

Its application is widely diffused, especially in orthopaedics, periodontics, maxillofacial surgery and plastic surgery,⁶ as its healing effects are especially significant for tendons, ligament and cartilage.⁵ In head and neck surgery, its use, as of today, is not widely diffused, and is mostly limited to phoniatric procedures^7–10 and naso-sinusal healing after endoscopic sinus surgery.^{11 12}

We present three cases of previously irradiated patients in which we decided to use PRP either to treat or prevent postoperative complications.

Case presentation

Case 1

A man in his 70s had a history of squamous cell carcinoma (SCC) of the right vocal cord, for which he underwent RT in 2019. The disease recurred and the patient underwent a total salvage laryngectomy + bilateral selective node dissection (levels II–VI) + thyroidectomy, with positioning of a Montgomery salivary stent¹³ in May 2021. Postoperative course was complicated by the occurrence of a fistula in the neopharynx, which necessitated surgical treatment. On surgical exploration, a vast dehiscence in the neopharyngeal suture became evident, plus a peritracheal fistula. A pectoralis major myocutaneous pedicled flap (PMMF) was harvested in order to reconstruct the integrity of the neopharynx, while the sternal end of the left sternocleidomastoid muscle was mobilised and used to close the tracheal portion of the fistula.

PRP obtained from centrifugation of the patient’s whole blood was injected in the neopharyngeal suture with the cutaneous portion of the PMMF and in the tracheal portion of the fistula (figure 1). A new Montgomery salivary stent was positioned.¹³

Figure 1.

Case 1, injection of autologous PRP in the tracheal portion of the fistula after surgical repair. The asterisk indicates the apron flap previously raised, the arrow points to the tracheostoma.

The patient was discharged from our clinic 2 weeks later; 20 days after surgery a videofluoroscopic swallow study (VFSS) (figure 2) showed the absence of fistulous tracts and the patient could resume oral feeding.

Figure 2.

Case 1, videofluoroscopic swallow study showing the absence of fistulous tracts. (A) Lateral view, (B) frontal view.

Case 2

A man in his late 70s had a previous diagnosis of laryngeal SCC (pT4a pN0 cM0), for which he had undergone a total laryngectomy extended to the prelaryngeal tissues + bilateral SND + thyroidectomy + reconstruction with PMMF in March 2020. He subsequently underwent RT.

In order to regain speech ability, in late February 2021, the patient underwent positioning of a voice prosthesis (Provox Vega) with creation of a tracheoesophageal fistula, under total anaesthesia. The patient was discharged 1 day later, after he had received training on how to use the voice prosthesis.

Two weeks later, the patient was conducted to our emergency room as he was experiencing periprosthetic leaking when drinking. On inspection, the tracheoesophageal fistula appeared to be dehiscent, enlarged, and the surrounding mucosa looked pale, ischaemic and fragile. The patient was admitted once again to our clinic. We decided to momentarily remove the voice prosthesis and position a nasogastric feeding tube.

Two days after admittance, we decided to inject PRP obtained from centrifugation of the patient’s whole blood in the tissue surrounding the tracheoesophageal fistula (figure 3). Four days later, the voice prosthesis was repositioned and the patient was made to eat and drink, with no leaking. The nasogastric feeding tube was removed and the patient was discharged from our clinic.

Figure 3.

Case 2, injection of autologous PRP in the enlarged tracheoesophageal fistula (black arrowhead) (endoscopic vision). The surrounding mucosa looks pale and ischaemic (black arrow). A nasogastric feeding tube is visible in the oesophagus (black asterisk).

Case 3

A man in his late 50s had a history of SCC of the left vocal cord, for which he had undergone RT in November 2020. The patient came to our attention in July 2021, as the cancer had recurred and was now extended to both vocal cords, with subglottic extension.

The patient underwent a total laryngectomy + reconstruction with PMMF (placed as a protection to the neopharynx) + positioning of a voice prosthesis (Provox Vega) with creation of a tracheoesophageal fistula, under total anaesthesia. As the patient had previously undergone RT, we decided to inject PRP obtained from centrifugation of the patient’s blood into the neopharyngeal suture (figure 4).

Figure 4.

Case 3, injection of autologous PRP in the neopharyngeal suture.

Postoperative course was regular. The patient was discharged 2 weeks later and 30 days after surgery a VFSS showed the absence of fistulous tracts and the patient could resume oral feeding.

Discussion

As it is widely known, head and neck major oncological surgery is a very complex and high-risk surgery, reflecting the anatomical and functional complexity of the region. Advanced age of the patient, comorbidities such as diabetes or cardiovascular diseases and previous tissue irradiation represent risk factors that can potentially increase the occurrence of postoperative complications, that can sometimes even lead to patient’s death. Furthermore, in the era of chemoradiotherapy aimed at organ preservation, salvage surgery after RT is becoming more and more frequent,¹⁴ increasing the risk of postoperative complications.

The three cases presented here concern patients with laryngeal SCC that had previously undergone RT, as means of organ preservation. Furthermore, patients in cases 1 and 2 had a history of tobacco smoking; the patient in case 1 was known for ischaemic heart disease, for which he had undergone multiple coronary artery bypass graft procedures, while the patient in case 3 had no significant comorbidities but was significantly overweight, having also undergone bariatric surgery in the past.

As it is widely known that previous tissue irradiation, especially in combination with the other risk factors mentioned above, greatly increases the risk of postoperative complications, particularly concerning the aberrant healing of surgical wounds, we decided to use PRP as adjuvant in the healing process. PRP is a fast, inexpensive and completely safe (as it is obtained from the patient’s own blood) mean that has been widely used in many fields of medicine (especially orthopaedics and plastic surgery).

As of today, PRP is not widely used in head and neck surgery. A brief literature search revealed mostly studies on its use in phoniatric procedures^7–9 and nasosinusal healing after endoscopic sinus surgery.^{11 12} Furthermore, many of these works were animal-based studies,^{8 10 11} reflecting the need of more studies to be carried out in humans.

Those presented here are intended to be preliminary results, with the intention of carrying out more studies and collecting more data, with the final aim of standardising the use of PRP in head and neck oncological surgery. As the results obtained from the first implementations of this treatment were extremely positive, we are starting to use PRP as a standard procedure in those patients more at risk of complications, in particular previously irradiated ones.

Ultimately, PRP represents an incredibly convenient method of treating, or better still preventing, postsurgical complications, especially in more fragile patients. PRP is extremely inexpensive, as the only equipment needed is a centrifuge, which is present in most hospital settings. As PRP has an autologous origin, being obtained from the patient’s blood, no significant adverse effects have been reported⁵; even though they are not numerous, studies in which PRP was used in head and neck surgery show that it is completely safe.7 9 12 15 16

Furthermore, the fact that the preparation of PRP is extremely fast and only needs the use of a centrifuge makes it possible for the surgeon to decide whether to use it or not even mid-surgery, as its preparation takes mere minutes. In our case, we used whole blood in a 10 cc test tube and centrifuged it for 9 min at 3900 rpm.

PRP implementation in head and neck surgery is only at the beginning. Of course, further studies are needed in order to standardise its usage in this field, but what we know now is that its implementation is extremely easy, inexpensive, fast and without adverse effects.

Learning points.

• Previous radiation therapy represents an important risk factor for the occurrence of postoperative complications, such as fistulas and dehiscences.

• Nowadays, many patients facing head and neck major surgery have received a previous tissue irradiation.

• Platelet-rich plasma is an easy, fast and inexpensive method that could help prevent and treat postsurgical complications, such as fistulas and dehiscences.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).