Voice rehabilitation with voice prosthesis: Long term results, complications and risk factors

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One of the most devastating outcomes after TL is loss of voice and currently there are three main methods for voice rehabilitation: esophageal speech, electronic aids and tracheoesophageal puncture (TEP) with voice prosthesis (VP).<a class="elsevierStyleCrossRef" href="#bib0145">4</a> Each of these methods has its advantages and disadvantages. VP provides a physiologically better voice quality and is currently the preferred choice for voice rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0135">2</a>The VP directs the exhaled air from the trachea into the pharyngo-oesophageal segment when the tracheostome is occluded. The result of the passage of high-pressure air from the trachea to the pharyngo-oesophageal segment is the vibration of the walls of this segment, which causes the production of sound. The valve is unidirectional, preventing the aspiration of food and saliva into the trachea.<a class="elsevierStyleCrossRef" href="#bib0150">5</a>This work aims to identify VP complications, its lifespan and factors that influence the prosthesis lifespan.MethodsStudy designWe performed a retrospective study at a Tertiary University Hospital. We collected medical records of patients that underwent total laryngectomy, between January 1st of 2008 and 31st of December of 2017. The study protocol was approved by the Ethics Committee (number 325/18) and was carried out in accordance to the principles of the Declarations of Helsinki.Study populationWe studied all the patients with laryngeal or hypopharyngeal cancer that underwent total laryngectomy. We used the Provox® voice prosthesis.We defined the following exclusion criteria: patients without voice prosthesis and loss of follow-up.Data collection was based on electronic medical records.VariablesVariables were collected using a structured database form.Demographic data, including gender and age at the time of surgery, cancer staging according to the TNM Classification – 8th edition, primary tumor localization, primary or secondary TEP, follow-up, prosthesis lifespan, reasons for prosthesis replacement and treatment with adjuvant radiation were analyzed<a class="elsevierStyleCrossRef" href="#bib0155">6</a>. The prostheses were used in accordance with the manufacturer's recommended use. Of note, all patients received pre-operative counseling and instructions on postoperative care of the prosthesis.Statistical analysisStatistical analysis was performed with Statistical Package for the Social Sciences® (version 26.0, SPSS®).Normality was evaluated by the Kolmogorov–Smirnov test and variances using the Levene test. Comparison between groups was performed using the Qui-square, Mann–Whitney U or ANOVA, as appropriate. For correlations between variables, Spearman and Pearson correlation coefficients were used.We used a regression model to analyze the determinants of the number of replacements of voice prosthesis.p value of less than 0.05 was considered as statistically significant.ResultsOf the 84 patients that underwent total laryngectomy, 60 (71.4%) had TEP and all but one had primary insertion of the voice prosthesis. We focused our analysis on the patients with TEP.The average age at the time of surgery was 60.2±8 years and there was a male preponderance (57:3). All the patients underwent primary surgery and most of the patients had T3 or T4 tumors (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Adjuvant radiotherapy was performed in 49 (81.7%) of the patients. Most of the patients are still alive [46 (76.7%)] at the time of the study.The mean follow-up in our consultation was 49.2±33 months and the mean lifetime of the prosthesis was 7.53±2.4 months.Leakage through the prosthesis was the most common reason of prosthesis replacement, in 41.1% of the time, followed by leakage around the prosthesis, in 25.9%. Other complications that motivated prosthesis replacement were granulomas, candida colonization, prosthesis nonfunctioning or extrusion, and others, namely, prosthesis degradation (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Of the 60 patients with TEP, 7 patients preferred to close it because they frequently needed to replace the prosthesis and 1 patient because he did not like the sound of his voice (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>There was no significant difference between the frequency of prosthesis replacement or the prosthesis lifetime and the tumor staging and location, type of esophageal suture, adjuvant radiotherapy and the number of years after surgery. The only statistically significant correlation was with follow up time (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>There was also no statistically significant relation between the T stage of the tumor and the type of suture used – manual vs mechanical stapler (p=0.572).In order to evaluate which covariates were predictive of a higher number of prosthesis replacement, a multiple linear regression model was performed, taking into account the following variables: T stage, type of suture, follow-up, adjuvant radiotherapy and tumor location. After multivariate analysis, manual suture (β=−1.751 95% CI [−3.323 to −0.178], p=0.031) and follow-up time (β=0.145 95% CI [0.93–0.196], p=0.00) were associated with a higher number of prosthesis replacement, accounting for almost 68% of its variation.DiscussionSince the introduction of TEP, by Singer and Blom, in 1980, the success of restoring vocal communication after TL has improved significantly.<a class="elsevierStyleCrossRef" href="#bib0160">7</a>Voice prosthesis is currently the gold standard method for voice rehabilitation after TL. However, a major limitation is its limited lifespan, requiring replacements. The reasons for device/voice failure can be attributed either to TEP or prosthesis-related complications or to poor understanding or motivation of the patient.<a class="elsevierStyleCrossRefs" href="#bib0160">7,8</a>The lifespan of the voice prosthesis shows considerable variation. In the literature, this device lasts 4–6 months in the majority of patients.<a class="elsevierStyleCrossRefs" href="#bib0170">9–11</a> However, variations regarding the prosthesis lifespan have been reported between different patient groups, device types and geographical regions. The shortest lifespan is seen in Western Europe (mean, 5–6 months) and the longest in Mediterranean countries and India, with the United States in between (mean, 9–12 months).<a class="elsevierStyleCrossRefs" href="#bib0180">11–16</a> In our study, the average lifetime was 7.53 months, comparable to the literature. Despite the limited lifespan of the voice prosthesis, the main advantage is that replacements can be done in outpatient setting in the vast majority of patients.There are common causes for replacement of the prosthesis, namely: incompetent valve leading to endoprosthetic leak, widening of TEP leading to periprosthetic leak, fungal colonization, prosthesis displacement, aspiration, granuloma formation and stenosis of tracheostoma.<a class="elsevierStyleCrossRef" href="#bib0160">7</a>In the literature multiple factors have been studied as causes for voice prosthesis complications. It was initially thought that xerostomia following radiation could decrease the lifespan of the prosthesis because of decreased antibacterial and antifungal salivary peptides. Some surgeons considered previous radiation as a contraindication for primary TEP, but studies have shown that there was no significant difference in TEP speech outcome between primary TL versus salvage TL or primary TEP versus secondary TEP.<a class="elsevierStyleCrossRefs" href="#bib0210">17,18</a> In our group, all the patients underwent primary surgery, so we could not study the influence of previous radiation in primary TEP. Similarly to the study of Gitomer et al., we found no difference in prosthesis lifespan with or without adjuvant radiation.<a class="elsevierStyleCrossRef" href="#bib0210">17</a>In our study the most common complications were leakage through the prosthesis and leakage around the prosthesis. While an endoprosthetic leak usually demands a prosthesis replacement, the management options for a periprosthetic leak range from conservative to invasive approaches. A periprosthetic leak may occur when the prosthesis is too long or due to widening of the TEP. Downsizing the valve may correct the leakage when the prosthesis is too long. Insertion of a nasogastric tube can be used to allow shrinkage of the fistula, which is followed by a subsequent prosthesis reinsertion. Use of a silastic wafer, collagen, autologous fat injection, hyaluronic acid injection or a purse string suture can potentially help improve the seal around the prosthesis and prevent leakage.<a class="elsevierStyleCrossRefs" href="#bib0160">7,19,20</a>Previous studies described that candida colonization can lead to device deterioration, leakage and aspiration, even though voice prosthesis usually have bacterial and fungal polyspecies contamination rather than fungal contamination alone. The current best practice state that the most effective treatment of persistent candida biofilms on voice prosthesis is removal and replacement of the device.<a class="elsevierStyleCrossRefs" href="#bib0230">21,22</a> In our study, 5.1% of the voice prosthesis replacements were caused by candida colonization.In most practices, factors related to the extent of surgery are recognized as important characteristics that influence the prosthesis replacement.<a class="elsevierStyleCrossRefs" href="#bib0165">8,23</a> However, like some previous studies, we found no significant association between the tumor location and the prosthesis lifespan.<a class="elsevierStyleCrossRef" href="#bib0165">8</a>In univariate analysis, follow-up time was associated with the number of prosthesis replacement. After performing a multivariate analysis, we found that follow-up and manual suture were associated with a more frequent replacement of the prosthesis, explaining around 67% of its variation. We analyzed the time after surgery (1st year; 2nd to 5th year; more than 5 years after surgery) and found that there was no significant difference regarding the number of prosthesis replacement or prosthesis lifetime along the years. Because the prosthesis has a limited lifespan, it makes sense that the longer the patients are followed, the higher number of replacements are made.In the literature, the type of suture is associated with pharyngocutaneous fistula but there is lack of evidence regarding its influence on voice prosthesis replacement.<a class="elsevierStyleCrossRefs" href="#bib0245">24,25</a> Manual suture is generally performed in patients with a larger resection, that usually affects esophageal mucosa, and so lack of tissue may alter muscle tone. In our data, we found no significant difference between the size of the tumor and the type of suture used. However, this result might be influenced by the fact that we had no register of the type of suture performed in 25 patients.Despite that, further studies are necessary to ascertain the relationship between the type of suture and the number of prosthesis replacement.Certain limitations to this study should be considered, particularly those related to the retrospective study design based on medical records with a potential information bias.ConclusionsThe rehabilitation after total laryngectomy is of major importance to improve quality of life after surgery. Voice rehabilitation is a major step during this process.TEP with voice prosthesis is a safe procedure for voice rehabilitation and was performed in the majority of patients in our study.The main reasons for prosthesis replacement were leakage through and around the prosthesis. The mean lifespan of the device was 7.53 months, which is similar to previous studies. Longer follow-up time and manual suture were associated with the number ofprosthesis replacement. However, further studies are necessary to ascertain the relationship between type of suture and prosthesis replacement. Interestingly, from those studied, no other factor was determinant of the prosthesis lifespan.FundingNone declared.Conflict of interestNone declared." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1746677" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1538883" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1746676" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1538884" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Variables" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-14" "fechaAceptado" => "2021-05-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1538883" "palabras" => array:4 [ 0 => "Voice prosthesis" 1 => "Voice rehabilitation" 2 => "Total laryngectomy" 3 => "Head and neck cancer" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1538884" "palabras" => array:4 [ 0 => "Prótesis de la voz" 1 => "Rehabilitación de voz" 2 => "Laringectomía total" 3 => "Cáncer de cabeza y cuello" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesDespite the advances in surgical and non-surgical organ preservation treatments, total laryngectomy (TL) remains the most effective treatment in advanced larynx cancer and as salvage procedure in chemoradiation failure.One of the most devastating sequel after TL is loss of voice. Voice prosthesis (VP) is currently the preferred choice for voice rehabilitation. The purpose of this study is to identify VP complications, its lifespan and factors that influence the longevity of the VP. MethodsWe performed a retrospective study at a Tertiary University Hospital. Medical records of patients that underwent total laryngectomy, between January 1st of 2008 and 31st of December of 2017 were analyzed. ResultsOf the 84 patients that underwent laryngectomy, 60 had VP. The average age at the time of surgery 60.2 years old and there was a male preponderance (57:3).The mean lifespan of the prosthesis was 7.53 months. Leakage through the prosthesis was the most common reason for replacement of the prosthesis, followed by leakage around the prosthesis.Follow up time and manual suture were associated with prosthesis replacement. There was no significant relationship between the staging, tumor location or adjuvant radiotherapy and number of prosthesis replacement or its lifespan. ConclusionsRehabilitation after TL is of major importance to improve quality of life after surgery. Tracheoesophageal puncture with voice prosthesis is a safe procedure for vocal rehabilitation and was performed in the majority of patients in our study.Follow-up time and type of suture were the main determinants of the lifespan of the prosthesis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosA pesar de los avances en los tratamientos quirúrgicos y no quirúrgicos para la preservación de órganos, la laringectomía total (LT) sigue siendo el tratamiento más efectivo en el cáncer avanzado de laringe, y como procedimiento de rescate en caso de fallo de la radioquimioterapia.Una de las secuelas más devastadoras tras la LT es la pérdida de la voz. Las prótesis de voz (PV) son actualmente la elección preferida para la rehabilitación de la voz. El objetivo de este estudio es identificar las complicaciones de las PV, su vida útil y los factores que influyen en la longevidad de dichas prótesis. MétodosRealizamos un estudio retrospectivo en un hospital universitario terciario, en el que se analizaron los registros médicos de los pacientes sometidos a laringectomía total entre el 1 de enero de 2008 y el 31 de diciembre de 2017. ResultadosDe los 84 pacientes sometidos a laringectomía, 60 tenían PV. La edad media en el momento de la cirugía fue de 60,2 años, y hubo una preponderancia de varones (57:3).La vida útil media de las prótesis fue de 7,53 meses. La fuga a través de la prótesis fue el motivo más común de su sustitución, seguida de la fuga alrededor del dispositivo.El tiempo de seguimiento y la sutura manual estuvieron asociados a la sustitución de la prótesis. No existió una relación significativa entre la estadificación, la localización del tumor o la radioterapia adyuvante y el número de sustituciones de prótesis o su vida útil. ConclusionesLa rehabilitación tras la LT es de gran importancia para mejorar la calidad de vida tras la cirugía. La punción traqueoesofágica con prótesis de voz es un procedimiento seguro para la rehabilitación de la voz, habiéndose realizado en la mayoría de los pacientes de nuestro estudio.El tiempo de seguimiento y el tipo de sutura fueron los principales determinantes de la vida útil de las prótesis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up (months±standard deviation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.2±33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean duration of the prosthesis (months±standard deviation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.53±2.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T stage (number (%)) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (46.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Descriptive analysis of the population." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leakage trough the prosthesis (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leakage around the prosthesis (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Granulomas (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Candida colonization (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prosthesis extrusion (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Other factors include prosthesis nonfunctioning, esophagus migration and cases with lack of information about the reason for replacement of prosthesis." ] ] ] "descripcion" => array:1 [ "en" => "Complications that motivated prosthesis replacement." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Status of voice prosthesis \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients who continue to use voice prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 (86.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients who have closed TEP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (13.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Status of the voice prosthesis." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Factors \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Counts (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p value (number of prosthesis replacement) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p value (prosthesis lifetime) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T stage<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.490 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.566 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (81.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of suture<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Manual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (31.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanical stapler (GIA™) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (26.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 (41.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjuvant radiotherapy<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (81.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.754 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumor location<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypopharynx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supraglottic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glottic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.536 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.317 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infraglottic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transglottic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (38.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up<a class="elsevierStyleCrossRef" href="#tblfn0020">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time after surgery<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1st year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.192 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.633 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2nd–5th year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.808 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.976 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.689 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.806 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Mann–Whitney U." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "ANOVA." ] 2 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "c" "nota" => "Pearson and Spearman correlation." ] ] ] "descripcion" => array:1 [ "en" => "Factors that may influence lifespan and replacement of the prosthesis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rehabilitación del paciente laringectomizado. 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Original article

Voice rehabilitation with voice prosthesis: Long term results, complications and risk factors

Rehabilitación de la voz con prótesis de voz: resultados a largo plazo, complicaciones y factores de riesgo

Mafalda Martins de Sousaa,b,

Corresponding author

mafaldajmsousa@gmail.com

Corresponding author.

, Ricardo Matosa,b, Helena Vilarinhoa, Margarida Santosa, Helena Silveiraa,b

a Department of Otorhinolaryngology, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal

b Department of Surgery and Physiology - Unit of Otorhinolaryngology - Faculty of Medicine, Porto University, Porto, Portugal

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            "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Results of SOT in a 43 years old female patient complaining of vertigo since 5 months with left HC-BPPV&#46; &#40;A&#41; Before repositioning maneuver&#58; All the scores were less than their respective reference values&#44; except for the AP somesthetic score&#46; &#40;B&#41; After the maneuver&#58; SOT was repeated one week after repositioning maneuver and showed improvement in all the sensory scores&#44; which exceeded their respective reference values&#46; Somesth&#46;&#58; somesthetic&#59; Vestibul&#46;&#58; vestibular&#59; Prefe&#46;&#58; preferential&#59; AP&#58; antero-posterior&#59; ML&#58; medio-lateral&#59; SOT&#58; Sensory Organization Test&#46;</p>"
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    "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
    "titulo" => "Voice rehabilitation with voice prosthesis&#58; Long term results&#44; complications and risk factors"
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        "autoresLista" => "Mafalda Martins de Sousa, Ricardo Matos, Helena Vilarinho, Margarida Santos, Helena Silveira"
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            "entidad" => "Department of Otorhinolaryngology&#44; Centro Hospitalar Universit&#225;rio de S&#227;o Jo&#227;o&#44; EPE&#44; Porto&#44; Portugal"
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      "es" => array:1 [
        "titulo" => "Rehabilitaci&#243;n de la voz con pr&#243;tesis de voz&#58; resultados a largo plazo&#44; complicaciones y factores de riesgo"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Despite the advances in surgical and non-surgical organ preservation treatments&#44; total laryngectomy &#40;TL&#41; remains the most effective treatment in advanced larynx cancer and as salvage procedure for failure of chemoradiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; TL is a radical surgery with functional and psychological consequences&#44; such as&#44; loss of normal voice&#44; swallowing problems&#44; loss of nasal function with altered smell and taste&#44; lung function changes and tracheostomal complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The awareness of the serious disablement related to larynx removal has driven the scientists to search for solutions to lessen these consequences&#46; One of the most devastating outcomes after TL is loss of voice and currently there are three main methods for voice rehabilitation&#58; esophageal speech&#44; electronic aids and tracheoesophageal puncture &#40;TEP&#41; with voice prosthesis &#40;VP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Each of these methods has its advantages and disadvantages&#46; VP provides a physiologically better voice quality and is currently the preferred choice for voice rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The VP directs the exhaled air from the trachea into the pharyngo-oesophageal segment when the tracheostome is occluded&#46; The result of the passage of high-pressure air from the trachea to the pharyngo-oesophageal segment is the vibration of the walls of this segment&#44; which causes the production of sound&#46; The valve is unidirectional&#44; preventing the aspiration of food and saliva into the trachea&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This work aims to identify VP complications&#44; its lifespan and factors that influence the prosthesis lifespan&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">We performed a retrospective study at a Tertiary University Hospital&#46; We collected medical records of patients that underwent total laryngectomy&#44; between January 1st of 2008 and 31st of December of 2017&#46; The study protocol was approved by the Ethics Committee &#40;number 325&#47;18&#41; and was carried out in accordance to the principles of the Declarations of Helsinki&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0035" class="elsevierStylePara elsevierViewall">We studied all the patients with laryngeal or hypopharyngeal cancer that underwent total laryngectomy&#46; We used the Provox&#174; voice prosthesis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We defined the following exclusion criteria&#58; patients without voice prosthesis and loss of follow-up&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Data collection was based on electronic medical records&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0050" class="elsevierStylePara elsevierViewall">Variables were collected using a structured database form&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Demographic data&#44; including gender and age at the time of surgery&#44; cancer staging according to the TNM Classification &#8211; 8th edition&#44; primary tumor localization&#44; primary or secondary TEP&#44; follow-up&#44; prosthesis lifespan&#44; reasons for prosthesis replacement and treatment with adjuvant radiation were analyzed<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a>&#46; The prostheses were used in accordance with the manufacturer&#39;s recommended use&#46; Of note&#44; all patients received pre-operative counseling and instructions on postoperative care of the prosthesis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with Statistical Package for the Social Sciences&#174; &#40;version 26&#46;0&#44; SPSS&#174;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Normality was evaluated by the Kolmogorov&#8211;Smirnov test and variances using the Levene test&#46; Comparison between groups was performed using the Qui-square&#44; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> or ANOVA&#44; as appropriate&#46; For correlations between variables&#44; Spearman and Pearson correlation coefficients were used&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We used a regression model to analyze the determinants of the number of replacements of voice prosthesis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">p</span> value of less than 0&#46;05 was considered as statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Of the 84 patients that underwent total laryngectomy&#44; 60 &#40;71&#46;4&#37;&#41; had TEP and all but one had primary insertion of the voice prosthesis&#46; We focused our analysis on the patients with TEP&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The average age at the time of surgery was 60&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 years and there was a male preponderance &#40;57&#58;3&#41;&#46; All the patients underwent primary surgery and most of the patients had T3 or T4 tumors &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Adjuvant radiotherapy was performed in 49 &#40;81&#46;7&#37;&#41; of the patients&#46; Most of the patients are still alive &#91;46 &#40;76&#46;7&#37;&#41;&#93; at the time of the study&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The mean follow-up in our consultation was 49&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33 months and the mean lifetime of the prosthesis was 7&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4 months&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Leakage through the prosthesis was the most common reason of prosthesis replacement&#44; in 41&#46;1&#37; of the time&#44; followed by leakage around the prosthesis&#44; in 25&#46;9&#37;&#46; Other complications that motivated prosthesis replacement were granulomas&#44; candida colonization&#44; prosthesis nonfunctioning or extrusion&#44; and others&#44; namely&#44; prosthesis degradation &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Of the 60 patients with TEP&#44; 7 patients preferred to close it because they frequently needed to replace the prosthesis and 1 patient because he did not like the sound of his voice &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">There was no significant difference between the frequency of prosthesis replacement or the prosthesis lifetime and the tumor staging and location&#44; type of esophageal suture&#44; adjuvant radiotherapy and the number of years after surgery&#46; The only statistically significant correlation was with follow up time &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">There was also no statistically significant relation between the T stage of the tumor and the type of suture used &#8211; manual vs mechanical stapler &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;572&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In order to evaluate which covariates were predictive of a higher number of prosthesis replacement&#44; a multiple linear regression model was performed&#44; taking into account the following variables&#58; T stage&#44; type of suture&#44; follow-up&#44; adjuvant radiotherapy and tumor location&#46; After multivariate analysis&#44; manual suture &#40;<span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;1&#46;751 95&#37; CI &#91;&#8722;3&#46;323 to &#8722;0&#46;178&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#41; and follow-up time &#40;<span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;145 95&#37; CI &#91;0&#46;93&#8211;0&#46;196&#93;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00&#41; were associated with a higher number of prosthesis replacement&#44; accounting for almost 68&#37; of its variation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Since the introduction of TEP&#44; by Singer and Blom&#44; in 1980&#44; the success of restoring vocal communication after TL has improved significantly&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Voice prosthesis is currently the gold standard method for voice rehabilitation after TL&#46; However&#44; a major limitation is its limited lifespan&#44; requiring replacements&#46; The reasons for device&#47;voice failure can be attributed either to TEP or prosthesis-related complications or to poor understanding or motivation of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The lifespan of the voice prosthesis shows considerable variation&#46; In the literature&#44; this device lasts 4&#8211;6 months in the majority of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9&#8211;11</span></a> However&#44; variations regarding the prosthesis lifespan have been reported between different patient groups&#44; device types and geographical regions&#46; The shortest lifespan is seen in Western Europe &#40;mean&#44; 5&#8211;6 months&#41; and the longest in Mediterranean countries and India&#44; with the United States in between &#40;mean&#44; 9&#8211;12 months&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11&#8211;16</span></a> In our study&#44; the average lifetime was 7&#46;53 months&#44; comparable to the literature&#46; Despite the limited lifespan of the voice prosthesis&#44; the main advantage is that replacements can be done in outpatient setting in the vast majority of patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There are common causes for replacement of the prosthesis&#44; namely&#58; incompetent valve leading to endoprosthetic leak&#44; widening of TEP leading to periprosthetic leak&#44; fungal colonization&#44; prosthesis displacement&#44; aspiration&#44; granuloma formation and stenosis of tracheostoma&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In the literature multiple factors have been studied as causes for voice prosthesis complications&#46; It was initially thought that xerostomia following radiation could decrease the lifespan of the prosthesis because of decreased antibacterial and antifungal salivary peptides&#46; Some surgeons considered previous radiation as a contraindication for primary TEP&#44; but studies have shown that there was no significant difference in TEP speech outcome between primary TL versus salvage TL or primary TEP versus secondary TEP&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">17&#44;18</span></a> In our group&#44; all the patients underwent primary surgery&#44; so we could not study the influence of previous radiation in primary TEP&#46; Similarly to the study of Gitomer et al&#46;&#44; we found no difference in prosthesis lifespan with or without adjuvant radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our study the most common complications were leakage through the prosthesis and leakage around the prosthesis&#46; While an endoprosthetic leak usually demands a prosthesis replacement&#44; the management options for a periprosthetic leak range from conservative to invasive approaches&#46; A periprosthetic leak may occur when the prosthesis is too long or due to widening of the TEP&#46; Downsizing the valve may correct the leakage when the prosthesis is too long&#46; Insertion of a nasogastric tube can be used to allow shrinkage of the fistula&#44; which is followed by a subsequent prosthesis reinsertion&#46; Use of a silastic wafer&#44; collagen&#44; autologous fat injection&#44; hyaluronic acid injection or a purse string suture can potentially help improve the seal around the prosthesis and prevent leakage&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">7&#44;19&#44;20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Previous studies described that candida colonization can lead to device deterioration&#44; leakage and aspiration&#44; even though voice prosthesis usually have bacterial and fungal polyspecies contamination rather than fungal contamination alone&#46; The current best practice state that the most effective treatment of persistent candida biofilms on voice prosthesis is removal and replacement of the device&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#44;22</span></a> In our study&#44; 5&#46;1&#37; of the voice prosthesis replacements were caused by candida colonization&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In most practices&#44; factors related to the extent of surgery are recognized as important characteristics that influence the prosthesis replacement&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">8&#44;23</span></a> However&#44; like some previous studies&#44; we found no significant association between the tumor location and the prosthesis lifespan&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In univariate analysis&#44; follow-up time was associated with the number of prosthesis replacement&#46; After performing a multivariate analysis&#44; we found that follow-up and manual suture were associated with a more frequent replacement of the prosthesis&#44; explaining around 67&#37; of its variation&#46; We analyzed the time after surgery &#40;1st year&#59; 2nd to 5th year&#59; more than 5 years after surgery&#41; and found that there was no significant difference regarding the number of prosthesis replacement or prosthesis lifetime along the years&#46; Because the prosthesis has a limited lifespan&#44; it makes sense that the longer the patients are followed&#44; the higher number of replacements are made&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the literature&#44; the type of suture is associated with pharyngocutaneous fistula but there is lack of evidence regarding its influence on voice prosthesis replacement&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">24&#44;25</span></a> Manual suture is generally performed in patients with a larger resection&#44; that usually affects esophageal mucosa&#44; and so lack of tissue may alter muscle tone&#46; In our data&#44; we found no significant difference between the size of the tumor and the type of suture used&#46; However&#44; this result might be influenced by the fact that we had no register of the type of suture performed in 25 patients&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Despite that&#44; further studies are necessary to ascertain the relationship between the type of suture and the number of prosthesis replacement&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Certain limitations to this study should be considered&#44; particularly those related to the retrospective study design based on medical records with a potential information bias&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">The rehabilitation after total laryngectomy is of major importance to improve quality of life after surgery&#46; Voice rehabilitation is a major step during this process&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">TEP with voice prosthesis is a safe procedure for voice rehabilitation and was performed in the majority of patients in our study&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The main reasons for prosthesis replacement were leakage through and around the prosthesis&#46; The mean lifespan of the device was 7&#46;53 months&#44; which is similar to previous studies&#46; Longer follow-up time and manual suture were associated with the number of</p><p id="par0210" class="elsevierStylePara elsevierViewall">prosthesis replacement&#46; However&#44; further studies are necessary to ascertain the relationship between type of suture and prosthesis replacement&#46; Interestingly&#44; from those studied&#44; no other factor was determinant of the prosthesis lifespan&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0200" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "identificador" => "sec0040"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflict of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-09-14"
    "fechaAceptado" => "2021-05-02"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1538883"
          "palabras" => array:4 [
            0 => "Voice prosthesis"
            1 => "Voice rehabilitation"
            2 => "Total laryngectomy"
            3 => "Head and neck cancer"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1538884"
          "palabras" => array:4 [
            0 => "Pr&#243;tesis de la voz"
            1 => "Rehabilitaci&#243;n de voz"
            2 => "Laringectom&#237;a total"
            3 => "C&#225;ncer de cabeza y cuello"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Despite the advances in surgical and non-surgical organ preservation treatments&#44; total laryngectomy &#40;TL&#41; remains the most effective treatment in advanced larynx cancer and as salvage procedure in chemoradiation failure&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">One of the most devastating sequel after TL is loss of voice&#46; Voice prosthesis &#40;VP&#41; is currently the preferred choice for voice rehabilitation&#46; The purpose of this study is to identify VP complications&#44; its lifespan and factors that influence the longevity of the VP&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study at a Tertiary University Hospital&#46; Medical records of patients that underwent total laryngectomy&#44; between January 1st of 2008 and 31st of December of 2017 were analyzed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Of the 84 patients that underwent laryngectomy&#44; 60 had VP&#46; The average age at the time of surgery 60&#46;2 years old and there was a male preponderance &#40;57&#58;3&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The mean lifespan of the prosthesis was 7&#46;53 months&#46; Leakage through the prosthesis was the most common reason for replacement of the prosthesis&#44; followed by leakage around the prosthesis&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Follow up time and manual suture were associated with prosthesis replacement&#46; There was no significant relationship between the staging&#44; tumor location or adjuvant radiotherapy and number of prosthesis replacement or its lifespan&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Rehabilitation after TL is of major importance to improve quality of life after surgery&#46; Tracheoesophageal puncture with voice prosthesis is a safe procedure for vocal rehabilitation and was performed in the majority of patients in our study&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Follow-up time and type of suture were the main determinants of the lifespan of the prosthesis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A pesar de los avances en los tratamientos quir&#250;rgicos y no quir&#250;rgicos para la preservaci&#243;n de &#243;rganos&#44; la laringectom&#237;a total &#40;LT&#41; sigue siendo el tratamiento m&#225;s efectivo en el c&#225;ncer avanzado de laringe&#44; y como procedimiento de rescate en caso de fallo de la radioquimioterapia&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Una de las secuelas m&#225;s devastadoras tras la LT es la p&#233;rdida de la voz&#46; Las pr&#243;tesis de voz &#40;PV&#41; son actualmente la elecci&#243;n preferida para la rehabilitaci&#243;n de la voz&#46; El objetivo de este estudio es identificar las complicaciones de las PV&#44; su vida &#250;til y los factores que influyen en la longevidad de dichas pr&#243;tesis&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Realizamos un estudio retrospectivo en un hospital universitario terciario&#44; en el que se analizaron los registros m&#233;dicos de los pacientes sometidos a laringectom&#237;a total entre el 1 de enero de 2008 y el 31 de diciembre de 2017&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">De los 84 pacientes sometidos a laringectom&#237;a&#44; 60 ten&#237;an PV&#46; La edad media en el momento de la cirug&#237;a fue de 60&#44;2 a&#241;os&#44; y hubo una preponderancia de varones &#40;57&#58;3&#41;&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La vida &#250;til media de las pr&#243;tesis fue de 7&#44;53 meses&#46; La fuga a trav&#233;s de la pr&#243;tesis fue el motivo m&#225;s com&#250;n de su sustituci&#243;n&#44; seguida de la fuga alrededor del dispositivo&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El tiempo de seguimiento y la sutura manual estuvieron asociados a la sustituci&#243;n de la pr&#243;tesis&#46; No existi&#243; una relaci&#243;n significativa entre la estadificaci&#243;n&#44; la localizaci&#243;n del tumor o la radioterapia adyuvante y el n&#250;mero de sustituciones de pr&#243;tesis o su vida &#250;til&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La rehabilitaci&#243;n tras la LT es de gran importancia para mejorar la calidad de vida tras la cirug&#237;a&#46; La punci&#243;n traqueoesof&#225;gica con pr&#243;tesis de voz es un procedimiento seguro para la rehabilitaci&#243;n de la voz&#44; habi&#233;ndose realizado en la mayor&#237;a de los pacientes de nuestro estudio&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El tiempo de seguimiento y el tipo de sutura fueron los principales determinantes de la vida &#250;til de las pr&#243;tesis&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivos"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
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        "etiqueta" => "Table 1"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of patients</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Follow-up &#40;months</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">standard deviation&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mean duration of the prosthesis &#40;months</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">standard deviation&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">T stage &#40;number &#40;&#37;&#41;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;46&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Descriptive analysis of the population&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leakage trough the prosthesis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leakage around the prosthesis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Granulomas &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Candida colonization &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prosthesis extrusion &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Others<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other factors include prosthesis nonfunctioning&#44; esophagus migration and cases with lack of information about the reason for replacement of prosthesis&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Complications that motivated prosthesis replacement&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
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        "tabla" => array:1 [
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Status of voice prosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patients who continue to use voice prosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">Patients who have closed TEP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8 &#40;13&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">11 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;81&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Manual&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;31&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;134&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mechanical stapler &#40;GIA&#8482;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Adjuvant radiotherapy</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;81&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;754&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">11 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glottic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;536&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;317&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transglottic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;38&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Follow-up</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 00016519
Original language: English

DOI:10.1016/j.otorri.2021.05.001

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