Laryngectomy Informed Consent & Patients' Rights

Laryngectomy, the method of removing the larynx for cancer has been carried out since 1873. Over 10,000 new laryngeal cancers are diagnosed each year, and about 5000 people with this disease will die each year. Professor William Coman a member of Invivo's Medical Advisory Panel raises major issues about informed consent and patients' rights.

History of the First Laryngectomy

The first laryngectomy was carried out by Christian Theodore Billroth in Vienna in 1873 (1, 2, 3). The patient was a 36 year old school teacher. The anaesthetic would have been either chloroform or ether, but it was extremely ineffective as there were constant interruptions by strong coughing spells whereby large amounts of blood were expelled from the trachea.

The tumour, treated initially with cauterisation, was soon found to invade cartilage leading to a decision to proceed to laryngectomy. The surgery consisted of dissection of the larynx on both sides with the assistants providing direct traction to the larynx. The trachea was divided below the second tracheal ring. The stoma was fixed to the skin with two sutures.

The entire procedure took a total of 1 hour and 45 minutes.

Four hours after the operation, the patient, following a bout of coughing, had a post-operative haemorrhage and was returned to the operating room to have the superior laryngeal vessels ligated, including the superior laryngeal artery.

The patient lived for 8 months and died from persistent disease.

In subsequent procedures the trachea was not separated from the pharynx. As a result, the patient had a most miserable time post-operatively whereby "The patient is utterly miserable, unable to communicate, food is taken in such a distressing way that suffocation is constantly imminent and death from starvation not infrequently takes place." Morel Mackenzie.

Only 8 patients of the first 138 laryngectomies survived for one year (2).

It should be remembered that this was pioneering surgery carried out without antibiotics, without blood transfusions, poor lighting (the modern electric light bulb we currently use today was not invented until 1879) and of course there were no lawyers.

Laryngectomy Procedures Today

In the modern era, total laryngectomy is indicated after a proper consideration of both radio-therapy and partial laryngectomy that often requires a laser. Informed consent requires a discussion of quality of life after laryngectomy.

Patients are also given notice that radiation therapy may be necessary post-operatively and that this comes attendant with its own set of complications which will be explained to the patient by a qualified radiation oncologist.

Loss of the larynx poses a major threat to the quality of life and the surgery itself has a significant morbidity and mortality rate. The patient must be advised of the natural history (a miserable death from choking or bleeding) of advanced laryngeal cancer as well as all immediate and long term risks of surgery. Infection, haemorrhage and delayed healing are recognised complications, especially if the surgery is carried out in an irradiated field. Prolonged hospitalisation is often required. Rupture of the carotid artery followed by stroke or death can occur. A lifetime of smoking generally means that respiratory complications are frequent. Long term follow up is essential.

Conclusion

In summary, patients with advanced laryngeal cancer are fully informed of their condition and of the effective methods of management of this condition, usually involving a laryngectomy. Most patients have a realisation of the seriousness of their predicament and it is very rare for these patients to pursue litigation for complications which may arise as a result of their treatment.

William B Coman, AM MD
MBBS, FRCS (Edin), FRCS (Eng), FRACS, FACS
Professor of Otolaryngology, Head and Neck Surgery
Invivo Medical Advisor

References

1. N. F. Weir, 1973. Theodore Billroth: The first laryngectomy for cancer. The Journal of Laryngology and Otology, December 1973, 1161-1169.
2. RL Keith, FL Darley, 1986. Laryngectomee Rehabilitation. College-Hill Press, San Diego CA, USA.
3. Schwartz AW, 1978. Dr. Theodor Billroth and the first laryngectomy. Ann Plast Surg. 1978 Sep;1(5):513-6.
4. M. H. Armstrong Davidson, 1957. The Evolution of Anaesthesia. Brit. J. Anaesth. (1957), 29, 575
5. Majer EH, Rieder W, 1959. Technique de laryngectomie permettant de conserver la perméabilité respiratoire (La cricohioidopexie). Ann Otolaryngol Chir Cervicofac. 1959;76:677-681.
6. Lefebvre JL, Calais G, 2005. Larynx preservation, state of the art. Cancer Radiother. 2005 Feb;9(1):37-41. Epub 2005 Jan 20.
7. Hilgers FJ, Balm AJ, 1993. Long-term results of vocal rehabilitation after total laryngectomy with the low-resistance, indwelling Provox voice prosthesis system. Clin Otolaryngol Allied Sci. 1993 Dec;18(6):517-23.