Closure of post-laryngectomy pharyngocutaneous fistulae

Isaac A Bohannon,J Scott Magnuson,William R Carroll,Eben L Rosenthal

doi:10.1186/1758-3284-3-29

Abstract

BackgroundClosure of salvage laryngectomy defects with vascularized tissue remains controversial.MethodsWe evaluate outcomes in patients who required repair of a fistula after attempted primary closure of salvage laryngectomy defect and assess risk factors for persistent fistula. Between 2001 and 2010, 20 patients were treated for pharyngocutaneous fistulae after primary closure of a salvage laryngectomy. All patients required free flap repair for definitive fistula management.ResultsPatients presented with fistulae from one to 18 months in duration; median time to closure was seven days. Radial forearm free flap was used in 86% of patients. With free flap alone 50% of patients achieved fistula closure. Additional procedures improved closure rate to 85%. Recipient vessels were used in the neck in 54.5%, compared to internal mammary vessels in 45.5%. Hypothyroidism was identified as a risk factor for persistent fistula (p = 0.01). Chronic steroid use (p = 0.08) did not reach significance as a risk factor for fistula closure. Gastroesophageal reflux disease was newly diagnosed or noted as a comorbidity in 14 patients (70%) in this study. It did not reach statistical significance as a risk factor in refistulization (p = 0.12). Complications included leak, carotid blowout, infection, free flap loss, and late refistulization. Overall flap failure in this study was 4.5%.ConclusionsDelayed secondary repair of pharygocutaneous fistulas after salvage laryngectomy is associated with a higher complication rate and poor success rates compared to use of vascularized tissue at the time of salvage laryngectomy. Prolonged wound healing in these patients is associated with hypothyroidism.

Highlights

There are almost 12,000 newly diagnosed cases of laryngeal cancer every year in the United States [1]
We identified 20 patients who required reconstruction of their pharyngocutaneous fistula after salvage laryngectomy with primary closure
With the evolution of organ sparing therapy for treatment of laryngeal and hypopharyngeal squamous cell carcinoma, chemoradiotherapy has increased over time

Summary

Introduction

There are almost 12,000 newly diagnosed cases of laryngeal cancer every year in the United States [1]. The primary advantage of chemoradiation protocols for squamous cell carcinoma of the head and neck is organ preservation–with the potential for preservation of natural speech and swallowing function. Structural preservation does not equate to normal function. Tissue in the field of radiation treatment undergoes multiple types of injury, most commonly referred to as radiation-induced fibroatrophy [7]. The vascular endothelial cells experience oxidative injury, which leads to the recruitment of inflammatory cells, and a cascade of cytokines. The capillary network is damaged both acutely and chronically. This impacts the normal surrounding mucosa in addition to the adjacent tumor. The mucosa remaining after laryngectomy is friable and poorly vascularized. Closure of salvage laryngectomy defects with vascularized tissue remains controversial

Methods

Results

Conclusion