Postoperative Pharyngocutaneous Fistula Research Articles

Is elective neck dissection necessary in cases of laryngeal recurrence after previous radiotherapy for early glottic cancer?

To assess the clinical utility of elective neck dissection in node-negative recurrent laryngeal carcinoma after curative radiotherapy for initial early glottic cancer. A retrospective review was undertaken of 110 consecutive early glottic cancer patients who developed laryngeal recurrence after radiotherapy (34 recurrent T1, 36 recurrent T2, 29 recurrent T3 and 11 recurrent T4a) and received salvage laryngeal surgery between 1995 and 2005. Six patients presented with laryngeal and neck recurrence and underwent salvage laryngectomy with therapeutic neck dissection, 97 patients with recurrent node-negative tumours underwent salvage laryngeal surgery without neck dissection and only 7 underwent elective neck dissection. No occult positive lymph nodes were documented in neck dissection specimens. During follow up, only three patients with neck failure were recorded, all in the group without neck dissection. There was no significant association between the irradiation field (larynx plus neck vs larynx) and the development of regional failure. A higher rate of post-operative pharyngocutaneous fistula development occurred in the neck dissection group than in the group without neck dissection (57.2 per cent vs. 13.4 per cent, p = 0.01). Multivariate logistic regression analysis showed that early (recurrent tumour-positive, node-positive) or delayed (recurrent tumour-positive, node-negative) neck relapse was not significantly related to the stage of the initial tumour or the recurrent tumour. An age of less than 60 years was significantly associated with early neck failure (recurrent tumour-positive, node-positive). Owing to the low occult neck disease rate and high post-operative fistula rate, elective neck dissection is not recommended for recurrent node-negative laryngeal tumours after radiation therapy if the initial tumour was an early glottic cancer.

Using a sternocleidomastoid muscle flap to prevent postoperative pharyngocutaneous fistula after total laryngectomy: a study of 88 cases.

Complications of total laryngectomy can have serious implications for the final outcome of treatment, including pharyngocutaneous fistula. We conducted a retrospective study of surgical techniques to determine how to best prevent or decrease the incidence of pharyngocutaneous fistula following total laryngectomy. We reviewed the hospital records of all patients who had undergone total laryngectomy for laryngeal carcinoma at Ghaem Hospital in Mashhad, Iran, from March 1989 through February 2005. We identified 88 such patients-80 men and 8 women. We divided this cohort into two groups according to the type of pharyngeal defect closure they received. A total of 37 patients-31 men and 6 women (mean age: 61.4 ± 5.9 yr) underwent primary closure along with a sternocleidomastoid muscle (SCMM) flap (flap group). The other 51 patients-49 men and 2 women (mean age: 61.3 ± 4.4 yr)-underwent standard primary closure without creation of an SCMM flap (nonflap group). Overall, postoperative pharyngocutaneous fistula occurred in 9 of the 88 patients (10.2%)-1 case in the flap group (2.7%) and 8 cases in the nonflap group (15.7%). The difference between the two groups was statistically significant (p < 0.001; odds ratio = 0.612, 95% confidence interval = 0.451 to 0.832), independent of other factors. We found no correlation between fistula development and age (p = 0.073), sex (p = 0.065), or tumor location (p = 0.435). Likewise, we found no correlation between tumor location and either sex (p = 0.140) or age (p = 0.241). We conclude that including an SCMM flap in the surgical process would significantly decrease the development of fistula, regardless of age, sex, and tumor site.

The effect of early oral feeding compared to standard oral feeding following total laryngectomy: a systematic review

Review question/objective The objective of this review is to identify and synthesise the best available evidence on effects of early feeding compared to standard oral feeding following total laryngectomy on the incidence of pharyngocutaneous fistula and hospital length of stay.More specifically, the review questions are: What is the effect of early oral feeding following total laryngectomy on the incidence of post-operative pharyngocutaneous fistula? What is the effect of early oral feeding following total laryngectomy on hospital length of stay? Inclusion criteria Types of participants This review will consider studies that include adults (18 years old or older) regardless of gender and co-morbidities who have commenced early oral feeding following total laryngectomy surgery. Studies focussing on enteral feeding will be excluded from this review. Types of interventions This review will consider studies that evaluate oral feeding following total laryngectomy. The intervention of interest is early oral feeding defined as oral intake in the first 6 days post-operatively. The comparator is standard care and is defined as oral intake from day 7 onwards. For the purpose of this review, oral feeding will include either food or liquid taken by mouth regardless of quantity or consistency. Oral feeding may be taken in conjunction with non oral nutrition. Types of outcomes This review will consider studies that include the following outcome measure: incidence of pharyngocutaneous fistula. In the context of this review, the term incidence refers to the number of new cases of pharyngocutaneous fistula within 6 months following total laryngectomy surgery. A further outcome may include but will not be limited to hospital length of stay measured as days of hospital inpatient admission.

Treatments of oropharyngeal anterior wall cancer by transhyoid surgery radiotherapy

To evaluate the transhyoid resection of oropharyngeal anterior wall cancer and oncological outcomes of the surgery combined with radiotherapy. A total of 24 cases with carcinoma located in the anterior wall of oropharynx was reviewed. The TNM stages were as follows: T2 in 7 cases, T3 in 2 cases, T4 in 15 cases; NO in 7 cases, N1 in 4 cases, N2 in 12 cases and N3 in 1 case. Tumor resection was performed via transhyoid approach, including 9 cases with partial glossectomy + partial laryngectomy, 7 cases with partial glossectomy + total laryngectomy, 7 cases with total glossectomy + partial laryngectomy and 1 case with partial glossectomy alone pectoralis major myocutaneous flaps were applied to repair synchronously the defects of tongue and lateral pharyngeal wall in 16 cases and the defect of cervical skin in 1 case. Radial forearm free flap and sternohyoid myocutaneous flap were used to repair the defect of tongue and lateral and posterior pharyngeal wall in 1 case. Sternohyoid myocutaneous flap was applied to reconstruct the tongue base in 2 cases. Bilateral and unilateral neck dissections were performed in 20 cases and 4 cases respectively. Five cases received preoperative radiotherapy and 16 cases received postoperative radiotherapy. All cases had negative surgical margin. Pathological examination showed neck lymph metastasis in 17 cases (70.8%). Three patients had postoperative pharyngocutaneous fistula. Two of them who underwent partial glossectomy + total laryngectomy and pectoralis major myocutaneous flaps synchronously reconstruction suffered from pharyngocutaneous fistula 4 days after operation. The fistula was closed by re-suturation following debridement and 2 weeks dressing change. The other one who underwent partial glossectomy + partial laryngectomy suffered from pharyngocutaneous fistula during postoperation radiotherapy and healed by the pectoralis major myocutaneous repair. Tracheostomy tubes were removed within 1-6 months, with good voice and swallowing functions, in 16 of 17 cases who underwent partial laryngectomy. Another one failed to pull out tracheotomy tube because of dyspnea. Twenty one cases were followed up over 3 years and Kaplan-Meier survival analysis showed the 3-year overall survival rate was 72.6%. The transhyoid tumor resection is an effective surgical approach for oropharyngeal anterior wall cancer. The defect following tumor resection is commonly need repair synchronously with various flaps. Acceptable outcome could be received by surgery combined with radiotherapy.

A minimally invasive method to prevent postlaryngectomy major pharyngocutaneous fistula using infrahyoid myofascial flap

To prevent postoperative pharyngocutaneous fistula (PCF) after total (pharyngo)laryngectomy, simultaneous coverage of pharyngeal anastomosis with vascularised flaps such as pectoralis major muscle, anterolateral thigh or radial forearm, has been reported to be effective. As an alternative to the invasive methods using distant flaps, we used the infrahyoid myofascial flap (IHMFF), which was harvested from the same operation field of (pharyngo)laryngectomy, for covering the site of pharyngeal anastomosis. Herein, we describe the safety and effectiveness of our minimally invasive method for preventing PCF. Eleven patients who were at a high risk of developing PCF due to previous chemoradiotherapy underwent simultaneous coverage of pharyngeal anastomosis with IHMFF after total (pharyngo)laryngectomy. The incidence of PCF and the rate of major fistula requiring surgical closure were determined, and the results were compared with the control group (23 patients without IHMFF cover after laryngectomy). PCF developed in 2 of the 11 patients (18.2%). The fistulae of these two patients were closed conservatively and did not require additional surgery. PCF developed in 6 of 23 patients (26.1%) in patients without IHMFF cover. All the six patients with fistula required additional closure surgery. The incidence of PCF did not differ in patients with or without IHMFF cover (Fisher's exact probability test; p=0.939, NS). However, the rate of major PCF requiring surgical closure was significantly lower in patients with IHMFF cover (Fisher's exact probability test; p=0.036<0.05). For (pharyngo)laryngectomy patients, IHMFF cover is a minimally invasive method that can prevent major PCF.

Expert's comment concerning grand rounds case entitled ''postoperative pharyngocutaneous fistula: treated with sternocleidomastoid flap repair and cricopharyngeus myotomy'' (by V.A. Iyoob).

Great care should be taken to minimise damage to the pharynx and upper oesophagus during an anterior approach to the cervical spine. If noticed at the time of surgery primary repair should be carried out; if noticed in the postoperative period, thorough cleaning and placement of a pharyngocutaneous drain will result in spontaneous healing of the majority of fistula. For persistent fistula secondary repair is required using well-vascularised tissue.

Postoperative pharyngocutaneous fistula: treated by sternocleidomastoid flap repair and cricopharyngeus myotomy

Pharyngoesophagocutaneous fistula (PEF) is one of the rare but serious complications of antero-lateral approach to cervical spine surgery. Because of its rarity, the true incidence of PEF is not clear. But, retrospective analysis of large series of cervical spine surgery reports 0-1.62 % incidence (Cloward in Surg 69:175-182, 1971; Elerkay et al. in J Neurosurg Spine 90(Suppl 1):35-41, 1999). Proximity to the vertebral column and thin walls makes the upper digestive tract vulnerable to injury in cervical trauma, surgical or nonsurgical. Presentation in early postoperative period is not rare and carries high morbidity and mortality (Jones and Ginsberg in Ann Thorac Surg 53(3):534-543, 1992). Various procedures for these fistulae such as simple closure, muscle flap interposition, esophageal diversion and jejunal interposition are reported. Some authors also advise removal of prosthetic plates and posterior stabilization, besides the repair of fistulae in a staged manner (Orlando et al. in Spine 28(15):E290-E295, 2003). Two similar cases of pharyngeal fistulae with similar etiology and clinical scenario are presented here, which were managed successfully with initial control of sepsis followed by delayed definitive repair with sternocleidomastoid muscle flap interposition and cricopharyngeus myotomy without removal of prosthetic plates. Postoperatively, both patients showed no evidence of any wound complications or collections until the seventh day. A contrast swallow study on seventh day showed no leak following which soft diet was started. Both patients were not having any difficulty in swallowing or aspiration. On 1-year follow-up, both patients were having no difficulty in swallowing, no episodes of aspiration and no recurrence of fistula. This case series highlights the importance of cricopharyngeus myotomy for treating PEF and the improved results with the prosthesis kept undisturbed.

Pharyngeal Horizontal Closure in Total Laryngectomies

Objective: To determine the viability of horizontal pharyngeal closure during total laryngectomies, as an alternative to vertical and T-closure methods, by evaluating the rates of pharyngocutaneous fistulas (PCFs) and dysphagia postoperatively. Method: Retrospective analysis of postoperative complications associated with horizontal pharyngeal closure during total laryngectomies at a tertiary institution from 2007 to 2011. Chart reviews were performed on a total of 15 total laryngectomy patients with horizontal pharyngeal closure, evaluating for fistula formation and dysphagia compared to reported rates in the literature. Results: Twenty percent (3/15) of patients developed postoperative PCFs, and 18% (2/11) with dysphagia. Patients that had not been tried on oral feeds due to wound complications or those with recurrent disease were excluded for evaluating dysphagia. Conclusion: A literature search revealed no studies evaluating horizontal pharyngeal closure. Reported ranges of PCFs are 13% to 25%, with dysphagia 17% to 70%. This study shows PCFs and dysphagia rates within these ranges. Thus, horizontal pharyngeal closure appears to be a viable alternative to T and vertical closures.

Assessment and incidence of salivary leak following laryngectomy

To determine the incidence and risk factors of pharyngocutaneous fistula formation in patients undergoing either primary or salvage laryngectomies and evaluate the role of barium esophagram in these patients. Retrospective cohort study. Medical records of 259 patients who underwent total laryngectomy between 2003 and 2009 at our institution were reviewed. Risk factors for fistula formation were analyzed, including primary treatment modality, comorbidities, and operative details, which included use of a free flap for closure, concurrent neck dissections, margin status, and preoperative tracheostomy. The length of time until leak, postoperative swallow study results, and fistula management strategies were also assessed. Fifty-five patients developed a pharyngocutaneous fistula (overall incidence, 21%) in a median time of 12 days (range, 4-105 days). Twenty of these patients underwent laryngectomy as their initial treatment modality, and 35 had failed previous radiotherapy. Fistula formation was significantly higher in salvage surgery patients (P = .03), particularly those with hypothyroidism (P < .0002). A barium swallow performed at approximately 1 week after laryngectomy demonstrated a sensitivity of 26% with a specificity of 94%. Sixty-two percent of the fistulas healed with conservative measures only. Our data confirmed that previous radiotherapy and hypothyroidism, particularly in salvage laryngectomy patients, are important significant predictors of postoperative pharyngocutaneous fistula. The use of a postoperative barium swallow in these patients may be useful but was not found to be highly sensitive in predicting who will develop a clinically evident leak and should be used with caution.

Surgical Management of Pharyngocutaneous Fistula After Total Laryngectomy

The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed. A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed. Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage. Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.

The effect of early oral feeding compared to standard oral feeding following total laryngectomy: a systematic review.

Review question/objective The objective of this review is to identify and synthesise the best available evidence on effects of early feeding compared to standard oral feeding following total laryngectomy on the incidence of pharyngocutaneous fistula and hospital length of stay.More specifically, the review questions are: What is the effect of early oral feeding following total laryngectomy on the incidence of post-operative pharyngocutaneous fistula? What is the effect of early oral feeding following total laryngectomy on hospital length of stay? Inclusion criteria Types of participants This review will consider studies that include adults (18 years old or older) regardless of gender and co-morbidities who have commenced early oral feeding following total laryngectomy surgery. Studies focussing on enteral feeding will be excluded from this review. Types of interventions This review will consider studies that evaluate oral feeding following total laryngectomy. The intervention of interest is early oral feeding defined as oral intake in the first 6 days post-operatively. The comparator is standard care and is defined as oral intake from day 7 onwards. For the purpose of this review, oral feeding will include either food or liquid taken by mouth regardless of quantity or consistency. Oral feeding may be taken in conjunction with non oral nutrition. Types of outcomes This review will consider studies that include the following outcome measure: incidence of pharyngocutaneous fistula. In the context of this review, the term incidence refers to the number of new cases of pharyngocutaneous fistula within 6 months following total laryngectomy surgery. A further outcome may include but will not be limited to hospital length of stay measured as days of hospital inpatient admission.

The effect of early oral feeding compared to standard oral feeding following total laryngectomy: a systematic review

The effect of early oral feeding compared to standard oral feeding following total laryngectomy: a systematic review

Effect of primary, cross-over, zigzag neopharyngoplasty on acoustic characteristics of alaryngeal, tracheoesophageal voice

To evaluate the effect of primary, cross-over, zigzag neopharyngeal construction on tracheoesophageal voice, compared with pharyngoesophageal myotomy, following total laryngectomy with partial pharyngectomy. Prospective clinical trial. Otolaryngology department, Tanta University Hospital (tertiary referral centre), Egypt. Over five years, 30 patients underwent total laryngectomy with partial pharyngectomy to manage stage III or IV laryngeal cancer, followed by primary tracheoesophageal puncture for voice restoration. For neopharyngeal construction, 15 patients underwent pharyngoesophageal myotomy (group one) and 15 cross-over, zigzag neopharyngoplasty (group two). Acoustic parameters of tracheoesophageal voice were compared. Most acoustic parameters were almost equivalent for the two groups, although significant differences were seen for loud intensity, dynamic range, shimmer, loud fundamental frequency, loud jitter, fluency and speaking rate. One post-operative pharyngocutaneous fistula (6.6 per cent) occurred in each group, and resolved with conservative measures. The cross-over neopharyngoplasty modification of hypopharyngeal closure may help avoid pharyngoesophageal spasm and assist maintenance of effective voice amplitude, fundamental frequencies, temporal measures and perceptual values.

Complications of total laryngectomy in the era of chemoradiation

As more total laryngectomies (TLE) are nowadays performed as salvage procedures, the rate of postoperative complications increases. The primary aim was to report the rates of postoperative local complications for total laryngectomy in patients with previous radiotherapy or chemoradiotherapy (RT/CRT) in comparison with primary TLE data. We attempted to identify patient- and tumor-related factors predictive of postoperative pharyngocutaneous fistula (PCF) formation. The secondary aims were to analyze the survival rate in relation to postoperative complications and to study prognostic factors of survival in TLE patients. A retrospective study was conducted in 208 patients. Logistic regression was used to determine the most significant risk factors for fistula formation. Survival was analyzed by the Kaplan-Meier method, log-rank test, and Cox multivariate regression. PCF developed in 20.7% of cases. In the group of patients with previous RT/CRT, the fistula rate was significantly higher (34%). In multivariate analysis, significant risk factors for fistula formation were previous radiotherapy or chemoradiotherapy (p = 0.02), higher N classification (p = 0.03), and procedure performed by a less experienced surgeon (p = 0.003). The survival and recurrence rates were not influenced by PCF formation. The overall survival rates were lower in patients with previous RT/CRT and in patients with lymph node involvement.

Effect of Perioperative Hypothyroidism on Pharyngocutaneous Fistula Formation Following Total Laryngectomy

Objective: To compare the effects of perioperative hypothyroidism on postoperative pharyngocutaneous fistula (PCF) formation in patients undergoing total laryngectomy. Study Design: Case series with chart review. Setting: University-based, tertiary care hospitals. Patients and Methods: We retrospectively analyzed 49 consecutive patients undergoing total laryngectomy between January 2003 and December 2007 having perioperative thyroid stimulating hormone (TSH) levels. We defined hypothyroidism according to American College of Clinical Endocrinology guidelines as serum TSH level above 4.5 mIU/mL. Patients were divided into 2 groups: Group I, comprised of hypothyroid patients and Group II, comprised of euthyroid patients. We collected demographic, clinical, laboratory and perioperative data for analysis. Results: Group I had 10 patients (20%). Group II was matched in nearly all clinical and perioperative variables. Overall, 18 patients (37%) had postoperative PCF. Only 4 of these patients (40%) were from Group I compared to 14 patients (36%) from Group II (p=1.000). Thirteen patients (27%) underwent a concurrent thyroidectomy; 2 from Group I and 11 from Group II. PCF formation was not related to concurrent thyroidectomy (p=0.508). None of the other clinical variables studied (TNM stage, alcohol and tobacco use, preoperative albumin and hemoglobin level, prior radiotherapy, diabetes, neogullet closure type) were associated with PCF formation. Conclusions: PCF formation is multifactorial and our data suggest that PCF is not singularly associated with perioperative hypothyroidism as defined by current standards. A greater degree of hypothyroidism may be required to affect PCF formation. Total laryngectomy should not be delayed secondary to moderately elevated pre-operative TSH values.

Salvage Laryngectomy After Primary Radiotherapy

In this evidence based case report we addressed the clinical question: which factors predict the occurrence of a pharyngocutaneous fistula after total laryngectomy in patients that already were treated with radiotherapy for a squamous cell carcinoma of the larynx? We searched for relevant synonyms for the domain, being patients earlier treated with radiotherapy for a squamous cell carcinoma of the larynx and having a recurrence for which a salvage total laryngectomy is necessary, with the outcome being the development of a post-operative pharyngocutaneous fistula. We searched for relevant publications in Embase, Pubmed and Web of Science using search terms in title and abstract fields. The search yielded 1764 records, of which three were relevant and valid for our clinical question. Our results show that the absolute risk of a pharyngocutaneous fistula after total laryngectomy in patients earlier treated with radiotherapy for a squamous cell carcinoma of the larynx mainly depends on characteristics and site of the primary tumor. In patients who have a primary glottic laryngeal T1 or T2 tumor the absolute risk of developing a fistula is 11% (95% CI 6; 15%), whereas the risk of developing a fistula in patients with a T3 or T4 extra laryngeal tumor is 35% (95% CI 25; 46%). Other patient and surgical characteristics can however not be ruled out as important prognostic factors since many of them have to date not been studied, e.g. diabetes mellitus, alcohol consumption, smoking, suture materials and surgical technique used.

Hairy Neck Skin Flap in a Pharyngostoma: An Unusual Complication of Total Laryngectomy

Postoperative pharyngocutaneous fistula is a common complication after total laryngectomy. A 58-year-old man had a pharyngocutaneous fistula after a total laryngectomy. Because of the prolonged hospital stay and expensive postoperative care, he refused to stay in the clinic until fistula closure. After 7 months, he returned with a hairy neck skin flap in the fistula region. This case emphasizes the importance of appropriate postoperative wound care and the possibility of neck skin curling throughout the fistula tract during fistula closure.

Fasciocutaneous free flap reconstruction for squamous cell carcinoma of the hypopharynx

The purpose of this study was to examine functional and surgical outcomes after fasciocutaneous free flap reconstruction of the hypopharynx. A retrospective review of the records of 48 consecutive patients that underwent hypopharyngectomy and reconstruction using fasciocutaneous free flaps between 1996 and 2009 was performed. Flap donor sites included the radial forearm (n = 42), anterolateral thigh (n = 5), and lateral thigh (n = 1). There was no perioperative mortality, and the free flap survival rate was 95.8%. Five (10.4%) patients developed a postoperative pharyngocutaneous fistula. In three (6.3%) patients a stricture developed during the postoperative period. Forty-four (92%) patients were decannulated and maintained their voice. Forty-four (92%) patients were able to take oral nutrition, although 4 (8%) needed additional PEG-tube feeding. Five-year overall and disease-specific survival rates were 56 and 61%, respectively. Functional reconstruction of extensive laryngohypopharyngeal defects can be achieved using fasciocutaneous free flaps with favorable functional and surgical results.

Reconstruction of Hypopharynx and Cervical Oesophagus for Treatment of Advanced Hypopharyngeal Carcinoma and Recurrent Laryngeal Carcinoma

To review our treatment strategy and outcomes in reconstructing the hypopharynx and cervical oesophagus with five techniques for advanced hypopharyngeal carcinoma and recurrent laryngeal carcinoma. Thirty-one patients treated between 1996 and 2007 were analysed retrospectively. Defects of the hypopharynx and cervical oesophagus were reconstructed using the remaining laryngeal mucosa flap, pectoralis major myocutaneous flap, forearm free flap, jejunal free flap or latissimus dorsi myocutaneous flap. All patients were treated successfully. Postoperative pharyngocutaneous fistulas occurred in four patients, one of whom died from haemorrhage of carotid artery 1 month after surgery, and the other three resolved spontaneously. Dysphagia occurred in three patients, which was caused by food mass occlusion, or oesophageal stricture and stoma stricture. The 3- and 5-year survival rates were 59.3% and 43.5%, respectively. A consensus treatment strategy for reconstructing the defect following hypopharyngectomy and cervical oesophagectomy has not been established. Every technique has its advantages and disadvantages. The treatment of choice depends upon the location and size of the carcinoma as well as the patient's characteristics and the doctor's experience.

Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula

Objective To determine the rate of pharyngocutaneous fistula after salvage laryngectomy and assess if pectoralis myofascial flap reinforcement over primary pharyngeal closure prevents pharyngocutaneous fistula. Study Design Case series with chart review. Setting Tertiary-care public hospital. Subjects and Methods This study included 43 patients undergoing total laryngectomy between 2003 and 2008. Pectoralis myofascial flap reinforcement of the pharyngeal closure during salvage laryngectomy was performed on patients after June 2006. The main outcome measure was pharyngocutaneous fistula after primary laryngectomy, salvage laryngectomy, and salvage laryngectomy with pectoralis flap reinforcement. Results Of the 43 patients, 26 were treated with primary total laryngectomy while 17 received salvage laryngectomy. Seven of 26 patients (27%) undergoing primary total laryngectomy developed pharyngocutaneous fistula. All patients in this group were closed primarily with no flap reinforcement. For salvage laryngectomy, four of seven patients (57%) with primary pharyngeal closure developed pharyngocutaneous fistula; however, none of 10 patients (0%) undergoing salvage laryngectomy with pectoralis myofascial flap reinforcement developed fistula ( P < 0.02; 0%-23%; 95% CI). Conclusions With pectoralis myofascial flap reinforcement, pharyngocutaneous fistula rate after salvage laryngectomy dropped to 0 percent in this study (0%-23%; 95% CI). This is a simple, reliable technique that prevents postoperative pharyngocutaneous fistula and its associated morbidity after salvage laryngectomy.