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Original Investigation |

Impact of Pharyngeal Closure Technique on Fistula After Salvage Laryngectomy

Urjeet A. Patel, MD1; Brian A. Moore, MD2; Mark Wax, MD3; Eben Rosenthal, MD4; Larissa Sweeny, MD4; Oleg N. Militsakh, MD5,6; Joseph A. Califano, MD7,8; Alice C. Lin, MD1; Christian P. Hasney, MD2; R. Brent Butcher, MD2; Jamie Flohr, MD5; Demetri Arnaoutakis, MD7; Matthew Huddle, MD8; Jeremy D. Richmon, MD8
[+] Author Affiliations
1Department of Otolaryngology–Head & Neck Surgery, Northwestern University, Chicago, Illinois
2Department of Otolaryngology–Head & Neck Surgery, Ochsner Health System, New Orleans, Louisiana
3Department of Otolaryngology–Head & Neck Surgery, Oregon Health Science University, Portland
4Department of Otolaryngology–Head & Neck Surgery, University of Alabama, Birmingham
5Department of Otolaryngology–Head & Neck Surgery, University of Nebraska Medical Center, Omaha
6Department of Otolaryngology–Head & Neck Surgery, Nebraska Methodist Hospital, Omaha
7Department of Otolaryngology–Head & Neck Surgery, Greater Baltimore Medical Center, Baltimore, Maryland
8Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins Hospital, Baltimore
JAMA Otolaryngol Head Neck Surg. 2013;139(11):1156-1162. doi:10.1001/jamaoto.2013.2761.
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Importance  No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post–radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge.

Objective  To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.

Design  Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.

Setting  Academic, tertiary referral centers.

Patients  The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.

Main Outcomes and Measures  Fistula incidence, severity, and predictors of fistula.

Results  Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).

Conclusions and Relevance  Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

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Figure.
Bar Graph for 94 Patients Who Experienced Fistula

The mean duration of fistula is shown according to closure technique. Fistula duration was longest for primary closure at 14.0 weeks. For pectoralis onlay, mean fistula duration was 9.0 weeks. Fistula duration was shortest for patients closed using interposed free tissue. The longer duration of fistula for patients who underwent primary closure was statistically significant (P = .004). Error bars indicate standard deviation.

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