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Original Investigation |

Intraluminal Negative Pressure Wound Therapy for Optimizing Pharyngeal Reconstruction

Scott A. Asher, MD1; Hilliary N. White, MD1; Elisa A. Illing, MD1; William R. Carroll, MD1; J. Scott Magnuson, MD1; Eben L. Rosenthal, MD1
[+] Author Affiliations
1Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, School of Medicine at the University of Alabama at Birmingham, Birmingham
JAMA Otolaryngol Head Neck Surg. 2014;140(2):143-149. doi:10.1001/jamaoto.2013.6143.
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Importance  Pharyngocutaneous fistula formation after pharyngeal reconstruction is one of the most common and challenging problems to manage. Despite many advances in management, the published success rates indicate a role for any adjuvant therapy that could potentially decrease this complication.

Objective  To describe the use of intraluminal negative pressure dressings (NPDs) in pharyngeal reconstruction.

Design, Setting, and Participants  Retrospective case series at a tertiary care academic hospital. Twelve laryngectomy patients underwent pharyngeal reconstruction augmented by placement of an intrapharyngeal NPD in combination with the introduction of vascularized tissue from August 2011 to May 2012. All patients had potential risk factors for compromised wound healing defined as previous radiation therapy, hypothyroidism, diabetes mellitus, compromised nutrition, or established pharyngocutaneous fistula.

Interventions  An NPD was placed in an intraluminal position spanning the length of the pharyngeal defect as part of the reconstructive procedure. The negative pressure sponge was attached to a standard nasogastric tube to which negative pressure was applied. External closure of the pharynx was then achieved with regional or free tissue transfer.

Main Outcomes and Measures  Pharyngeal closure rates, timing until return to oral diet, identification of wound healing risk factors, and adverse events related to use of the device.

Results  Eleven of 12 patients (92%) achieved pharyngeal closure with reconstruction using negative pressure wound therapy. All patients had at least 1 potential risk factor for compromised wound healing, with 11 of 12 (92%) having 2 or more. Seven patients had an established pharyngocutaneous fistula, and 5 patients underwent primary reconstruction after laryngopharyngectomy. In 6 of these 7 patients undergoing fistula repair, pharyngeal closure was achieved, and they resumed an oral diet at 1 week postoperatively. The other had successful leak repair initially, but 1 week later developed a separate area of wound breakdown and a second fistula. All 5 patients in whom an intraluminal NPD was placed at the time of initial vacularized tissue reconstruction were able to resume an oral diet by 3 weeks postoperatively, with 3 of them eating by mouth at 1 week postoperatively. No serious adverse events could be attributed to the use of intraluminal NPDs.

Conclusions and Relevance  Intraluminal negative pressure wound therapy is feasible and safe. Future research should be conducted to determine its potential in optimizing pharyngeal reconstruction in high-risk patients.

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Figure 1.
Design of Intraluminal Negative Pressure Wound Therapy System

A, Begin with a standard nasogastric tube (NGT) and standard wound vacuum sponge. The sponge should be trimmed to the appropriate size. B, Scissors or trocar can then be used to create a stab incision in the sponge. C, The NGT is then sized so that no suction fenestrations lie outside of sponge, the NGT is sewn to sponge, and often a Xeroform bolster is attached as well to create optimal seal in the pharynx. The rulers are in centimeters on one side and inches on the other side.

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Figure 2.
Fistula Closure Strategy

A, Wound prepared with neck flaps reopened, pharyngeal leak identified (arrow), and pectoral flap (PEC) raised and tunneled into the wound. CHIN indicates chin. A red Robinson rubber catheter (RR) is in place from prior tracheoesophageal puncture. ETT indicates an endotracheal tube in a tracheostoma. B, Profile view of a nasogastric tube (NGT) inserted through the nose and led out of the pharyngeal defect, then secured to sponge. C, Sponge positioned into pharyngeal defect. D, PEC flap sewn into position. The NGT can be seen in this view, where it is traveling down from the nose.

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Figure 3.
Confirmation of Pharyngocutaneous Fistula Closure

Preoperative (A) and postoperative (B) radiographic swallow studies demonstrating leak (arrow) and resolution of leak after repair. C, Endoscopy shows granulation at sight of repair with no sign of fistula.

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