Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

Abstract

Objective To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. Methods Retrospective review. Results Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety‐six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)‐tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G‐tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). Conclusion Despite MVFTT reconstruction after STL, G‐tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. Level of Evidence 4 Laryngoscope, 131:E875–E881, 2021

Do Salivary Bypass Tubes Reduce the Risk of Pharyngocutaneous Fistula after Laryngopharyngectomy—A Systematic Review and Meta-Analysis

“…Our study is in accordance with the literature, revealing that PCF occurred in approximately 1/3 of all patients, increasing even up to 2/3 [ 3 ] in salvage procedures [ 1 , 2 ]. Although there is an overall trend ( p = 0.057) that SBT could help to drop the PCF rate, the question is still pending in regard to the reason why SBT usage has failed to gain statistical significance.…”

“…Despite early identification and, if possible, reduction in risk factors, PCF incidence ranges between 10–60% [ 1 , 2 , 3 ]. Hence, it was necessary to apply additional tools that would help in decreasing the incidence of PCF.…”

“…The incidence of PCF ranges between 10–50% [ 1 , 2 ] and sometimes may increase up to 60% [ 3 ] when dealing with previously irradiated tissues in the case of salvage surgery. It is already known that previous radiation therapy (RT) leads to prolonged wound healing [ 4 , 5 ] and carries an increased risk of local infection.…”

“…In order to prevent PCF, conservative management such as avoidance of COX-2 inhibitors for antiphlogistic and anti-inflammatory treatment [ 7 ] and the application of surgical strategies, such as regional pedicled or free microvascular flaps as a second pharyngeal coverage, can be performed [ 8 ]. Although recent data support the use of vascularized flaps (either inlay or overlay) to bolster and support the newly created pharyngeal tube, PCF rates are still reported to range between 10% and 30% [ 1 ].…”

Poor treatment tolerance in head and neck cancer patients with low muscle mass

“…It is conceivable that patients with sarcopenia are more likely to suffer wound complications, including fistula, given their metabolic status. Modifications to the surgery, with liberal use of chimeric free flap reconstruction to bolster and reduce the risk of prolonged wound complications may reduce delays to initiation of adjuvant therapy 19–22 . Although the literature on chimeric reconstruction of mucosal defects of the head and neck is limited, reconstruction with a chimeric fasciocutaneous and muscle free flap is thought to eliminate dead space and allow a two layer of closure to the aerodigestive tract 21 .…”