<p>Optimal Management of Post-Laryngectomy Pharyngo-Cutaneous Fistula</p>

Abstract

The pharyngocutaneous fistula (PCF) is one of the most common post-operative complications in patients undergoing laryngectomy. Up till now, there is no universally accepted algorithm for managing of PCFs and several treatment modalities are used for wound healing. The English language literature was searched using PUBMED databases with the keywords "laryngectomy", "pharyngocutaneous", "fistula", "treatment", and "management" from January 1, 1999 to June 1, 2019; we selected 35 studies according to inclusion criteria and we conducted a systematic review of the articles. The analysis of the international literature shows a high variability of treatment approaches; there is no consensus about conservative treatment and waiting time, and neither about the indication for surgical treatment or the ideal surgical technique. A first attempt of a conservative measure is mandatory in all cases of PCF. In case of failure of conservative measures surgical treatment should be considered: direct closure and local flap are suitable for small defects, pedicled or free flaps showed good to excellent results in closure of large and complex cervical defects. Other non-invasive treatment such as hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT) showed promising results but in limited case series. Keywords: laryngectomy, pharyngo-cutaneous fistula, reconstructive surgery, hyperbaric oxygen therapy, negative pressure wound therapy, laryngeal cancer 14.3% for primary total laryngectomy (PTL) and 27.6% for salvage total laryngectomy (STL), according to the most recent meta-analysis published in the international literature. 1 Several risk factors have been analyzed in order to understand the etiology of this major complication: previous radiotherapy (RT) or chemoradiotherapy (CHT), type of surgery, T and N stage, a short interval between the end of RT and laryngectomy, hemoglobin levels lower than 125 g/L preoperative as well as postoperative, comorbidities such as diabetes, liver diseases or hypothyroidism, and surgical aspects such as neck dissection, previous tracheotomy, surgical wound infection, resection of the pharynx and its closure after laryngectomy, or the use of non-irradiated tissue to reinforce the pharyngeal suture. [2][3][4][5] The treatment of PCF is crucial in patients who underwent laryngectomy; the persistence of this abnormal communication is associated with delay in adjuvant treatment, prolonged hospital stay, requirement for reoperation, and mortality from, for example, carotid blowout or aspiration pneumonia. The increased incidence of post-laryngectomy PCF in the modern era of organ preservation therapy has driven considerable efforts to develop

Fistula Management in Head and Neck Cancer

“…22 In a recent systematic review, primary conservative therapy was found to have a pooled effectiveness of 56 to 90% in patients with head and neck fistulae. 23 As it has long been known that many fistulas will close with appropriate wound care, and foundations of conservative fistula management are well established, it is advisable to avoid intraoral feedings with concurrent enteral or parenteral nutrition, antibacterial therapy, routine debridement, and pressure dressings or packing. 24 Minimizing contamination of the surrounding tissues is paramount to optimal healing of fistula tracts and, as such, patients should remain strictly nothing per os for the duration of therapy.…”

“…Optimization of nutritional status remains critical to adequate wound healing and, as such, enteral feedings via nasogastric tube-or if contraindications to enteral feedings exist, parenteral nutrition-are an essential component of fistula management and monitoring of albumin and prealbumin levels is routinely recommended. 23 In an effort to reduce drainage of secretions into the fistula tract, some authors also recommend placement of a salivary bypass tube. 25 Similar to nutritional status, the patient's volume status should be closely monitored in the healing period, with maintenance of euvolemic through intravenous fluids or transfusions as needed as fistula have been shown to cause fluid losses similar to those of a large burn.…”

“…Similarly, no studies have directly assessed the effect of frequency of wound debridement on fistula healing; however, many authors recommend at a minimum use of daily mechanical debridement with wet-to-dry dressings for optimal effect. 23 While the classic wet-to-dry dressing with saline-impregnated gauze remains the workhorse of many conservative regimens, many other dressings have been suggested based on potential benefits to wound healing. Both hydrocolloid dressings and hydrogel pastes have been considered as alternative dressings in the setting of head and neck fistulae based on in vitro properties of increased exudate absorbance.…”

“…22 Additionally, while conservative management has been shown to be less successful in patients with a previous history of radiation (44-82%) compared with nonirradiated patients (80-95%), an initial trial of conservative therapy in radiation patients is generally indicated. 23 As to the length of primary conservative therapy, while many authors agree on an initial duration of 1 month, many reports of, successful, extended trials of conservative management lasting up to 18 weeks have also been published. 23 Notably, in their series, Hyman et al reported fistula closure to take an average of 61 days.…”

“…23 As to the length of primary conservative therapy, while many authors agree on an initial duration of 1 month, many reports of, successful, extended trials of conservative management lasting up to 18 weeks have also been published. 23 Notably, in their series, Hyman et al reported fistula closure to take an average of 61 days. 22 Conversely, Iteld and Yu detail markedly easier reconstructive surgeries in patients having early (less than 30 days) compared with late surgical repair of pharyngocutaneous fistulae, which forms the basis for their recommendation of only short trials of conservative therapy before proceeding with operative repair of fistulae.…”