Non-Surgical Strategies for Assisting Closure of Pharyngocutaneous Fistula after Total Laryngectomy: A Systematic Review of the Literature

Abstract

Background: Pharyngocutaneous fistula (PCF) is a frequent complication after total laryngectomy, with an incidence of up to 65%. Many conservative or invasive approaches are available and the choice among them is usually made on a case-by-case basis. The aim of the present review is to critically summarize the available evidence of the effectiveness of the non-surgical management of PCF. Methods: A systematic review and a meta-analysis of the literature were conducted, according to the PRISMA guidelines. Studies investigating botulinum toxin therapy, scopolamine transdermal patch, hyperbaric oxygen therapy (HBOT), and negative pressure wound therapy (NPWT) were assessed. Complete fistula closure after the initiation of non-surgical treatment was the main outcome. Results: After the application of selection criteria, a total of seven articles and 27 patients were included in the present review. All the eligible studies were descriptive case series, while only one article used a standard group as a comparison. The mean age was 63.3 and 14 patients (51.9%) had previously received RT. The reported comorbidities were diabetes, ischemic heart disease, hypertension, dyslipidemia, COPD, and atrial fibrillation. With a mean healing time of 25.0 days, the overall success rate was 92.6%. Conclusions: Non-surgical treatment of PCF is only based on the experience of small series. Although success rates seem promising, the absence of properly designed comparative studies does not allow us, at present, to identify ideal candidates for these non-invasive management strategies for PCF.

Effect of possible risk factors for pharyngocutaneous fistula after total laryngectomy of laryngeal carcinomas and surgical wound infection: A meta‐analysis

“…This was also emphasised in previous studies that used a related meta-analysis technique and found equivalent results of the effect. [41][42][43][44][45][46][47][48][49][50][51] Well-led RCTs are necessary to weigh these features as well as the blend of diverse ethnicities, gender, ages, and other parameters of subjects as the meta-analysis could not define whether differences in them are linked to the outcomes studied. In conclusion, the PCF had a significantly higher surgical wound infection, and preoperative radiation had a significantly lower spontaneous PCF closure in total laryngectomy of laryngeal carcinomas.…”

The Management of Salivary Fistulas

“…While many of these complications can be successfully managed with conservative measures, the prompt recognition of when and how to escalate therapy is critical to avoid potentially devastating complications. Future investigation into medical therapies (e.g., octreotide and the use of botulinum toxin A in settings other than parotid surgery 38 ) may help add options to the nonsurgical armamentarium. Medical optimization of patients is paramount to increase the chances of healing, especially when a second surgical procedure is needed to achieve salivary fistula closure.…”

Negative Pressure Wound Therapy in the Head and Neck: A Summary of Uses and Application Techniques

“…Referenced studies using NPWT for fistulae all include radiated patients; 29 of 61 total patients. 8 32 33 34 35 36 37 However, only Inatomi et al stratified patients by history of radiation and they surprisingly showed that there was no significant difference in resolution rate. 34 The accepted, speculated mechanism of action of NPWT for resolution of head and neck fistulae is that, when sponge is placed near the superficial aspect of the fistula tract, the negative pressure results in the walls of the fistula collapsing and opposing one another resulting in eventual seal.…”

“…Only 8 patients were treated in this manner, but there was a 100% resolution in a mean of 20.1 days. 37 We have successfully used NPWT at the bedside to treat a PCF that developed years after a salvage laryngectomy. We simultaneously placed fibrin sealant (Vistaseal, Ethicon, Raritan, NJ) intraorally to the approximate location of the intraoral communication.…”