Pharyngocutaneous Fistula Following Primary Total Laryngectomy: a Meta-analysis

Risk Factors of Pharyngocutaneous Fistula Following Primary and Salvage Total Laryngectomy

OBJECTIVES

Pharyngocutaneous fistula (PCF) is the most frequent complication following total laryngectomy (TL). Its incidence increases in the presence of multiple risk factors related to the patient, the tumor, and the surgical procedure. Our study aimed to determine the incidence of PCF and its risk factors.

METHODS

We performed a retrospective study including patients who underwent primary TL (PTL) or salvage TL (STL) between 2007 and 2023. We studied the factors that increased the risk of PCF occurrence, thar are related to the patient, the disease, and the received treatment.

RESULTS

We included 132 patients with a male-to-female ratio of 32, who received PTL (91%) or STL (9%). The tumor was staged as T4a in 62% of patients. PCF occurred in 17 patients (13%) after a median of 14 days (5-36). PCF was managed conservatively in 13 patients (76%), while a surgical re-suture was required in four patients (24%).In the univariate analysis, preoperative anemia, STL, widened forward TL, wound infection, and preoperative hypoproteinemia were significantly associated with PCF. In the multivariate analysis, preoperative anemia (P = .012), wound infection (P = .049), and STL (P = .005) were risk factors of PCF. At the multivariate analysis, preoperative anemia [P = .012, odds ratio (OR) = 6.9], wound infection (P = .049, OR = 6.5), and STL (P = .005, OR = 18.45) were independent risk factors of PCF.

CONCLUSION

We demonstrated that preoperative anemia, wound infection, and STL were independent risk factors of PCF following TL. Avoiding these circumstances can help prevent PCF occurrence.

Application of Biomaterials for the Prevention of Pharyngeal Fistulae: A Systematic Review

BACKGROUND

PharyngoCutaneous Fistulae (PCF) represent a significant clinical challenge in otorhinolaryngology practice. The use of biomaterials could improve outcomes or even replace the use of a flap in pharyngolaryngeal surgery.

METHODS

This systematic review included all studies evaluating the application of biomaterials for the prevention of PCF after pharyngeal surgery.

RESULTS

A total of 19 articles (12 clinical and 7 animal studies) were included. They assessed the use of a biomaterial to cover mucosal sutures (n = 15) or to replace a mucosal defect and guide secondary healing (n = 4). Most studies evaluated commercialized biomaterials (n = 11) rather than experimental devices (n = 5) or platelet-derived autologous medical devices (n = 4).

CONCLUSION

There are already strong arguments to support the use of several biomaterials to cover pharyngeal sutures in order to decrease the rate of PCF after TL or TPL. Replacing a pharyngeal mucosal defect by a biomaterial is currently a more elusive goal.

Temporal Variability in the Incidence and Risk Factors for Pharyngocutaneous Fistula Development after Total Laryngectomy

Background: This study aimed to analyse the variability in the incidence of the pharyngocutaneous fistula (PCF), the most common complication following a total laryngectomy (TLE), and to identify the underlying causes for fluctuations in incidence rates. Methods: In the retrospective study, the annual PCF incidence data and comprehensive clinicopathologic data from 540 patients who underwent TLE between January 2004 and December 2022 were reviewed. Distinct peri ods of both high and low PCF incidence were identified. Within these periods, patients were categorized into groups with PCF (study groups) and without it (control groups). These groups were statistically compared based on potential risk factors for PCF development. The high-incidence periods were specially analysed for recurring risk factors and the corresponding corrective measures were reviewed. Results: The analysis revealed four high-incidence periods with an overall PCF incidence of 37.61%, along with three low-incidence periods in between with an overall incidence of 19.38%. Surgical wound infection (SWI) and a history of head and neck cancer alongside their related treatments were repeatedly identified as independent risk factors during high-incidence periods, with SWI being the most consistent predictor of PCF development. Conclusions: Continuous monitoring of PCF incidence is crucial, as it allows for the identification of emerging risk factors and the immediate implementation of corrective measures to mitigate these newly identified risk factors.

Management of pharyngocutaneous fistula following laryngectomy with autologous fat graft: A case report and literature review

INTRODUCTION AND SIGNIFICANCE

Pharyngocutaneous fistula (PCF) is a serious complication following total laryngectomy, significantly impacting patients' quality of life and treatment costs. Management is complex, with potential for recurrence after surgical intervention.

CASE PRESENTATION

We present a case of PCF that developed following laryngectomy. Initial conservative treatment failed to resolve the fistula. A pectoralis major myofascial flap was then attempted, but the fistula recurred. Finally, autologous fat grafting was performed with excellent results.

CLINICAL DISCUSSION

Conservative management should be the first-line approach for PCF, as most cases respond favorably. However, if the fistula persists, alternative methods should be explored to achieve optimal outcomes. Our case highlights the importance of not persisting with a failed approach. Autologous fat grafting offers a promising alternative with demonstrably positive outcomes.

CONCLUSION

Pharyngocutaneous fistula presents a significant challenge in post-laryngectomy care. Surgical repair can be complex with potential complications. Our case demonstrates the effectiveness of autologous fat grafting as a successful treatment modality.

Infrahyoid muscle flap as augmentation of pharyngeal repair after total laryngectomy

INTRODUCTION

To assess the usage of contralateral infrahyoid muscles as onlay flap in prevention of pharyngo-cutaneous fistula (PCF) in total laryngectomy (TL) patients with high risk factors of PCF development.

METHODS

This study included 10 patients who suffered from advanced laryngeal carcinoma with presence of risk factors for development of PCF. We added an enforcement muscular layer during neo-pharynx wall repair, the infrahyoid muscle flap of the contralateral side of the tumour origin as an onlay muscular flap to cover the anastomotic site for healing augmentation. Patients were followed up for PCF development where the PCF incidence was calculated.

RESULTS

One patient died from congestive heart failure in the 21th post-operative day so, the actual PCF rate in TL patients with high risk factors of PCF development in our study was 11.11% (1 out of 9 cases).

CONCLUSIONS

Infrahyoid muscle flap may have a role in preventing PCF after TL in patients with high risk factors of PCF development in this case series study to be further assessed in other studies to justify its role.

LEVEL OF EVIDENCE: 4

Videofluoroscopic swallowing study to detect pharyngeal leak after total (pharyngo-) laryngectomy: Retrospective assessment of a single-institution protocol

BACKGROUND

We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL).

METHODS

This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL.

RESULTS

Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases.

CONCLUSION

This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF.

Pharyngeal Reconstruction Methods to Reduce the Risk of Pharyngocutaneous Fistula After Primary Total Laryngectomy: A Scoping Review

INTRODUCTION

The most common early postoperative complication after total laryngectomy (TL) is pharyngocutaneous fistula (PCF). Rates of PCF are higher in patients who undergo salvage TL compared with primary TL. Published meta-analyses include heterogeneous studies making the conclusions difficult to interpret. The objectives of this scoping review were to explore the reconstructive techniques potentially available for primary TL and to clarify which could be the best technique for each clinical scenario.

METHODS

A list of available reconstructive techniques for primary TL was built and the potential comparisons between techniques were identified. A PubMed literature search was performed from inception to August 2022. Only case-control, comparative cohort, or randomized controlled trial (RCT) studies were included.

RESULTS

A meta-analysis of seven original studies showed a PCF risk difference (RD) of 14% (95% CI 8-20%) favoring stapler closure over manual suture. In a meta-analysis of 12 studies, we could not find statistically significant differences in PCF risk between primary vertical suture and T-shaped suture. Evidence for other pharyngeal closure alternatives is scarce.

CONCLUSION

We could not identify differences in the rate of PCF between continuous and T-shape suture configuration. Stapler closure seems to be followed by a lower rate of PCF than manual suture in those patients that are good candidates for this technique.

The Incidence and the Risk Factors for Pharyngocutaneous Fistula following Primary and Salvage Total Laryngectomy

The pharyngocutaneous fistula (PCF) is the most common complication following a total laryngectomy (TL) with a wide range of incidence and various potential risk factors. The aim was to analyse the incidence and potential risk factors for PCF formation in a large study set collected over a longer period of time. In the retrospective study at the Department of Otorhinolaryngology and Cervicofacial Surgery of Ljubljana, 422 patients who were treated for head and neck cancer by TL between 2007 and 2020 were included. The comprehensive clinicopathologic data were collected including potential risk factors related to the patient, disease, surgical treatment and post-operative period for the development of fistulae. The patients were categorized into a group with the fistula (a study group) and one without it (a control group). The PCF then developed in 23.9% of patients. The incidence following a primary TL was 20.8% and 32.7% following salvage TL (p = 0.012). The results demonstrated that surgical wound infection, piriform sinus invasion, salvage TL, and total radiation dose were determined as independent risk factors for PCF formation. A diminishing surgical wound infection rate would contribute to a further reduction of the PCF rate.