Pharyngocutaneous fistula following total laryngectomy: analysis of risk factors, prognosis and treatment modalities

Mapping the risk factors, pathogens, and antibiotic of pharyngocutaneous fistula in patients after neck open surgery

PURPOSE

Current literature lacks consensus on risk factors for pharyngocutaneous fistula (PCF), and empirical antibiotic guidelines for PCF are limited. The aim of this study was to reduce the incidence of PCF and improve antibiotic treatment efficacy for patients with PCF after open neck surgery by analyzing their clinical characteristics, pathogenic bacteria, and antibiotic susceptibility.

METHODS

This study was a 13-year single-center retrospective cohort study, including 699 patients who underwent open neck surgery for laryngeal and hypopharyngeal cancer. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors associated with the occurrence of PCF after surgery. The microbial species causing PCF were analyzed, and the antibiotic sensitivity of the top three pathogens was assessed. Venn diagrams were used to illustrate the antibiotics that exhibited 100% sensitivity against all three identified pathogens.

RESULTS

The incidence of PCF after open neck surgery was 8%. Logistic univariate and multivariate analyses revealed that flap reconstruction (OR = 3.62, 95% CI [2.02-6.52]), history of preoperative radiotherapy (OR = 2.01, 95% CI [1.31-2.73]), significant postoperative bleeding (OR = 1.79, 95% CI [1.11-2.69]), and history of diabetes (OR = 1.34, 95% CI [1.29-2.46]) were significantly associated with PCF occurrence. Among the 38 cases of PCF patients, the top three identified pathogens were Pseudomonas aeruginosa, Escherichia coli, and Enterobacter cloacae. The antibiotics cefepime, meropenem, ticarcillin/clavulanic acid, and cefoperazone/sulbactam showed 100% sensitivity against these top three pathogens.

CONCLUSION

Special attention should be given to patients undergoing open neck surgery, especially those with intraoperative flap reconstruction, a history of preoperative radiotherapy, postoperative bleeding, or diabetes. Strengthening monitoring and care is crucial in preventing the occurrence of PCF. According to antibiotic usage guidelines and considering the distribution of pathogens in PCF patients, empirical antibiotic treatment with cefoperazone/sulbactam or ticarcillin/clavulanic acid is recommended prior to obtaining susceptibility test results.

The use of Montgomery salivary bypass tubes and pharyngocutaneous fistula following salvage laryngectomy

Objectives

Pharyngocutaneous fistula (PCF) is the most common complication to follow total laryngectomy (TL) and is associated with increases in length of hospital stay and with a need for revision surgery or readmission, as well as with delays in return to oral diet. Patients who require salvage TL (STL) or primary (chemo)radiation therapy are at higher risk for developing PCF. Due to the quality-of-life burden of PCF on patients, limiting this occurrence is crucial.

Methods

We conducted a retrospective cohort study of patients undergoing STL with placement of Montgomery salivary bypass tube (MSBT)™ for at least 2 weeks duration between 2013 and 2017 at a single institution. Our patients all underwent free flap reconstruction. Our primary outcome of interest was development of PCF. Secondary outcomes included demographics, previous treatment, base of tongue (BOT) involvement, extent of defect, concurrent neck dissection (ND), and margin status. Univariate χ 2 analysis was used to evaluate factors associated with PCF.

Results

Forty-four patients underwent STL with Montgomery tube placement and free flap reconstruction. Eight developed PCF (18.2%). The average age was 61.6 years; 36 patients were male (81.8%), whereas eight patients were female (18.2%). There was no association between PCF and previous chemoradiation versus radiation (15.8% vs. 33.3%, P < 0.30), BOT involvement versus not (11.1 vs. 22.2%, P < 0.38), circumferential versus partial defect (18.8% vs. 17.9%, P < 0.94), ND versus none (10% vs. 25%, P < 0.20), or margin status.

Conclusion

PCF complicated 18.2% of STL cases at our institution and was not associated with differences in primary treatment modality, presence of concomitant ND, extent of pharyngeal defect, BOT involvement, or positive frozen or permanent surgical margin.

Prophylactic pectoralis major flap to compensate for increased risk of pharyngocutaneous fistula in laryngectomy patients with low skeletal muscle mass (PECTORALIS): study protocol for a randomized controlled trial

BACKGROUND

Total laryngectomy (TL) is a surgical procedure commonly performed on patients with advanced laryngeal or hypopharyngeal carcinoma. One of the most common postoperative complications following TL is the development of a pharyngocutaneous fistula (PCF), characterized by a communication between the neopharynx and the skin. PCF can lead to extended hospital stays, delayed oral feeding, and compromised quality of life. The use of a myofascial pectoralis major flap (PMMF) as an onlay technique during pharyngeal closure has shown potential in reducing PCF rates in high risk patients for development of PCF such as patients undergoing TL after chemoradiation and low skeletal muscle mass (SMM). Its impact on various functional outcomes, such as shoulder and neck function, swallowing function, and voice quality, remains less explored. This study aims to investigate the effectiveness of PMMF in reducing PCF rates in patients with low SMM and its potential consequences on patient well-being.

METHODS

This multicenter study adopts a randomized clinical trial (RCT) design and is funded by the Dutch Cancer Society. Eligible patients for TL, aged ≥ 18 years, mentally competent, and proficient in Dutch, will be enrolled. One hundred and twenty eight patients with low SMM will be centrally randomized to receive TL with or without PMMF, while those without low SMM will undergo standard TL. Primary outcome measurement involves assessing PCF rates within 30 days post-TL. Secondary objectives include evaluating quality of life, shoulder and neck function, swallowing function, and voice quality using standardized questionnaires and functional tests. Data will be collected through electronic patient records.

DISCUSSION

This study's significance lies in its exploration of the potential benefits of using PMMF as an onlay technique during pharyngeal closure to reduce PCF rates in TL patients with low SMM. By assessing various functional outcomes, the study aims to provide a comprehensive understanding of the impact of PMMF deployment. The anticipated results will contribute valuable insights into optimizing surgical techniques to enhance patient outcomes and inform future treatment strategies for TL patients.

TRIAL REGISTRATION

NL8605, registered on 11-05-2020; International Clinical Trials Registry Platform (ICTRP).

Nutritional status and post-operative complications in patients undergoing surgery for advanced pharyngeal or laryngeal cancer

PURPOSE

Malnutrition is an important prognostic indicator of post-operative outcomes in patients undergoing surgery for head and neck cancer, however, limited studies utilize validated nutrition assessment tools to accurately assess risk. The aim of this study was to determine the relationship between nutritional status on post-operative complications and length of stay for patients undergoing either a laryngectomy, pharyngectomy or pharyngolaryngectomy for head and neck cancer.

METHODS

Patients with head and neck cancer undergoing a laryngectomy, pharyngectomy or pharyngolaryngectomy at a tertiary hospital in Australia were eligible for this retrospective cohort study (n = 40). Nutritional status was assessed by the dietitian on admission using the validated Subjective Global Assessment tool. Clinical outcomes were collected via retrospective chart review and included length of stay and post-operative complications.

RESULTS

Pre-operative malnutrition incidence was 40%. Malnourished patients had higher incidences of any type of complication (57% vs 44%, p = 0.013) and pressure injury (86% vs 14%, p = 0.011) compared to well-nourished patients. Well-nourished patients had a clinically important shorter median length of stay compared to malnourished patients (17.5 vs 20 days).

CONCLUSION

Early identification and management of malnutrition is essential to minimize risk of post-operative complications and reduce length of stay and should be considered a key component of prehabilitation programs.

Clinical factors associated with severe surgical complications in patients with hypopharyngeal cancer: a single-center case-cohort study

BACKGROUND

Surgical complications are a major concern in the surgical treatment of hypopharyngeal cancer.

OBJECTIVE

To identify clinical factors that predispose patients with hypopharyngeal cancer to severe surgical complications.

MATERIALS AND METHODS

The data of 449 patients who were underwent surgery as a part of the initial treatment with curative intent or as salvage treatment were retrospectively reviewed. The Chi-square test and logistic regression were used to evaluate the association of different factors with severe surgical complications.

RESULTS

The incidence of severe complications was 22% (99/449), and 10 patients (2.2%) experienced rupture of the carotid artery. Multivariate analysis identified T3/4 stage (p = .002, odds ratio (OR) = 1.58, 95% confidence interval (CI) 1.177-2.122), radiotherapy (RT) (p < .001, OR = 2.744, 95% CI 1.680-4.482), diabetes mellitus (DM) (p = .007, OR = 2.697, 95% CI 1.308-5.56), and nonprimary closure (p = .008, OR = 1.992, 95% CI 1.193-3.327) as significant risk factors for severe surgical complications.

CONCLUSIONS AND SIGNIFICANCE

T3/4 stage, RT, nonprimary closure, and DM were independent predisposing factors for severe surgical complications in our study population of hypopharyngeal cancer patients. Taking measures to lower the tumor stage and simplify the surgical procedure may be crucial in reducing the incidence of severe surgical complications among these patients.

Pharyngocutaneous Fistula Following Total Laryngectomy: a High-Volume Tertiary Centre Series

Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding risk factors for fistula development. A standard score for fistula prediction is lacking. Study population included all patients submitted to total laryngectomy (with or without pharyngectomy) due to laryngeal or hypopharyngeal tumours, occurring between January 1st, 2012, and December 31st, 2016. Patient demographics were recorded as well as disease and treatment variables. Statistical analysis was performed using the IBM SPSS Statistics 25®. A previously described predictive model for fistula occurrence was applied. A total of 212 patients were included, the vast majority with advanced local disease (97.5%). Only 10% were submitted to rescue surgery. Fistula incidence was 39.9%. Our rates of locally advanced tumours, with extensive hypopharyngeal involvement, were higher than in most series. Age, tumour location, diabetes, previous chemoradiotherapy, advanced local and regional disease, extensive pharyngectomy, flap reconstruction, manual suture and low post-operative albumin level were associated to fistula occurrence on univariate analysis. Only salvage surgery and advanced local disease remained significant on multivariate analysis. An adapted Cecatto score correlated with fistula occurrence but has not achieved statistical significance. Predictive models for fistula occurrence are lacking. Cecatto score showed promising results in our population but large multicentric studies are necessary for cut-off adjustments.

Risk Factors for Pharyngocutaneous Fistula Following Total Laryngectomy

Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding which patients are at higher risk for fistula development. This article comprised a literature review about risk factors for fistula development. All articles published on an on-line database (PUBMED™) using MESH terms "larynx cancer" and "fistula" in a 5-year period (January 1st, 2014 to January 27th, 2019) were included. Further articles were selected due to expert suggestion by one of the senior surgeons. Only articles written in Portuguese or English were included. Animal studies were excluded. 151 articles were selected and abstracts analysed. 82 articles were selected for full text revision. 32 were later excluded because they described single clinical cases, experimental surgical technics, irrelevant data or poor methodology. Final selection comprised 50 studies: 9 systematic reviews, one non-systematic review, 34 unicentric and 4 multicentric retrospective analysis and two prospective studies. There is no consensus regarding risk factors for fistula development. Patients submitted to salvage surgery for advanced disease seem to be at greater risk. Bad nutritional status is a logical contributor, but the ideal surrogate marker is still missing. Several variables are inconsistently pointed as risk factors and should be abandoned unless proved otherwise. There are no standard scores for fistula occurrence despite being a common complication following surgery.

Evaluation of the Incidence of Pharyngocutaneous Fistula after Total Laryngectomy

Introduction

Laryngeal squamous cell carcinoma is one of the most critical head and neck cancers. Total laryngectomy is one of the main options for treating laryngeal squamous cell carcinoma responsible for forming pharyngocutaneous fistula (PCF), which increases morbidity and mortality. This study aimed to determine PCF incidence and identify the factors associated with this complication.

Materials and Methods

In a retrospective cohort study, 85 patients who underwent total laryngectomy at Imam Khomeini Hospital (Tehran, Iran) from 2011 to 2019 were selected as the study population. The presence/absence of PCF, weight, anemia status (Hb <12.5 g/dl), renal dysfunction status (GFR <90 mL/min/1.73m2), malnutrition status (Albumin <3.5 g/dl), and marginal involvement status was extracted from postoperative medical records. The data were analyzed using SPSS ver. 26.0.

Results

The overall incidence of PCF was 11.8%. The mean ±SD of the duration of hospitalization in patients with PCF was 32.40 ±14.75 days, and in patients without PCF was 16.89 ±7.05 days (P = 0.009). The mean ±SD of time to develop a fistula was 7.4 ±3.74 days.

Conclusions

The statuses of anemia, malnutrition, renal dysfunction, surgical margin, history of radiotherapy, pharynx closure, gender, and age were unrelated to the incidence of PCF. Further studies with a larger sample size are recommended.

Predictive Value of Risk Factors for Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES

To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool.

RESULTS

A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84).

CONCLUSION

Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023.

Predictive value of procalcitonin level for pharyngocutaneous fistula after laryngectomy

BACKGROUND

Pharyngocutaneous fistula (PCF) is among the most common postoperative infective complications following laryngectomy. Its diagnosis is often late and identified only after the formation of an abnormal, bacterial infection-harboring fistula track between the pharynx and the skin. This study was aimed at determining whether procalcitonin (PCT), white blood cell count (WBC), C-reactive protein (CRP), and neutrophil percentage are good predictors of PCF.

METHODS

We prospectively analysed 65 consecutive patients undergoing total laryngectomy. Clinicodemographic, surgical, and body mass index data were collected. Data on serum levels of PCT, WBC, CRP, and neutrophils were obtained before surgery and on postoperative days 2, 4, 6, 8, and 10 by immunofluorescence, immune turbidimetry, and automatic blood analyzer. The area under the receiving operating characteristic (ROC) curve was calculated for each marker.

RESULTS

There were 65 patients with a mean age of 60.34 years. The PCF occurrence rate was 18.46 % (12/65). Serum levels of PCT and CRP determined on postoperative day 2, 4, 6, 8, and 10 after surgery were higher in patients with PCF (P < 0.01). PCT level was identified as a good predictor area under the curve (AUC) > 0.800 on postoperative days 2, 4, and 6. Considering the sensitivity and specificity, the best combination was PCT on postoperative days 4, which with a cutoff level of 0.12 μg/L showed 91.67 % sensitivity and 100 % specificity.

CONCLUSIONS

Procalcitonin can predict PCF following laryngectomy. PCT > 0.12 μg/L on postoperative day 4 was a reliable predictor of PCF. This may help guide postoperative antibiotic management.

Resurgence of Emergency Total Laryngectomy: An Impact of COVID-19 Pandemic

Laryngeal cancer is one of the most common head and neck cancers in India. Surgery is the preferred modality of treatment in majority of cT4a cases and selective cT3 cases of Carcinoma Larynx. COVID-19 outbreak became a global pandemic and caused significant delays and disruptions in every aspect of cancer care. Similarly, patients of laryngeal cancer presented with advanced disease and significant stridor. In such cases, Emergency total laryngectomy (ETL) proved to be a valid treatment modality in the place of conventional workup and treatment. We present our experience with Emergency laryngectomy during the COVID-19 pandemic and how we overcame its challenges.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03422-5.

Factors predicting pharyngocutaneous fistula in patients after salvage laryngectomy for laryngeal malignancy - A multicenter collaborative cohort study

OBJECTIVES

Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada.

RESULTS

In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (<5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis.

CONCLUSION

We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.

Botulinum Neurotoxin A in the Treatment of Pharyngocutaneous Fistula after Salvage Surgery in Head and Neck Cancer Patients: Our Preliminary Results

Objective: To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods: A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results: Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7-18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different (p < 0.05). Conclusions: BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Incidence of Pharyngocutaneous Fistula After Total Laryngectomy and Its Relationship With the Shapes of Mucosa Closure: A Meta-Analysis

Background and objective

Pharyngocutaneous fistula is the most common complication after total laryngectomy. The aim of this study was to examine the incidence of fistula and the association between fistula and the shape of mucosal closure (T-shaped, vertical, or horizontal closure).

Method

A search of English language databases from 1979 to 2021 was undertaken for studies of total laryngectomy that commented on pharyngeal closure techniques and fistulas. Pooled estimates for fistula incidence and odds ratios were calculated.

Results

A total of 24 retrospective studies were included. The pooled fistula rates in primary total laryngectomy were 19.9% with T-shaped closure, 16.1% with vertical closure, and 16.4% with horizontal closure. In salvage total laryngectomy, the pooled fistula rates were 35.1%, 36.1%, and 17.9% with T-shaped, vertical, and horizontal closure, respectively. In the analysis of association, the risk of fistula formation in the T-shaped closure was not significantly different compared to that in the vertical closure, (odds ratio, 0.96; 95% confidence interval, 0.46-2.00). The horizontal closure, when compared to vertical closure, was significantly associated with lower risk of fistula formation (odds ratio, 0.31; 95% confidence interval, 0.12-0.78), but had nonsignificant lower risk of fistula formation when compared to the T-shaped closure (odds ratio, 0.46; 95% confidence interval, 0.19-1.12).

Conclusion

Horizontal closure seems to be the best closure shape for primary repair after total laryngectomy. However, analysis bias may have occurred because of the lack of well-controlled studies.

Is There any Association Between Total Laryngectomy and Sexual Disorders in Men?

Introduction

According to the prevalence of sexual enjoyment reduction in total or partial laryngectomy patients, the present study aimed to evaluate sexual disorders among men who had undergone total laryngectomy.

Materials and Methods

In this cross-sectional case-control study, purposive sampling was carried out to select all the samples that had experienced total laryngectomy. The control group was selected among the male patients who were referred for a routine checkup. In order to compare the groups, the international index of erectile function (IIEF) was performed, and the data were statistically analyzed in SPSS software (version 21).

Results

Based on the obtained results, laryngectomy patients had experienced problems with sexual problems, especially in the field of erectile function, sexual desire, and intercourse satisfaction (P<001).

Conclusions

According to various studies, sexual dissatisfaction negatively impacts the Quality of life. This problem, commonly observed in total laryngectomy patients, needs to be considered.

Synchronous cervical necrotizing fasciitis and pharyngocutaneous fistula: A case report

Introduction and importance

Necrotizing fasciitis is a fulminant infection that spreads along the fascial planes. It is a rare entity with potentially fatal outcomes. The head and neck involvement is infrequent, with primary source either odontogenic or pharyngeal infection by single or mixed bacterial flora. To our knowledge, synchronous cervical necrotizing fasciitis (CNF) and pharyngocutaneous fistula is rarely reported in pieces of literature.

Case presentation

We present a 38-years-old female patient who presented with CNF and pharyngocutaneous fistula. Diabetes mellitus was accidentally discovered during the investigation. The patient was successfully treated with broad-spectrum antibiotics, serial surgical debridement sessions, wound irrigation, and multiple muscular and myocutaneous skin flaps.

Clinical discussion

Rapid diagnosis, radical surgical debridement of all necrotic tissue, intravenous broad-spectrum antibiotics, and close monitoring of patients with CNF are crucial to avoid critical complications and better patient survival. Due to the poor healing process in the neck area, the pharyngocutaneous fistula should be repaired with good musculocutaneous flaps such as the pectoralis major myocutaneous flap. Meticulous suturing of the flap to the mucosa, reinforcement of the repair with muscle, and suturing of the skin without tension are essential to obtaining a successful outcome.

Conclusion

Synchronous CNF and pharyngocutaneous fistula are rare events. Initial diagnosis and serial surgical debridement, along with aggressive broad-spectrum antibiotics and adequate resuscitation with great attention to the poor healing process in the diabetic patients' neck area, are critical for a beneficial result. In our case, the reconstruction was performed successfully using multiple muscular and skin flaps.

•

Cervical necrotizing fasciitis (CNF) is a fetal infection with a high mortality rate even under ideal medical conditions.

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Synchronous CNF and pharyngocutaneous fistula are rare occurrence.

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In CNF with pharyngocutaneous fistula, initial diagnosis, surgical debridement, broad-spectrum antibiotics and resuscitation with attention to poor healing process, are critical for a beneficial result.

Management of oral feeding following total laryngectomy around the world: A YO-IFOS international study

BACKGROUND

To analyze worldwide practices regarding the initiation of oral feeding after total laryngectomy (TL).

METHODS

Online survey.

RESULTS

Among the 332 responses received, 278 from 59 countries were analyzed. Our results showed that 45.6% of respondents started water and 45.1% started liquid diet between postoperative days 7 and 10. Semi-solid feeds were initiated between days 10 and 14 for 44.9% of respondents and a free diet was allowed after day 15 for 60.8% of respondents. This timing was significantly delayed in cases of laryngo-pharyngectomy and after prior radiotherapy (p < 0.001). A greater proportion of respondents in Africa and Oceania allowed early oral feeding before day 6 as compared with the rest of the world (p < 0.001).

CONCLUSION

Despite increasing number of publications, there is still a lack of evidence to support early oral feeding. The majority of respondents preferred to delay its initiation until at least 7 days after surgery.

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

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.

Inflammation-Based Score (Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio) Predicts Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES/HYPOTHESIS

Postoperative complications may depend on the systemic inflammatory response. We evaluated the predictive potential of the combination of platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for the incidence of pharyngocutaneous fistula (PCF) in patients who have undergone total laryngectomy.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients who underwent total laryngectomy between 2000 and 2020 were recruited from four hospitals. The correlations between the incidence of PCF and several risk factors, including the COP-NLR, were examined. Patients with both elevated platelet count and elevated neutrophil-to-lymphocyte ratio (NLR) were categorized as COP-NLR 2, and patients with either one or no abnormal values of both parameters were assigned as COP-NLR 1 and COP-NLR 0, respectively.

RESULTS

A total of 235 patients were identified. The overall incidence of PCF was 12.3%. The cut-off value for NLR before surgery was set at 3.95 (sensitivity = 58.6%, specificity = 69.4%, area under the curve [AUC] = 0.635), and the platelet count was set at 320 × 10⁹ /L (sensitivity = 27.6%, specificity = 87.9%, AUC = 0.571). Multivariate analysis revealed that COP-NLR was an independent risk factor for PCF (COP-NLR 1 vs. COP-NLR 0: odds ratio [OR], 4.17; 95% confidence interval [CI], 1.64 to 10.59; and COP-NLR 2 vs. COP-NLR 0: OR, 5.33; 95% CI, 1.38 to 20.56).

CONCLUSIONS

COP-NLR is a novel predictive factor for the development of PCF in patients undergoing total laryngectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Comparison of Patients With Total and Salvage Laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P = .000) and between fistula and infection (P = .000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P = .038), T4 (P = .026), lymphovascular invasion (P = .019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P = .005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P = .026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Nonsurgical Risk Factors Associated With Pharyngocutaneous Fistula in Patients Who Have Undergone Laryngectomy

Importance

Pharyngocutaneous fistula (PCF) is a serious complication after total laryngectomy. Despite the well-described clinical risk factors for PCF and its association with poor quality of life, there is a paucity of data on the nonclinical factors that may be associated with this complication.

Objective

To determine whether nonclinical risk factors (eg, age, sex, race and ethnicity) are associated with an increased risk of developing a PCF after total laryngectomy, and whether or not the method of reconstruction explains any differences found.

Design, Setting, and Participants

This retrospective multicenter cohort study used data from a nationally validated, risk-adjusted, outcomes-based, surgical quality improvement database (the National Surgical Quality Improvement Program) to examine outcomes in patients who underwent a total laryngectomy from 2005 to 2018. The database was queried from January 1, 2005, to December 31, 2018; data analyses were performed from September 1, 2020, to March 31, 2021.

Main Outcomes and Measures

The primary outcome was development of a PCF within 30 days of a total laryngectomy. Patient characteristics, including age, sex, race and ethnicity, comorbidities, and mode of reconstruction, were analyzed.

Results

A cohort of 1573 adult patients (median age [IQR], 63 [56-71] years; 1280 [81.4%] men; 293 [18.6%] women; 1001 [63.6%] non-Hispanic White individuals) had undergone a total laryngectomy during the study period and were included in the analyses. The overall rate of PCF formation was 4.3% (68 of 1573 patients). Hispanic patients had the highest rate (9.5%; 9 of 95 patients) of PCF formation, which was more than twice the rate among non-Hispanic White patients (3.8%; 38 of 1001) and non-Hispanic Black patients (4.7%; 11 of 236). After adjusting for clinical and other covariates, women were 1.9 times more likely to develop a PCF compared with men (adjusted odds ratio, 1.90; 95% CI, 1.08-3.35). We also found that the odds of developing a PCF were 3-fold higher among Hispanic patients compared with non-Hispanic White patients (adjusted odds ratio, 2.96; 95% CI, 1.36-6.47). The type of reconstruction did not differ across age or race and ethnicity after controlling for clinical risk factors.

Conclusions and Relevance

This multicenter cohort study found that 2 nonclinical risk factors-Hispanic ethnicity and female sex-were associated with an increased risk of PCF formation. Knowledge of these risk factors should be included in patient-physician decision-making as well as future interventions to decrease the rate of PCF formation after laryngectomy.

Total Laryngectomy: A Review of Surgical Techniques

Since the first total laryngectomy was performed in the late 18th century, several improvements and variations in surgical techniques have been proposed for this procedure. The surgical techniques employed in total laryngectomy have not been comprehensively discussed to date. Thus, the main objective of this article was to address controversial aspects related to this procedure and compare different surgical techniques used for a total laryngectomy procedure from the beginning to the end.

Although the management paradigms in laryngeal and hypopharyngeal squamous cell carcinomas have shifted to organ-preserving chemoradiotherapy protocols, total laryngectomy still plays a prominent role in the treatment of advanced and recurrent tumors. The increased incidence of complications associated with salvage total laryngectomy has driven efforts to improve the surgical techniques in various aspects of the operation. Loss of voice and impaired swallowing are the most difficult challenges to be overcome in laryngectomies, and the introduction of tracheoesophageal voice prostheses has made an enormous difference in postoperative rehabilitation and quality of life. Advancements in reconstruction techniques, tumor control, and metastatic management, such as prophylactic neck treatments and paratracheal nodal dissection (PTND), as well as the use of thyroid gland-preserving total laryngectomy in selected patients have all led to the increasing success of modern total laryngectomy. Several conclusions regarding the benchmarking of surgical techniques cannot be drawn. Issues regarding total laryngectomy are still open for discussion, and the technique will continue to require improvement in the near future.

The effect of salivary bypass tube use on the prevention of pharyngo-cutaneous fistulas after total laryngectomy

INTRODUCTION

The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL).

METHODS

A consecutive series of 133 patients who underwent total laryngectomy between 1997 and 2019 was reviewed. The incidence of PCF was compared between patients who did not receive SBT (nSBT group; n = 55) and those preventively receiving SBT (SBT group; n = 78) in both primary and salvage TL. Risk factors for PCF were evaluated in a univariate and multivariate analyses.

RESULTS

The overall PCF rate was 30%. Preoperative characteristics were similar between the nSBT and SBT groups, except for older age (p = 0.016), lower preoperative hemoglobin (p = 0.043), and lesser neoadjuvant chemotherapy (p = 0.015) in the SBT group. The rate of PCF the nSBT group, was 41.5%, compared to 21.8% in the SBT group (p = 0.020). In multivariate analysis, only the use of SBT was associated with lower risk of PCF (OR = 0.41 (95% CI 0.19-0.89), p = 0.026). This effect was verified only in the subgroup of patient operated for salvage TL (OR = 0.225; 95% CI 0.09-0.7; p = 0.008).

CONCLUSION

The use of SBT in our series in salvage TL, appears to be associated with a decreased risk of PCF.

Development of Pharyngocutaneous Fistula after Total Laryngectomy: The Predictive Value of C-reactive Protein/Albumin Ratio

BACKGROUND

We aimed to evaluate whether C-reactive protein(CRP)/ Albumin ratio (CAR) performed in the early postoperative period after total laryngectomy could be a predictive factor for the development of pharyngocutaneous fistula (PCF).

METHODS

The files of patients with laryngeal squamous cell carcinoma who underwent total laryngectomy between January 2005 and January 2019 were retrospectively reviewed. Patients were divided into two groups: patients with PCF (PCF group) and without (Non-PCF group). CAR values and risk factors were compared between groups.

RESULTS

The overall incidence of PCF was 23.2%. There was a statistically significant difference between the two groups in terms of CRP and CAR levels (p = 0.001). The CAR value of 27.05 (sensitivity = 75.0% , specificity 68.2%, area under curve (AUC) = 0.742, 95% confidence interval 0.616-0.868) was determined as a cutoff value to describe the development of fistula in the early postoperative period. In multiple linear regression analysis, there was an independent relationship between presence of PCF and previous RT and CAR value.

CONCLUSIONS

CAR, performed in the early postoperative period, may be a new and useful marker for predicting PCF after total laryngectomy.

"Fistula Zero" Project After Total Laryngectomy: The Candiolo Cancer Institute Experience

Objectives

Pharyngocutaneous fistula (PCF) is a troublesome complication after total laryngectomy. The “Fistula zero” project aims to reduce the number of PCF by following a detailed protocol based on three fundamental key points.

Materials and Methods

The Fistula zero project included 77 patients who underwent total laryngectomy in the period from January 2019 to December 2020. The protocol consisted of three main aspects: the systematic placement of a Har-El salivary bypass tube, the continuous horizontal watertight pharyngeal suture using a barbed suture, onlay insetting of a pedicled flap in pre-treated patients.

Results

One case of PCF (1.3%) and three small blind fistulas (3.9%) were observed in this series. The mean length of hospitalization was 18 days.

Conclusion

Pharyngocutaneous fistula (PCF) prolongs hospitalization and delays adjuvant treatments. Thanks to a strict adherence to the protocol, it was possible to reduce PCF rates, avoiding lengthy hospitalization and additional surgical procedures.

Enhanced Recovery After Surgery Nutrition Protocol for Major Head and Neck Cancer Surgery

Objective

To determine whether an enhanced recovery after surgery (ERAS) nutrition protocol is reasonably possible among our head and neck cancer (HNC) population with respect to system feasibility and patient compliance. Second, we aim to identify improvements in patient outcomes as a result.

Methods

Preexperimental research design among patients undergoing major HNC surgery after implementation of the ERAS nutrition protocol from July 2018 to July 2019 as quality improvement (QI). Preoperative clinical nutritional assessment and laboratory values were completed the same day as informed surgical consent in the clinic. Protocol focus was patient consumption of nutritional supplements perioperatively, monitored by our outpatient dietitian. Early postoperative enteral nutrition was initiated with monitoring of nutritional laboratory values. To support our model, we provide preliminary analysis of HNC patient outcomes after implementation of the ERAS nutritional protocol.

Results

Twenty-five patients were enrolled. Preoperatively, 40% of patients were malnourished, and 100% complied with perioperative nutrition supplementation. Health care provider compliance obtaining preoperative laboratory values was 56%. There was a strong negative correlation between modified Nutrition-Related Index (mNRI) and number of complications (P = .01), specifically, fistula rate (P = .04) and unplanned reoperation (P = .04). Enrolled patient average length of stay was 7 ± 4.4 days.

Discussion

Our patients demonstrated compliance with implementation of an ERAS nutrition protocol likely facilitated by dietitian engagement. mNRI potentially reflects risk for head and neck surgery complications.

Implications for Practice

QI processes demand reassessment and modification to ensure efficient and targeted approaches to improving patient care.

Stapler closure versus manual closure in total laryngectomy for laryngeal cancer: A systematic review and meta-analysis

OBJECTIVE

Total laryngectomy (TL) is a life-saving procedure for individuals with advanced laryngeal cancer and those suffering from recurrence after initial treatment. The present study aimed to evaluate the differences between stapler closure (SC) and manual closure (MC) of the pharynx during TL for patients with laryngeal cancer.

DESIGN/SETTING

A systematic literature search was performed using the PubMed, EMBASE and Cochrane Library databases. The data were analysed using Comprehensive Meta-Analysis software (Version 3; Biostat). Dichotomous data were calculated as odds ratios (ORs), and continuous data were calculated as mean differences (MD) with 95% confidence intervals (CI).

MAIN OUTCOME/RESULTS

A total of seven studies (535 patients) were included in this meta-analysis. Pooled analysis showed that the operative time of TL was significantly reduced in the SC group (MD, -63.2; 95% CI, -106.0 to -20.4). Moreover, the SC group had a lower incidence of pharyngocutaneous fistula (OR = 0.38; 95% CI, 0.18 to 0.83; P = .016) and hospital stay (MD, -2.9; 95% CI, -5.6 to -0.1). The incidence of postoperative surgical site infection (OR = 0.41; 95% CI, 0.02 to 8.73; P = .565) was comparable between the two groups.

CONCLUSION

Based on these results, SC may be a useful option for patients who need TL.

Early glottic cancer recurrence: A critical review on its current management

INTRODUCTION

Recurrent early glottic cancer (rEGC) poses several issues in terms of timely diagnosis, correct re-staging, and treatment. We want to critically review the latest evidence about rEGC considering its epidemiology, biology, diagnostic challenges, and treatment strategies.

METHODS

A systematic search of the literature using PubMed from 1990 to October 31, 2020 was performed.

RESULTS

There are many different treatment options available (open surgery, transoral mini-invasive surgery, radiotherapy), and many factors related to the patient's status and previous treatments must be considered when planning the best management strategy for rEGC. While its overall prognosis remains satisfactory, it is of the utmost importance to appreciate all the clinical implications derived from the choice of the initial therapeutic modality, and from a correct primary and recurrent staging.

CONCLUSION

The balance between oncological and voice and swallowing functions represents the fundamental principle underlying rEGC management. Future studies should focus on molecular profiling of rEGC, and on the results of the emerging radiation delivery techniques and mini-invasive procedures.

Comparison of patients with total and salvage laryngectomy

INTRODUCTION AND OBJECTIVES

Total laryngectomy (TL) is one of the treatments available in locally advanced laryngeal carcinomas or as a salvage therapy when organ preservation fails, achieving high survival rates and few complications. The aim of this study was to analyse the oncological outcomes, comparing the data obtained with the current literature and analysing complications and survival.

METHODS

The study included 62 patients with primary carcinoma of the larynx treated by primary or salvage TL between 2003 and 2019. We analysed the demographic, clinical and pathological characteristics, tumour stage, complementary treatments, postoperative complications, locoregional recurrences, metastases, and causes of death.

RESULTS

The mean age was 64 years, 90.3% were men, 96.8% were smokers, 43.5% had multiple pathologies and 82.3% had a locally advanced stage. Of all TL 71% were primary and 29% salvage. Neck dissection was performed in 59.6%. Lymphovascular invasion was present in 30.6%, perineural invasion in 30.6% and margin involvement in 14.5%. During the follow-up, 17.7% presented locoregional recurrence and 11.3% distant metastases. Regarding complementary treatments, 56.4% of the patients received adjuvant therapy. The incidence of haemorrhage was 11.3%, infection 14.5%, and pharyngocutaneous fistula 21%. There was a statistically significant correlation between fistula and haemorrhage (P=.000) and between fistula and infection (P=.000). No statistically significant differences were found between the studied factors of primary and salvage TL. The 3-year overall survival was 92% and 5-year overall survival was 88%, finding statistical significance with the locally advanced stage (P=.038), T4 (P=.026), lymphovascular invasion (P=.019) and the involvement of more than 3 lymph nodes in the pathological anatomy (P=.005). On the multivariate analysis, the only variable that showed a significant relationship with survival was lymphovascular invasion (P=.026).

CONCLUSIONS

Although organ preservation is a primary objective, TL remains a leading treatment in locally advanced carcinomas and as salvage in case of failure of medical therapy or partial surgery.

Fistula Management in Head and Neck Cancer

Fistulas in head and neck cancer patients are a common and challenging issue. Despite their commonality, there is little consensus regarding optimal treatment strategies or in preventative measures that might be taken preoperatively. A general knowledge and understanding of what factors correlate with fistula formation can assist a surgeon in optimizing a patient for surgery, thus decreasing prevalence. In addition, surgical techniques can aid in both the prevention and treatment of fistulas once they form. This review details risk factors for fistula formation, the use of vascularized tissue as a preventative measure, conservative and nonconservative treatment of fistulas, and possible strategies to decrease the likelihood of their formation.

Regenerative medicine approaches for the management of respiratory tract fistulas

Respiratory tract fistulas (or fistulae) are abnormal communications between the respiratory system and the digestive tract or the adjacent organs. The origin can be congenital or, more frequently, iatrogenic and the clinical presentation is heterogeneous. Respiratory tract fistulas can lead to severely reduced health-related quality of life and short survival. Therapy mainly relies on endoscopic surgical interventions but patients often require prolonged hospitalization and may develop complications. Therefore, more conservative regenerative medicine approaches, mainly based on lipotransfer, have also been investigated. Adipose tissue can be delivered either as unprocessed tissue, or after enzymatic treatment to derive the cellular stromal vascular fraction. In the current narrative review, we provide an overview of the main tissue/cell-based clinical studies for the management of various types of respiratory tract fistulas or injuries. Clinical experience is limited, as most of the studies were performed on a small number of patients. Albeit a conclusive proof of efficacy cannot be drawn, the reviewed studies suggest that grafting of adipose tissue-derived material may represent a minimally invasive and conservative treatment option, alternative to more aggressive surgical procedures. Knowledge on safety and tolerability acquired in prior studies can lead to the design of future, larger trials that may exploit innovative procedures for tissue processing to further improve the clinical outcome.

Reconstructive Options During Nonfunctional Laryngectomy

OBJECTIVE

A paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability.

METHOD

We performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed.

RESULTS

A total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty-four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube-dependent (P = < .0001).

CONCLUSION

Herein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long-term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1510-E1513, 2021.

A Novel Laryngoscope-assisted Method for Sealing Pharyngocutaneous Fistula

Pharyngocutaneous fistula (PCF) is one of the most common but stranded complications for salvage laryngectomy. As for localized fistula, there is no convincing standard and method to cure. This paper described a patient who was submitted to extensive resection of mass in right lingual root, total laryngectomy, and pharyngoesophageal reconstruction with an anterolateral thigh flap (ALTF), because of recurred carcinoma of right lingual root which invaded bilateral epiglottis. 2 weeks after surgery, subsequent pharyngocutaneous fistula developed at the junction of the tracheostomy, and maintained over 2 months under conservative treatment. With the assistance of laryngoscope, inner and outer orificiums of fistula were found and sealed by bundled iodoform strip. 9 days after sealing, fistula had been already filled with fresh granulation tissue. During 2 years after surgery, the fistula area dose not recur. This technique provides a safe and effective way for sealing the inner and outer orificiums of fistula.

Platelet-rich fibrin: an autologous biomaterial for healing assistance of pharyngeal repair in total laryngectomy

OBJECTIVES

The aim of this study was to evaluate the potential role of platelet-rich fibrin (PRF) application on the pharyngeal repair on decreasing the incidence of pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

This randomized controlled clinical trial was conducted on 67 patients with advanced laryngeal carcinoma who underwent total laryngectomy, over 2 years in the Otorhinolaryngology Department, Mansoura University Hospitals, Egypt. Patients were randomly assigned into two groups: PRF group (n = 35) and control group (n = 32). Risk factors for development of PCF as well as the incidence of PCF were studied in both groups.

RESULTS

There was no statistically significant difference between groups regarding demographic data, medical comorbidities, basal hemoglobin and albumin levels, data related to the tumor (location, grade and TNM staging) and surgical details (preoperative tracheotomy and neck dissection). However, regarding the incidence of PCF, there was a statistically significant difference between groups as shown in Table 2. PCF was detected in 2/35 patients (5.7%) in the PRF group and in 10/32 patients (31.3%) in the control group (p = 0.004).

CONCLUSION

PRF application on the pharyngeal repair after total laryngectomy enhances the healing process and consequently decreases the incidence of PCF.

Incidence and risk factors of pharyngocutaneus fistula formation after total laryngectomy. Review

Introduction and objective: The pharyngocutaneous fistula is a troublesome complication after total laryngectomy, increasing morbidity and mortality. We aimed to determine the incidence of pharyngocutaneus fistula after total laryngectomy and to define the possible predictors for pharyngocutaneus fistula formation. Method: We conducted a review of 31 articles with a total of 1100 patients, to evaluate the incidence of fistula in patients with total laryngectomy and risks factors involved. Results: The overall incidence of pharyngocutaneus fistula is 22,3%, and ranges from 3 to 65%. The review revealed that prior radiation treatment was the most common antecedent, following this associated comorbidity, hypoalbuminemia, anemia, and history of tracheotomy prior to laryngectomy. Discussion: Among the series studied, there is significant heterogeneity in the results, because although irradiated patients have a greater number of pharyngostomas, in some studies no relationship was found, which could explain the association with other risk factors. Conclusions: The incidence of pharyngocutaneus fistula is very variable and there are a large number of risk factors involved, the most frequent is radiotherapy associated or not with chemotherapy.

Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy

INTRODUCTION

Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol.

METHODS

Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent.

RESULTS

Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%).

CONCLUSION

The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Treatment Principle Based on the Clinical Staging of Pharyngocutaneous Fistula

Objective

Studies on factors affecting pharyngocutaneous fistulas (PCFs) and PCF repair methods have been widely reported. However, the healing phases of PCF are unclear, and their elucidation could guide clinical treatment.

Methods

Clinical stages of the PCF healing process were identified by a retrospective study of 39 patients with head and neck cancer who developed a PCF.

Results

Different conservative treatments were performed in turn according to three defined stages of the PCF healing process: stage I (drainage and debriding period), stage II (pressure dressing period), and stage III (healing period). A 7-day course of antibiotic therapy was only performed in stage I in 23 patients. The PCF was cured in 30 (76.9%) of 39 patients; the remaining 9 patients underwent subsequent surgical interventions for PCF healing.

Conclusion

The three stages of PCF healing have a certain reference value in guiding clinical treatments. Moreover, antibiotics should be used in stage I when signs of infection are present, but they should not be used in all three phases of conservative treatment.

Risk factors of pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to systematically evaluate the risk factors of pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

We systematically searched Pubmed, Web of Science, Cochrane Library, and Embase databases and included the literature according to the inclusion and exclusion criteria.

RESULTS

A total of 52 studies with 8605 patients were included in the meta-analysis. The total incidence of PCF was 21% (1808/8605). Meta-analysis results indicated that age (OR = 1.29, 95% CI 1.06-1.58, P = 0.01), smoking (OR = 1.62, 95% CI 1.27-2.07, P < 0.01), COPD (chronic obstructive pulmonary disease) (OR = 1.62, 95% CI 1.19-2.22, P < 0.01), CAD (coronary atherosclerotic heart disease) (OR = 1.82, 95% CI 1.36-2.45, P < 0.01), T-stage (OR = 0.81, 95% CI 0.67-0.98, P = 0.03), previous radiotherapy (OR = 2.41, 95% CI 2.00-2.90, P < 0.01), preoperative albumin (OR = 2.95, 95% CI 1.47-5.91, P < 0.01), preoperative hemoglobin (OR = 1.97, 95% CI 1.28-3.03, P < 0.01), tumor site (OR = 0.28, 95% CI 0.22-0.36, P < 0.01), and treatment method (OR = 1.85, 95% CI 1.44-2.38, P < 0.01) were risk factors associated with PCF.

CONCLUSIONS

In our study, age, smoking, COPD, CAD, T-stage, previous radiotherapy, preoperative albumin, preoperative hemoglobin, tumor site, and treatment method were risk factors of PCF.

Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review

Background

Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported.

Materials and Methods

Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores.

Conclusions

Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.

Bradykinin Receptor B1 and C-Reactive Protein as Prognostic Factors for Pharyngocutaneous Fistula Development After Laryngectomy

Pharyngocutaneous fistulae (PCF) are one of the most common complications after laryngectomy. Predisposing risk factors have been studied, yet knowledge to determine which patients are prone to developing a fistula remains scarce. This study aims to establish prognostic parameters to identify individual patients at risk for PCF development. As PCF and inflammation seem to be interwoven, this work focuses on markers able to detect an inflammatory response. We retrospectively analyzed all patients who had undergone a laryngectomy at our clinic in the years 2007 to 2017 (n = 182). Immunohistochemical expression of bradykinin type 1 and 2 receptor and vascular endothelial growth factor receptor 2 was studied in all available tumor samples. Additionally, the clinical inflammation parameters 'body temperature', 'pain', 'c-reactive protein (CRP)', and 'leucocytes' were postoperatively tracked in all patients. The times between fistula diagnosis, therapeutic approach, and hospital discharge were recorded. We found a strong correlation between inflammation and the formation of a fistula. High bradykinin 1 receptor expression in the tumor samples correlated with postoperative PCF development. Persistently elevated CRP and leukocyte levels beyond the 6th postoperative day were also risk factors. A decreased time lapse between PCF diagnosis and surgical revision clearly correlated with a shorter hospital stay. In this study, we identified a bradykinin 1 receptor positive patient group at high risk for development of PCF. We recommend close monitoring for fistula formation in these patients to ensure timely intervention.

Head and neck reconstruction with pedicled flaps in the free flap era

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

The national landscape of unplanned 30-day readmissions after total laryngectomy

OBJECTIVES/HYPOTHESIS

Examine rates of readmission after total laryngectomy and determine primary etiologies, timing, and risk factors for unplanned readmission.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Nationwide Readmissions Database was queried for patients who underwent total laryngectomy between January 2013 and November 2013. Patient-, procedure-, admission-, and institution-level characteristics were compared for patients with and without unplanned 30-day readmission. Outcomes of interest included rates, etiology, and timing of readmission. Multivariate logistic regression was used to identify predictors of 30-day readmission.

RESULTS

There were 2,931 total laryngectomies performed in 2013 with an unplanned readmission rate of 17.5%. Postoperative fistula accounted for 13.7% of readmissions. The odds of readmission were elevated for patients undergoing concurrent procedures, including primary tracheoesophageal fistulization (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.15-5.18, P = .02) and/or pedicle graft or flap procedures (aOR: 1.73, 95% CI: 1.13-2.66, P = .01). Additionally, patients with comorbid coagulopathy (aOR: 3.04, 95% CI: 1.13-8.22, P = .03), liver disease (aOR: 2.48, 95% CI: 1.08-5.71, P = .03), and valvular heart disease (aOR: 3.18, 95% CI: 1.20-8.41, P = .02) had increased risk for unplanned 30-day readmission. Private insurance and longer lengths of stay were associated with decreased odds of readmission.

CONCLUSIONS

Nearly one-fifth of total laryngectomy patients are readmitted to the hospital within 30 days of discharge. Risk factors identified in this nationally representative cohort should be carefully considered during the postoperative period to reduce preventable readmissions after total laryngectomy.

LEVEL OF EVIDENCE

2c Laryngoscope, 1842-1850, 2018.

Acellular dermal graft pharyngeal repair augmentation after laryngectomy

PURPOSE

Pharyngocutaneous fistula (PCF) after laryngectomy continues to be a serious complication, especially after radiation. Recruitment of non-radiated tissue into the surgical defect may decrease the risk of fistula. These techniques however have significant morbidity and increases operative time. We hypothesized that using acellular dermal graft to reinforce the pharyngeal closure could decrease the risk of fistula, without the added morbidity of a vascularized flap.

METHODS

We performed a retrospective chart review of all patients that underwent a laryngectomy between 2005 and 2015 at an acedemic tertiary referral center. Patients who underwent primary pharyngeal closure with Alloderm® reinforcement without any other flap reconstruction were identified. Basic demographics, previous treatment, operative technique and fistula were extracted from the medical records. The primary outcome was PCF rate. The time to closure, margin status and disease recurrence was also evaluated.

RESULTS

Among 16 patients with AlloDerm® augmentation, eight had primary laryngectomy and eight had salvage laryngectomy. A total of three in the salvage laryngectomy with prior history of radiation developed PCF. The fistula closed in all three cases with conservative treatment. There was no PCF in the primary laryngectomy group without prior history of radiation.

CONCLUSION

The rate of PCF among the salvage laryngectomy group with previous radiation did not differ from historical data. AlloDerm® can however, provide a simple alternative for repair in radiation patients where flap cannot be performed for pharyngeal reconstruction. In non-radiated patients, AlloDerm® augmentation may have a protective effect on fistula formation.