title: Surgical management of pharyngocutaneous fistula after total laryngectomy.
abstract: OBJECTIVE
  The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed.
  
  
  METHODS
  A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed.
  
  
  RESULTS
  Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage.
  
  
  CONCLUSIONS
  Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.
authors: Division of Plastic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
authors: J Nicolas
authors: JN
authors: McLean
authors: Claire
authors: C
authors: Nicholas
authors: Praveen
authors: P
authors: Duggal
authors: Amy
authors: A
authors: Chen
authors: William G
authors: WG
authors: Grist
authors: Albert
authors: A
authors: Losken
authors: Grant W
authors: GW
authors: Carlson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000532:radiotherapy / Q000601:surgery; D017577:Cutaneous Fistula / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D016154:Digestive System Fistula / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D007012:Hypopharyngeal Neoplasms / Q000532:radiotherapy / Q000601:surgery; D007822:Laryngeal Neoplasms / Q000532:radiotherapy / Q000601:surgery; D007825:Laryngectomy; D008297:Male; D008875:Middle Aged; D010608:Pharyngeal Diseases / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D010611:Pharyngectomy; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D019651:Plastic Surgery Procedures / Q000379:methods*; D012008:Recurrence; D012189:Retrospective Studies; D013524:Surgical Flaps; D016896:Treatment Outcome