title: Impact of pharyngeal closure technique on fistula after salvage laryngectomy.
abstract: OBJECTIVE
  No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge.
  
  
  OBJECTIVE
  To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.
  
  
  METHODS
  Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.
  
  
  METHODS
  Academic, tertiary referral centers.
  
  
  METHODS
  The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.
  
  
  METHODS
  Fistula incidence, severity, and predictors of fistula.
  
  
  RESULTS
  Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).
  
  
  CONCLUSIONS
  Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.
authors.affiliation: Department of Otolaryngology-Head & Neck Surgery, Northwestern University, Chicago, Illinois.
authors.forename: Urjeet A
authors.initials: UA
authors.lastname: Patel
authors.forename: Brian A
authors.initials: BA
authors.lastname: Moore
authors.forename: Mark
authors.initials: M
authors.lastname: Wax
authors.forename: Eben
authors.initials: E
authors.lastname: Rosenthal
authors.forename: Larissa
authors.initials: L
authors.lastname: Sweeny
authors.forename: Oleg N
authors.initials: ON
authors.lastname: Militsakh
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Califano
authors.forename: Alice C
authors.initials: AC
authors.lastname: Lin
authors.forename: Christian P
authors.initials: CP
authors.lastname: Hasney
authors.forename: R Brent
authors.initials: RB
authors.lastname: Butcher
authors.forename: Jamie
authors.initials: J
authors.lastname: Flohr
authors.forename: Demetri
authors.initials: D
authors.lastname: Arnaoutakis
authors.forename: Matthew
authors.initials: M
authors.lastname: Huddle
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Richmon
mesh_terms: D002294:Carcinoma, Squamous Cell / Q000601:surgery; D017577:Cutaneous Fistula / Q000209:etiology / Q000601:surgery*; D005260:Female; D005402:Fistula / Q000209:etiology / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D007822:Laryngeal Neoplasms / Q000601:surgery*; D007825:Laryngectomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010608:Pharyngeal Diseases / Q000209:etiology / Q000652:urine*; D010614:Pharynx / Q000601:surgery*; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016879:Salvage Therapy; D013524:Surgical Flaps; D016896:Treatment Outcome