title: Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Concurrent chemoradiotherapy is the gold-standard nonsurgical organ-preservation treatment for advanced laryngeal carcinoma. Total laryngectomy (TL) is increasingly reserved for surgical salvage. Salvage surgery is associated with more complications than primary surgery. A systematic review and meta-analysis was undertaken to establish the impact of organ preservation protocols on pharyngo-cutaneous fistula incidence following TL, and to synthesize evidence on the role of "onlay" prophylactic tissue flaps in reducing this complication in salvage TL.
  
  
  METHODS
  The English language literature (January 1, 2000, to September 1, 2013) was searched, using PUBMED and EMBASE databases, for the terms "laryngectomy" and "fistula." Of 522 studies identified from database searches, 33 were included in the quantitative synthesis.
  
  
  METHODS
  Studies reporting fistula incidence following primary TL (PTL), salvage TL (STL), and STL with "onlay" flap-reinforced pharyngeal closure were included. Data were extracted by the first author (M.S.). Meta-analysis of fistula incidence was performed.
  
  
  RESULTS
  PTL fistula incidence is 14.3% (95% CI 11.7-17.0), STL 27.6% (23.4-31.8), and STL with flap-reinforced closure 10.3% (4.6-15.9). Chemoradiotherapy is associated with a pooled fistula incidence of 34.1% (22.6-45.6), compared to 22.8% (18.3-27.4) for radiotherapy alone. Relative risk of fistula is 0.566 (0.374-0.856, P = 0.001) for STL with flap-reinforced closure compared to STL alone. The number needed to treat (NNT) to prevent one fistula is 6.05.
  
  
  CONCLUSIONS
  Prophylactic flaps used in an "onlay" technique reduce fistula incidence in STL. Chemoradiotherapy increases fistula incidence more than radiotherapy alone. Prophylactic flaps should be offered in salvage cases after failed chemoradiation protocols.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Queen's Medical Centre, Nottingham University Hospitals' NHS Trust, Nottingham, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Sayles
authors.forename: David G
authors.initials: DG
authors.lastname: Grant
mesh_terms: D003131:Combined Modality Therapy; D017577:Cutaneous Fistula / Q000209:etiology / Q000517:prevention & control*; D005402:Fistula / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007822:Laryngeal Neoplasms / Q000628:therapy*; D007825:Laryngectomy; D010608:Pharyngeal Diseases / Q000209:etiology / Q000517:prevention & control*; D016879:Salvage Therapy; D013524:Surgical Flaps
keywords: Laryngectomy; chemotherapy; flap; pharyngo-cutaneous fistula; prophylactic; radiotherapy; salvage surgery