title: Pharyngocutaneous fistula after total laryngectomy: a single-institution experience, 2001-2012.
abstract: OBJECTIVE
  The purpose of this study was to determine the incidence of and risk factors for pharyngocutaneous fistula in patients undergoing total laryngectomy at a single institution.
  
  
  METHODS
  The records of 59 patients undergoing primary or salvage total laryngectomy at our institution from 2001 to 2012 were retrospectively reviewed. Data collected included patient, tumor and treatment characteristics, and surgical technique. Risk factors were analyzed for association with pharyngocutaneous fistula formation.
  
  
  RESULTS
  Twenty patients (34%) developed fistulas. Preoperative tracheostomy (OR 4.1; 95% CI 1.3-13 [p=0.02]) and low postoperative hemoglobin (OR 9.1; 95% CI 1.1-78 [p=0.04]) were associated with fistula development. Regarding surgical technique, primary sutured closure of the total laryngectomy defect had the lowest fistula rate (11%). In comparison, primary stapled closure and pectoralis onlay flap over primary closure had nonsignificantly increased fistula rates (43%, OR 6.0; 95% CI 1.0-37.3 [p=0.06] and 25%, OR 2.7; 95% CI 0.4-23.9 [p=0.38], respectively). Pectoralis flap incorporated into the suture line had a significantly increased fistula rate (50%, OR 7.1; 95% CI 1.4-46 [p=0.02]). After stratification for salvage status, patient comorbidities were associated with fistula in non-salvage cases whereas disease-related characteristics were associated with fistula in salvage cases. Fistula development was associated with increased length of hospital stay (p<0.001) and increased time before oral diet initiation (p<0.001).
  
  
  CONCLUSIONS
  Pharyngocutaneous fistula is a common complication of total laryngectomy. Preoperative tracheostomy, postoperative hemoglobin, and surgical technique are important in determining the risk of fistula.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States. Electronic address: ebenson6@jhmi.edu.
authors.forename: Eleni M
authors.initials: EM
authors.lastname: Benson
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hirata
authors.affiliation: Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, United States.
authors.forename: Carol B
authors.initials: CB
authors.lastname: Thompson
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Patrick K
authors.initials: PK
authors.lastname: Ha
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, United States.
authors.forename: Carole
authors.initials: C
authors.lastname: Fakhry
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: John R
authors.initials: JR
authors.lastname: Saunders
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Califano
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States.
authors.forename: Demetri
authors.initials: D
authors.lastname: Arnaoutakis
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Marshall
authors.initials: M
authors.lastname: Levine
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Mei
authors.initials: M
authors.lastname: Tang
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Neuner
authors.affiliation: Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Barbara P
authors.initials: BP
authors.lastname: Messing
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.
authors.forename: Ray G F
authors.initials: RG
authors.lastname: Blanco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D017577:Cutaneous Fistula / Q000209:etiology*; D005260:Female; D005402:Fistula / Q000209:etiology*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D015994:Incidence; D007818:Laryngeal Diseases / Q000601:surgery*; D007825:Laryngectomy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010608:Pharyngeal Diseases / Q000209:etiology*; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D014139:Tracheostomy / Q000009:adverse effects; D016896:Treatment Outcome
chemical_list: D006454:Hemoglobins