Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis.
BACKGROUND
Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents.


METHODS
We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived.


RESULTS
There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]).


CONCLUSIONS
Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.
Department of Ear Nose and Throat Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand. Electronic address: RN@cantab.net.
S A R
SA
Nouraei
Department of Ear Nose and Throat Surgery, University College Hospital NHS Foundation Trust, 250 Euston Road, London, UK.
A
A
Dias
Department of Ear Nose and Throat Surgery, University College Hospital NHS Foundation Trust, 250 Euston Road, London, UK.
H
H
Kanona
Department of Ear Nose and Throat Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand.
D
D
Vokes
Department of Ear Nose and Throat Surgery, University College Hospital NHS Foundation Trust, 250 Euston Road, London, UK.
P
P
O'Flynn
Department of Ear Nose and Throat Surgery, Charing Cross Hospital, Fulham Palace Road, London, UK.
P M
PM
Clarke
Dr Foster Ltd, 3 Dorset Rise, London, EC4Y 8EN, UK.
S E
SE
Middleton
Academic Surgical Unit, Department of Surgery & Cancer, Imperial College Healthcare Trust, St Mary's Hospital, Praed Street, London, UK.
A
A
Darzi
Dr Foster Unit at Imperial College, Department of Primary Care and Public Health, Imperial College London, Dorset Rise, London, UK.
P
P
Aylin
Department of Plastic & Reconstructive Surgery, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
N
N
Jallali
D017677:Age Distribution; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D007012:Hypopharyngeal Neoplasms / Q000453:epidemiology / Q000601:surgery*; D007822:Laryngeal Neoplasms / Q000453:epidemiology / Q000601:surgery*; D007825:Laryngectomy / Q000379:methods / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010611:Pharyngectomy / Q000379:methods / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D013524:Surgical Flaps; D016896:Treatment Outcome; D058106:Wound Closure Techniques / Q000706:statistics & numerical data
Gastric pull-up; Health informatics; Hypopharyngeal cancer; Pharyngolaryngectomy