Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

Laryngoscope. 2021 Mar;131(3):E875-E881. doi: 10.1002/lary.28939. Epub 2020 Aug 24.

Abstract

Objective: To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature.

Methods: Retrospective review.

Results: Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09).

Conclusion: Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes.

Level of evidence: 4 Laryngoscope, 131:E875-E881, 2021.

Keywords: Laryngectomy; TEP; fistula; free flap; gastrostomy tube; microvascular reconstruction.

Publication types

  • Review

MeSH terms

  • Aged
  • Carcinoma, Squamous Cell / pathology
  • Carcinoma, Squamous Cell / surgery
  • Cutaneous Fistula / epidemiology
  • Cutaneous Fistula / prevention & control*
  • Female
  • Free Tissue Flaps*
  • Humans
  • Laryngeal Neoplasms / pathology
  • Laryngeal Neoplasms / surgery*
  • Laryngectomy / adverse effects*
  • Male
  • Middle Aged
  • Pharyngeal Diseases / epidemiology
  • Pharyngeal Diseases / prevention & control*
  • Pharyngectomy / adverse effects
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Reconstructive Surgical Procedures*
  • Retrospective Studies
  • Treatment Outcome