www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Repair
of
post-laryngectomy
pharyngocutaneous
fistulas
using
a
pectoralis
major
flap
夽
Anna
Sumarroca
a,∗,
Elena
Rodríguez-Bauzà
b,
Joan
Lop-Gros
a,
Jacinto
García
a,
Montserrat
López
a,
Miquel
Quer
a,
Xavier
León
aaUniversitatAutònomadeBarcelona,HospitaldelaSantaCreuiSantPau,OtorhinolaryngologyDepartment,Barcelona,Spain bUniversitatAutònomadeBarcelona,HospitaldelaSantaCreuiSantPau,PlasticSurgeryDepartment,Barcelona,Spain
Received8August2017;accepted1March2018 Availableonline5April2018
KEYWORDS Totallaryngectomy; Pharyngocutaneous fistula;
Pectoralismajorflap; Bypasssalivarytube; Pharynxclosure
Abstract
Introduction:Thepectoralismajorflapisareconstructiveoptiontoconsiderinthetreatment ofpharyngocutaneousfistulaafteratotallaryngectomy.Therearenotlargestudiesassessing variables related to pharyngocutaneousfistula recurrenceafter removal ofthe larynx.Our objectivesweretoreviewtheresultsobtainedwiththistypeoftreatmentwhen pharyngocu-taneousfistulaappearsinlaryngectomizedpatients,andtoevaluatevariablesrelatedtothe results.
Methods:Weretrospectivelyreviewedourresultsusingeitheramyocutaneousor fasciomus-cularpectoralismajorflaptorepairpharyngocutaneousfistulain50patients.
Results:Therewerenocasesofflapnecrosis.Oralintakeafterfistularepairwithapectoralis majorflapwasrestoredin94%ofcases.Fistularecurrenceoccurredin22cases(44%),andit wasassociated withalengtheningofthehospitalstay.Performingtheflapasanemergency procedurewasassociatedwithasignificantlyhigherriskoffistularecurrence.Hospitalstaywas significantlyshorterwhenasalivarytubewasplaced.
Conclusions: Thepectoralismajorflapisausefulapproachtorepairpharyngocutaneousfistula. Placingsalivarytubesduringfistularepairsignificantlyreduceshospitalstayandcomplication severityincaseofpharyngocutaneousfistularecurrence.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:SumarrocaA,Rodríguez-BauzàE,Lop-GrosJ,GarcíaJ,LópezM,QuerM,etal.Repairofpost-laryngectomy pharyngocutaneousfistulasusingapectoralismajorflap.BrazJOtorhinolaryngol.2019;85:351---6.
∗Correspondingauthor.
E-mail:annasumarroca@gmail.com(A.Sumarroca).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2018.03.002
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Laringectomiatotal; Fístula faringocutânea; Retalhodomúsculo peitoralmaior; Tubodederivac¸ão salivar;
Fechamentoda faringe
Reparodefístulasfaringocutâneaspós-laringectomiautilizandoretalhodomúsculo peitoralmaior
Resumo
Introduc¸ão: Oretalhodomúsculopeitoralmaioréumaopc¸ãoaserconsideradanofechamento de fístula faringocutânea pós-laringectomia total. Não há grandes estudos que avaliem as variáveisrelacionadasàrecorrênciadafístulafaringocutâneaapósesseprocedimento. Nos-sosobjetivosforamavaliarosresultadosobtidoscomessetipodetratamentoempacientes laringectomizadoscomfístulafaringocutâneaeasvariáveisrelacionadasaosresultados.
Método: Revisamosretrospectivamente os nossos resultados em 50 pacientes nosquais um retalhomiocutâneooufasciomusculardomúsculopeitoralmaiorforamutilizadosparareparar afístulafaringocutânea.
Resultados: Nãohouvecasosdenecrosederetalho.Apósoreparodafístulacomumretalhodo músculopeitoralmaior,aingestãooralfoirestauradaem94%doscasos.Houverecorrênciada fístulaem22casos(44%),aqualfoiassociadaàdurac¸ãodahospitalizac¸ão.Ousodoretalhocomo procedimentodeemergênciafoiassociadoaumriscosignificativamentemaiorderecorrência dafístula.Apermanênciahospitalarfoisignificativamentemenorquandoutilizadoumtubode derivac¸ãosalivar.
Conclusões:Ousodoretalhodomúsculopeitoralmaioréumaabordagemútilparareparara fístulafaringocutânea.Acolocac¸ãodetubosdederivac¸ãosalivarduranteoreparodafístula reduzsignificativamenteotempodehospitalizac¸ãoeagravidadedascomplicac¸õesemcasode recorrênciadafístulafaringocutânea.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http://
creativecommons.org/licenses/by/4.0/).
Introduction
The appearance of a pharyngocutaneous fistula (PCF)
remainsoneofthemostcommonanddifficultpostoperative
complications in patients undergoing total laryngectomy.
This complication increases morbidity,length of
hospital-ization,andcostsassociatedwithtreatment.Thereported
incidenceof pharyngocutaneous fistulas after total
laryn-gectomyishighlyvariable,rangingbetween4%and65%.1
Severalstudieshaveevaluatedtheriskfactorsassociated
withtheappearanceofPCFaftertotallaryngectomy:
previ-oustreatmentwithradiotherapy2---8orchemoradiotherapy9;
a shorter interval between the end of radiotherapy
and laryngectomy7,8,10; hemoglobin levels below 125g/L
preoperative4 as well aspostoperative5,6,11; comorbidities
such as diabetes, liver disease, or hypothyroidism2---4,12;
and surgical aspects such as neck dissection,2,7,8 prior
tracheotomy,6 resection of the pharynx,8,13 or the use
of nonirradiated tissue to reinforce the pharyngeal
suture.14 The results of a meta-analysis of 26 studies
conducted by Paydafar et al.15 showed that risk factors
significantly associated withthe appearance of PCFwere
hemoglobin level less than 125g/L, prior tracheostomy,
preoperativeradiotherapy,andconcurrentneckdissection.
The results also showed that PCF was more severe in
patients with previous radiotherapy. In a case-control
study conducted in laryngectomized patients by Venegas
et al.,16 no significant differences were found in the
percentageof PCF between non-irradiated andirradiated
patients (12% vs. 18%, p>0.05). However, patients with
previous radiotherapy and PCF required more surgical
repair procedures and the length of hospitalization was
increased.
TreatmentforPCFisusuallyconservative.Itconsistsof
medicaltreatment withantibiotics,enteralnutritionwith
a nasogastric tube, and daily local wound care including
removalof allnecrotictissue,cleaning withan antiseptic
solution,andplacementofacompressivedressing.Between
62%3 and 86%17 of PCF spontaneously close with medical
treatment,particularlythoseinnon-irradiatedpatientswith
small fistulas. Surgical closure of the fistula is indicated
whenconservativetreatmentfails,butthereisnoconsensus
aboutwaitingtime.Severalauthorsconsiderthereisno
rea-sontowaitanylongerifPCFclosureisnotobtainedinone
monthwithmedicalmanagement;surgicalclosureshouldbe
consideredinthesepatients.2,11,18
Manysurgicaltechniquesareusedinthetreatmentofthe
PCF:directclosure2,11;endoscopicrepairwithaplatysmal
flap19;axialfasciocutaneousflapssuchasthedeltopectoral
flap18,20 or theinternal mammaryarteryperforator flap21;
musculocutaneousflapssuchasthesternocleidomastoid,22
pectoralis major flap,18,20,23---25 trapezius26 or latissimus
dorsi22 flaps;andfreeflapssuchasthejejunum,23,27radial
forearm5,12,25,28andanterolateralthighflaps.29
Inourcenter,themethodofchoicetotreat aPCFthat
does notrespondadequately toconservative treatment is
fistulaclosureusingapectoralismajorflap(PMF).Since1994
wehavesystematicallyaddedplacementofabypasssalivary
tube (Montgomery® Salivary Bypass Tube; Boston Medical
Products)incombinationwiththePMF.
The aims of this study were to review the results
Table1 Characteristicsofpatients includedinthestudy (n=50).
Age,years(average,standard deviation) 61.4(9.1) Sex Male 47(94%) Female 3(6%) Location Larynx 35(70%) Hypopharynx 15(30%) Priorradiotherapy No 11(22%) Yes 39(78%) Previousflap No 44(88%) Yes 6(12%) PreoperativeHbg/L(average, standarddeviation) 109.9(18.7)
Fistulaperiodindays (average,range)
32(5---300)
laryngectomizedpatientsandtoevaluatevariablesrelated totheresults.
Methods
Data were obtained retrospectively from a registry that prospectivelycollectsinformationfromreconstructive pro-ceduresperformedinourcentersince1990.From1990to 2014,atotalof50patientsweretreatedwithaPMFtoclose post-laryngectomyPCF.Table1showsthecharacteristicsof
patientsincludedinthisstudy.
In one case, the fistula appeared due to necrosisof a
radialfreeskinflapusedinreconstructionofthe
hypophar-ynx.IntwopatientsaPMFwasusedafterthepreviousfailure
ofarepairattemptwithaninternalmammaryartery
perfo-ratorflap.Insixpatientstreatedwithatotallaryngectomy
andapartialortotalpharyngectomyaPMFwasusedinthe
reconstructionofthehypopharynxattheprimarysurgery.
The decisionforelective surgicalclosureofPCFwitha
PMFwascarriedoutafterafailedconservativemanagement
of at leastfour weeksdurationand wasbasedonclinical
parameterssuchfistulasizeandcervicalsofttissuestatus.
Treatment involved the use of a myocutaneous or
fas-ciomuscularflaps.The criteriatouseamyocutaneousflap
or afasciomuscularflapdependedbasically onthesizeof
thedefecttobereconstructedandthemorphology ofthe
patient.Wechoseamuscleflapwithout skinpaddlewhen
fistularepairrequiredreconstructionoflessthanathirdof
the hypopharynx, or when the thickness of the skin
pad-dlewas considered excessive.In thesecases, we directly
sutured the superficial fascia of the pectoralis muscle to
thedefectmargins.Inthecaseoflargepharyngocutaneous
fistulasrequiringreconstructionofmorethanathirdofthe
hypopharynx,weusedmyocutaneousflaps,suturingtheskin
paddletothemarginsofthepharyngealdefect.Since1994,
we routinely place a bypass salivary tube simultaneously
withpharyngocutaneousfistularepair.
FulloralintakerestorationafterPCFrepairusingthePMF
wasconsideredasasuccessfuloutcome,aslongasnonew
furtherPCFrepairprocedureswereneeded.Analysisofthe
resultsincludedthepercentageofcomplicationsatthe
cer-vicalsurgical woundsite andthoracic donorsite,andthe
periodofhospitalizationafterperformingthepectoralisflap
repair.
Qualitative variables were compared using the
Chi-squaretestorFisher’sexacttest.Therelationshipbetween
qualitative andcontinuous variables wasperformed using
thenonparametricMann---Whitneytest.Alogisticregression
wasusedinthemultivariateanalysis.
This study wasapproved by the institutional
oncologi-cal scientific committee of our center, and conducted in
accordancewiththeDeclarationofHelsinki.
Results
Apectoralismyocutaneousflapwasperformedin12cases
(24.0%),andafasciomuscularflapwithoutaskinpaddlein
38cases(76.0%).Nosignsofflapnecrosiswereobservedin
anycase.
Theflapwasperformedwithin14dayspost-laryngectomy
in13patientswithapharyngocutaneousfistulaandcervical
bleeding.Inthesecases,theflapwasusedinanemergency
contexttoprotectthevascularaxisandtoreconstructthe
pharyngealdefect,performingthesutureonacontaminated
area. In the remaining patients, the fistula was repaired
electively,andnoevidenceofcervicalwoundinfectionwas
notedduringsurgery.
OnepatientwithaPCFhadahemorrhageoftheinternal
jugularveinonthe12thpostoperativeday. Followingvein
ligationwerepairedthefistulausingamyocutaneous
pec-toralisflap.Thepatientdiedeightdayslaterduetoseptic
shockassociatedwithcomplicationsofthecervicalwound;
the fistula persisted at the time of death. Two patients
requiredasecond surgerytorepairthe recurrenceof PCF
after treatment withthe PMF. In the two cases, surgical
treatmentconsisted of theuse of asecond PMF torepair
thedefect.
Restoration of full oral intake is considered the goal
oftreatment. Post-laryngectomy PCFsurgical repairusing
CMPMwassuccessfulin94%ofpatients(47/50).PCF
recur-renceoccurred in 22 of the50 procedures (44%).Table 2
showsthepercentageofpatientswithfistularecurrencein
relationtopatientage,hemoglobinlevels,thenumberof
daysbeforerepair,thelocationoftheprimarytumor,
pre-viousradiotherapy,theuse ofPMFattheprimarysurgery,
thetypeofflap,theuseofasalivarybypasstube,andthe
contextofthe repairsurgery(elective or emergencywith
acervical bleeding).Therewerenosignificantdifferences
infistularecurrenceaftercompletionofthepectoralisflap
forany of theanalyzed variables. Wefound a correlation
for fistularecurrencewhen surgery wascarriedout asan
emergencyprocedure.Twoof thepatients operatedin an
emergencysituationneededasecondreconstructive
proce-durewithacontralateralPMFinordertoacloserecurrent
PCF.
We performed a multivariate study considering fistula
recurrenceasthedependent variableandincludingthose
Table2 Fistularecurrenceafterrepairwithapectoralflap inrelationtoclinicalandoperativevariables.
Fistularecurrence p No Yes Ageinyears (median) 60.8 62.7 0.453 Periodof previousfistula days(median) 32.0 33.0 0.692 Preoperative Hbing/L (median) 114.1 106.0 0.140 Location Larynx 21(57%) 16(43%) 0.757 Hypopharynx 8(53%) 7(47%) Radiotherapy No 6(55%) 5(45%) 0.927 Yes 23(56%) 18(44%) Previousflap No 26(57%) 20(43%) 0.762 Yes 3(50%) 3(50%) Flap Myocutaneous 8(67%) 4(33%) 0.386 Fasciocuta-neous 21(53%) 19(47%) Salivary No 8(42%) 11(58%) 0.132 Yes 21(64%) 12(36%) Emergency No 25(64%) 14(37%) 0.054 Yes 4(31%) 9(69%)
Table3 Resultsofmultivariateanalysisconsideringfistula recurrenceasadependentvariable.
HR 95%CI p Salivary Yes 1 No 3.42 0.94---12.37 0.060 Emergency No 1 Yes 4.68 1.05---20.83 0.043 PreoperativeHb 0.984 0.951---1.01 0.356
independent variables (Table 3). The only variable
asso-ciated with a significant risk of fistula recurrence was
undergoingflapsurgeryasanemergencyprocedure.Inthis
situation, the risk of fistula recurrence was 4.68 times
higher (95% CI 1.05---20.83, p=0.043). Patients in whom
salivary tube bypass was not used had an increased risk
of recurrence, but in this case the hazard ratio did not
reachstatisticalsignificance(HR=3.42,95%CI0.94---12.37,
p=0.060). 120 100 80 60 40 20 0 No Yes Hospitalization sta y (da ys)
Figure1 Lengthofhospitalizationstayindaysinrelationto theuseofsalivarybypasstube.
Three patients were discharged from hospital with a
nasogastric tube due tothe persistenceof asmall fistula
thatwasresolvedonan outpatientbasis.Withthe
excep-tionofthepatientwhodiedduringthepostoperativeperiod,
all patients achieved successful oral intake. The median
lengthofhospitalizationaftercompletionofthepectoralis
flap was 24.5 days (range 9---120 days). Length of
hospi-talization after completion of a pectoralis flap differed
significantlydependingonfistularecurrence(p=0.001).The
medianhospitalizationforpatientswhoweretreatedwith
thepectoralisflapwas16.0days(range9---31days)forthose
who achievedprimary closure of the fistula, and 45 days
(range 13---120 days) for patients with fistula recurrence.
PeriodsofhospitalizationaftercompletionofthePMFwere
analyzedconsideringthelocationoftheprimarytumor,
pre-viousradiotherapy,typeofflap,theuseofashuntsalivary
tube, and whether the flapwas performed aselective or
emergencysurgery.Placementofasalivarybypasstubewas
theonlyvariablesignificantlyrelatedtothelengthofstay
(Fig.1). The median hospitalizationwas20.5 days(range
9---90days)forpatientsinwhomasalivarytubewasplaced,
and40.0days(range13---120)forpatientsinwhomnotube
wasplaced(p=0.013).Consideringonlypatientswithfistula
recurrence(n=22),themedianlengthofhospitalizationwas
41.5 days(range13---90days)for patientsin whoma
sali-vary tube wasplaced (n=12) and 66 days (range40---120
days) for patients in whom no tube was placed (n=10)
(p=0.036).
Fivepatients(9.6%)hadachestwoundinfectioninthe
donor area and 2 (3.8%) had a hematoma. All 7 cases
of chest level complication resolved with local wound
Discussion
SeveralstudieshaveshowntheefficiencyofthePMFin
clos-ingthepharynxduringalaryngectomyandhencereducing
the frequency of postoperative PCF.30,31 However, to our
knowledgenostudieshavebeenperformedinalargeseries
ofpatientstoexaminetheusefulnessofPMFtotreat
post-operativePCFsortodeterminethevariablesrelatedtothe
appearanceoffistularecurrence.
According to our results, fasciomuscular and
myocuta-neouspectoralisflapsfortheclosureofpost-laryngectomy
PCFaresafeandeffective.Withtheexceptionofthepatient
whodiedduetocomplicatedpostoperativewoundinfection
andsecondarysepticshock,oralintakewasrestoredinall
patients, althougha second procedure usingcontralateral
PMFwasneededintwoofthem.Despitetheusefulnessand
efficacy of this technique, 44% of patients developed
fis-tula recurrence.Performing this surgery in an emergency
situationduetopostoperativelocalbleedingwasthe
vari-ablemost stronglyassociatedwiththe recurrenceofPCF,
with a 67% rate of fistula recurrence. In contrast, when
surgerywasperformedaselectivenon-emergencysurgery,
thefrequencyoffistularecurrencewas37%,aratesimilar
tothatreportedbyotherauthors.McLeanetal.23analyzed
theresultsobtained in17cases ofpost-laryngectomyPCF
repairedwithPMFinagroupofpatientsinwhich82.4%had
receivedpre-operativeirradiation.Thesepatientshad58.8%
ofcomplicationsassociatedwithPMFreconstruction,witha
35.3%rateoffistularecurrence.InMagdyetal.25study,the
rateoffistularecurrencein10patientsusingPMFtorepair
post-laryngectomyPCFwas30%.
The results of a multivariate analysis showed that the
useofthePMFinanemergencysituationincreasedtherisk
of fistularecurrencealmost nine-fold. In ouropinion, the
increasedrisk of fistula recurrencewhen PMF
reconstruc-tioniscarriedoutinanemergencybackgroundisjustifiedby
theprecarioussystemicandlocalcontextinwhichsurgeryis
performed.Whencervicalbleedingisassociatedwith
phar-ynxand cervical dehiscencethe pectoralisflapis sutured
oninfectedtissue.Cervicalbleedingmeans, furthermore,
thatweareworkingonhemodynamicallyunstablepatients.
Giventheseresults,unlessaflapisrequiredtoprotectthe
vascular axis, in the emergency situation we now prefer
toperform a pharyngostoma, suturingthe margins of the
pharyngeal dehiscence tocervical skin, and to defer the
reconstructionofthePCFwithaPMFuntillocalandsystemic
conditionsimprove.
In an attempttoreduce theincidenceof fistula
recur-rence, since 1994 we have been systematically placing a
salivarybypasstubeduringPCFclosure.Ourresultsshowed
atrendtoreducethepercentageoffistularecurrence(56%
incases without abypasstube versus37% incases witha
bypasstube),thedifferencesnotreachingstatistical
signif-icance.However,weobservedasignificantdecreaseinthe
lengthofhospitalizationinpatients withasalivarybypass
tube,eveninpatientswithfistularecurrence.
The mainadvantages inusingthepectoralisflapin the
repairofPCFarethatitisatechnicallysimpleprocedure,
andthatitprovidesawell-vascularizedtissuewitha
pedi-cle thateasily reaches the cervical region. Disadvantages
ofthisflaparethemorbiditycausedatthedonorsite,and
excessivebulkdependingonthephenotypeofthepatient,
especiallyin cases where amyocutaneous flap is used.It
shouldbekept in mind,however, that asall ourpatients
wereoperatedbythesamesurgicalteam,thelearningcurve
usingthePMFintheclosureofPCFcouldhaveplayedarole
inthebetterresultsachievedovertime.
Analternativetopectoralisflapsaremicroanastomosed
freeflaps.27 The advantagesof thistypeofrepairarethe
availabilityofdifferentdonorsitesandtheiradaptabilityto
thespecificrequirementsofeachtypeofdefect.Freeflaps,
however,alsohavedisadvantages.Theseincludeincreased
complexity of the microsurgical technique and problems
arising from a lack of viable vascular neck structures in
patientswithahistoryofneckdissection,radiotherapy,or
cervicalinfection. Inthe seriesof Bohannon andcols27 in
whichfree flapswere usedtorepair 20cases of PCF,the
authorschosetouserecipientvesselsfromareasotherthan
theneckin45.5%ofcases,anastomosingthefreeflaptothe
internalmammaryvessels.
Conclusions
The myocutaneous or fasciomuscular PMF is a useful
reconstructivetool for the repair of PCFs after
laryngec-tomy. Placing salivary by-pass tubes during fistula repair
significantly reduces hospital stay and the severity of
complicationsofPCFrecurrence.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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