Impact of pharyngeal closure technique on fistula after salvage laryngectomy

Urjeet A. Patel, Brian A. Moore, Mark Wax, Eben Rosenthal, Larissa Sweeny, Oleg N. Militsakh, Joseph A. Califano, Alice C. Lin, Christian P. Hasney, R. Brent Butcher, Jamie Flohr, Demetri Arnaoutakis, Matthew Huddle, Jeremy D. Richmon

Research output: Contribution to journalArticle

71 Citations (Scopus)

Abstract

IMPORTANCE: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy.We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. OBJECTIVE: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx. DESIGN Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers. SETTING: Academic, tertiary referral centers. PATIENTS: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up. MAIN OUTCOMES AND MEASURES: Fistula incidence, severity, and predictors of fistula. RESULTS Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P <.001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P <.001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25%(P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15%(P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks). CONCLUSIONS AND RELEVANCE: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

Original languageEnglish (US)
Pages (from-to)1156-1162
Number of pages7
JournalJAMA Otolaryngology - Head and Neck Surgery
Volume139
Issue number11
DOIs
StatePublished - Nov 2013

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Laryngectomy
Fistula
Inlays
Incidence
Length of Stay
Free Tissue Flaps
Radiotherapy
Post and Core Technique
Pharynx
Tertiary Care Centers
Wound Healing

ASJC Scopus subject areas

  • Otorhinolaryngology
  • Surgery

Cite this

Patel, U. A., Moore, B. A., Wax, M., Rosenthal, E., Sweeny, L., Militsakh, O. N., ... Richmon, J. D. (2013). Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngology - Head and Neck Surgery, 139(11), 1156-1162. https://doi.org/10.1001/jamaoto.2013.2761

Impact of pharyngeal closure technique on fistula after salvage laryngectomy. / Patel, Urjeet A.; Moore, Brian A.; Wax, Mark; Rosenthal, Eben; Sweeny, Larissa; Militsakh, Oleg N.; Califano, Joseph A.; Lin, Alice C.; Hasney, Christian P.; Butcher, R. Brent; Flohr, Jamie; Arnaoutakis, Demetri; Huddle, Matthew; Richmon, Jeremy D.

In: JAMA Otolaryngology - Head and Neck Surgery, Vol. 139, No. 11, 11.2013, p. 1156-1162.

Research output: Contribution to journalArticle

Patel, UA, Moore, BA, Wax, M, Rosenthal, E, Sweeny, L, Militsakh, ON, Califano, JA, Lin, AC, Hasney, CP, Butcher, RB, Flohr, J, Arnaoutakis, D, Huddle, M & Richmon, JD 2013, 'Impact of pharyngeal closure technique on fistula after salvage laryngectomy', JAMA Otolaryngology - Head and Neck Surgery, vol. 139, no. 11, pp. 1156-1162. https://doi.org/10.1001/jamaoto.2013.2761
Patel, Urjeet A. ; Moore, Brian A. ; Wax, Mark ; Rosenthal, Eben ; Sweeny, Larissa ; Militsakh, Oleg N. ; Califano, Joseph A. ; Lin, Alice C. ; Hasney, Christian P. ; Butcher, R. Brent ; Flohr, Jamie ; Arnaoutakis, Demetri ; Huddle, Matthew ; Richmon, Jeremy D. / Impact of pharyngeal closure technique on fistula after salvage laryngectomy. In: JAMA Otolaryngology - Head and Neck Surgery. 2013 ; Vol. 139, No. 11. pp. 1156-1162.
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abstract = "IMPORTANCE: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy.We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. OBJECTIVE: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx. DESIGN Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers. SETTING: Academic, tertiary referral centers. PATIENTS: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up. MAIN OUTCOMES AND MEASURES: Fistula incidence, severity, and predictors of fistula. RESULTS Of the 359 patients, fistula occurred in 94 (27{\%}). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P <.001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P <.001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34{\%}. For the interposed free flap group, the fistula rate was lower at 25{\%}(P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15{\%}(P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks). CONCLUSIONS AND RELEVANCE: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.",
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T1 - Impact of pharyngeal closure technique on fistula after salvage laryngectomy

AU - Patel, Urjeet A.

AU - Moore, Brian A.

AU - Wax, Mark

AU - Rosenthal, Eben

AU - Sweeny, Larissa

AU - Militsakh, Oleg N.

AU - Califano, Joseph A.

AU - Lin, Alice C.

AU - Hasney, Christian P.

AU - Butcher, R. Brent

AU - Flohr, Jamie

AU - Arnaoutakis, Demetri

AU - Huddle, Matthew

AU - Richmon, Jeremy D.

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N2 - IMPORTANCE: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy.We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge. OBJECTIVE: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx. DESIGN Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers. SETTING: Academic, tertiary referral centers. PATIENTS: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up. MAIN OUTCOMES AND MEASURES: Fistula incidence, severity, and predictors of fistula. RESULTS Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P <.001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P <.001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25%(P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15%(P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks). CONCLUSIONS AND RELEVANCE: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.

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