Salvage total laryngectomy: is a flap necessary?

Abstract Introduction: Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy. Objective: Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors. Methods: We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed. Results: We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes. Conclusions: Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.

摘要：咽喉皮肤瘘（pharyngocutaneous fistula）是既往接受过放疗（伴或不伴化疗）的患者行挽救性全喉切除术（salvage total laryngectomy）后最严重的并发症。
研究目的：本研究旨在回顾接受放疗的患者行挽救性全喉切除术后的瘘管发生率，明确胸大肌皮瓣（pectoralis major flap）置入是否可降低瘘管的发生率与持续时间，并探究其他相关危险因素。
研究方法：我们对2000年至2017年间，因原发性根治性放疗失败后仅罹患喉癌、行挽救性全喉切除术的患者开展回顾性分析，对患者的一般资料、危险因素及其他并发症进行统计分析。
研究结果：本研究共纳入27例患者，平均年龄为66.4岁，以男性为主（占比92.5%）。其中，未行胸大肌皮瓣的一期闭合组共14例患者，行胸大肌皮瓣闭合组共13例患者。共计15例患者（55.5%）发生咽喉皮肤瘘。未行胸大肌皮瓣组的整体咽喉皮肤瘘发生率显著高于皮瓣置入组（78.6% vs 30.8%，p=0.047）。此外，需手术修复的咽喉皮肤瘘（64.3% vs 7.7%，p=0.03）及大型咽瘘口（64.3% vs 0%，p=0.0004）的发生率在未行胸大肌皮瓣的一期闭合组中更高。本研究未发现其他具有统计学意义的危险因素。预防性应用胸大肌皮瓣的患者，其经口进食启动时间（84天 vs 21.5天，p=0.039）与住院时长（98.3天 vs 27.2天，p=0.0041）均显著缩短。另有2例患者因大型咽瘘口并发症死亡。
研究结论：预防性胸大肌皮瓣可降低瘘管的发生率、严重程度及持续时间，因此在挽救性全喉切除术术中应考虑应用该皮瓣修复技术。