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Using a sternocleidomastoid muscle flap to prevent postoperative pharyngocutaneous fistula after total laryngectomy: a study of 88 cases.

Abstract

Complications of total laryngectomy can have serious implications for the final outcome of treatment, including pharyngocutaneous fistula. We conducted a retrospective study of surgical techniques to determine how to best prevent or decrease the incidence of pharyngocutaneous fistula following total laryngectomy. We reviewed the hospital records of all patients who had undergone total laryngectomy for laryngeal carcinoma at Ghaem Hospital in Mashhad, Iran, from March 1989 through February 2005. We identified 88 such patients--80 men and 8 women. We divided this cohort into two groups according to the type of pharyngeal defect closure they received. A total of 37 patients--31 men and 6 women (mean age: 61.4 [+ or -] 5.9 yr) underwent primary closure along with a sternocleidomastoid muscle (SCMM) flap (flap group). The other 51 patients--49 men and 2 women (mean age: 61.3 [+ or -] 4.4 yr)--underwent standard primary closure without creation of an SCMM flap (nonflap group). Overall, postoperative pharyngocutaneous fistula occurred in 9 of the 88 patients (10.2%)--1 case in the flap group (2.7%) and 8 cases in the nonflap group (15.7%). The difference between the two groups was statistically significant (p < 0.001; odds ratio = 0.612, 95% confidence interval = 0.451 to 0.832), independent of other factors. We found no correlation between fistula development and age (p = 0.073), sex (p = 0.065), or tumor location (p = 0.435). Likewise, we found no correlation between tumor location and either sex (p = 0.140) or age (p = 0.241). We conclude that including an SCMM flap in the surgical process would significantly decrease the development of fistula, regardless of age, sex, and tumor site.

Introduction

Pharyngocutaneous fistula is a common and troublesome postoperative complication of total laryngectomy. (1,2) It increases morbidity, the length of hospital stay, and even the risk of death. (3,4) Similarly, late complications such as pharyngeal stenosis can result in swallowing difficulties. (5) Pharyngocutaneous fistula is especially bothersome because it is always associated with tissue necrosis, which can result in carotid artery rupture and massive bleeding. (6,7) Saliva leakage from a fistula can cause tissue infection and microvenous thrombosis, which can result in tissue loss due to partial sloughing of the mucosa; these events generally occur 5 to 7 days postoperatively. (8-11)

In March 1989, surgeons at our hospital began to routinely use the sternal head of a sternocleidomastoid muscle (SCMM) flap in closing pharyngeal defects following total laryngectomy. The flap is inserted between the pharyngeal anastomotic line and the skin, and it is wrapped around the repaired pharynx like a collar. Our use of this procedure was part of a trial to assess its usefulness in preventing or decreasing the incidence of pharyngocutaneous fistula. In this article, we describe some of our findings in this regard.

Patients and methods

For this retrospective study, we reviewed the records of all patients who had undergone total laryngectomy for laryngeal carcinoma in the Department of Otolaryngology at Ghaem Hospital in Mashhad, Iran, from March 1989 through February 2005. All operations had been led by the same group of surgeons. We excluded patients who had undergone a total pharyngolaryngectomy for pharyngeal and upper esophageal carcinomas. We also excluded patients with other tumors and those at a higher risk of developing postoperative hypopharyngocutaneous fistula.

We identified 88 eligible patients--80 men and 8 women. In addition to demographic data, we compiled information on preoperative interventions, tumor stage, tumor site, and the method of defect closure.

All patients had received preoperative radiation therapy with 6,000 Gy over a 6-week period more than a year prior to surgery, but they had either not responded or they had experienced a recurrence. The recurrences were rated as category T3N0M0 or T4N0M0. Even though none exhibited lymph node involvement or metastasis, all had stage III or IV disease prior to surgery.

We divided this group into two subgroups according to the type of pharyngeal defect closure they received (table 1). A total of 37 patients--31 men and 6 women (mean age: 61.4 [+ or -] 5.9 yr) underwent standard primary closure along with an SCMM flap (flap group). The other 51 patients--49 men and 2 women (mean age: 61.3 [+ or -] 4.4 yr)--underwent standard closure without creation of an SCMM flap (nonflap group). There were no statistically significant differences between the two groups in terms of age or sex. The standard closure was achieved with an absorbable suture reinforced by interrupted suturing along the midline constrictor muscle.

Patients in both groups had undergone cricopharyngeal myotomy and unilateral pharyngeal neurectomy. Broad-spectrum antibiotic therapy was initiated at the beginning of surgery and continued for 1 week postoperatively. Both the antibiotic regimen and the pharyngeal defect closure technique were the same for both groups. The only difference between the two groups was the use of the SCMM flap (figure).

Statistical analysis was performed with the Statistical Package for the Social Sciences software (v. 15.00 for Windows; SPSS; Chicago). Descriptive statistics and the chi-square ([chi square]) test were applied for comparisons of the two groups.

Results

Type of closure. Overall, postoperative pharyngocutaneous fistula occurred in 9 of the 88 patients (10.2%)--1 case in the flap group (2.7%) and 8 cases in the nonflap group (15.7%). The difference between the two groups was statistically significant (p < 0.001; odds ratio = 0.612, 95% confidence interval = 0.451 to 0.832), independent of other factors (table 2).

Demographic variables. We found no correlation between fistula development and age (p = 0.073) or sex (p = 0.065).

Tumor location. Of the 88 tumors, 46 (52.3%) were located in the glottis, 35 (39.8%) in the supraglottis, and 7 (8.0%) in the subglottis. There was no significant correlation between fistula development and tumor location (p = 0.435), and no correlation between tumor location and either sex (p = 0.140) or age (p = 0.241).

Discussion

In 1974, Stell and Cooney reported that they had reduced the fistula rate to 13% by adapting a surgical technique that involved a collar incision, closure of the pharyngeal defect in a straight line, a separate skin incision for the tracheostoma, and efficient suction drainage. (12)

In 2005, Righini et al documented the advantage of placing a pectoralis myocutaneous flap during post-radiotherapy laryngectomy in a selected group of patients with diabetes mellitus, poor nutritional status, or a history of vascular disease. (13) However, 2 years earlier, Smith et al demonstrated a dramatic decrease in the incidence of fistula from 22.9% to less than 1% with the routine addition of a pectoralis major myogenic flap to cover the pharyngeal defect at surgery. (14)

Unlike the use of the myocutaneous flap, use of the myogenic flap does not require extending the procedure beyond the surgical field of the opened neck. Moreover, use of the myogenic flap required only 5 to 7 minutes of additional operating time, and it did not lead to any limitations of head and neck movement. Finally, Smith et al encountered no problems related to muscle bulk. Postoperatively, the authors noted dramatic reductions in morbidity and mortality, lengths of hospital stay, and costs to the health care system.

Albirmawy compared the use and nonuse of a SCMM collar flap to prevent pharyngocutaneous fistula in 65 patients who had undergone total laryngectomy. (15) The rates of postoperative fistula formation were 34% in his nonflap group and only 3.3% in his flap group (our study found rates of 15.7 and 2.7%, respectively). In addition to reductions in morbidity, mortality, and length of hospital stay, Albirmawy's flap group experienced more successful voice rehabilitation and better swallowing function.

Akduman et al studied 53 patients who had undergone total laryngectomy with standard closure for the removal of epidermoid carcinoma. (16) They observed pharyngocutaneous fistula in 19 of these patients (35.8%), a rate more than twice as high as the rate we found in our nonflap group (15.7%). In their study, there were significant associations between fistula development and T4 category, alcohol consumption, postoperative anemia, and hypoproteinemia. (16)

Qureshi et al conducted a prospective study of 143 patients who underwent total laryngectomy for squamous cell carcinoma of the larynx and piriform sinus. (17) They found that the risk of a pharyngocutaneous fistula was associated with the use of a pectoralis major myocutaneous flap to reconstruct the neopharynx, primary disease in the piriform sinus, and extensive soft-tissue infiltration. Factors that were not related to fistula formation were previous radiotherapy and chemotherapy, the type of closure (T closure, Y closure, or vertical closure), the type of closure layer (full thickness interrupted, submucosal interrupted, submucosal continuous), the type of suture material (silk or Vicryl), age, sex, tumor stage, the use of preoperative tracheostomy, cut margin status, pre- and postoperative hemoglobin levels, and the surgeon's experience.

Finally, Cavalot et al reported that the incidence of fistula following total laryngectomy ranged from 2% to more than 35%. (18) This finding is consistent with our findings.

In addition to its retrospective nature, two particular limitations of our study were a lack of data on TNM categories and a lack of details about our patients' primary radiotherapeutic treatment.

In conclusion, our study demonstrated a dramatic decrease in the incidence of postlaryngectomy pharyngocutaneous fistula by addition of an SCMM flap to cover the pharyngeal defect at surgery. Our data show that this technique is beneficial regardless of age, sex, or tumor location.

References

(1.) Ganly I, Patel SG, Matsuo J, et al. Analysis of postoperative complications of open partial laryngectomy. Head Neck 2009;31(3):338-45.

(2.) Saki N, Nikakhlagh S, Kazemi M. Pharyngocutaneous fistula after laryngectomy: Incidence, predisposing factors, and outcome. Arch Iran Med 2008; 11(3):314-17.

(3.) Dedivitis RA, Ribeiro KC, Castro MA, Nascimento PC. Pharyngocutaneous fistula following total laryngectomy. Acta Otorhinolaryngol Ital 2007;27(l):2-5.

(4.) Virtaniemi JA, Kumpulainen EJ, Hirvikoski PP, et al. The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae. Head Neck 2001;23(1):29-33.

(5.) Ward EC, Bishop B, Frisby J, Stevens M. Swallowing outcomes following laryngectomy and pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg 2002;128(2):181-6.

(6.) Dedo DD, Alonso WA, Ogura JH. Incidence, predisposing factors and outcome of pharyngocutaneous fistulas complicating head and neck surgery. Ann Otol Rhinol Laryngol 1975;84(6):833-40.

(7.) De Jong PC, Struben WH. Pharyngeal fistulae after laryngectomy J Laryngol Otol 1970;84(9):897-903.

(8.) Kent SE, Liu KC, Das Gupta AR. Post-laryngectomy pharyngocutaneous fistulae. J Laryngol Otol 1985:99(10): 1005-8.

(9.) McCombe AW, Jones AS. Radiotherapy and complications of laryngectomy. J Laryngol Otol 1993;107(2): 130-2.

(10.) Natvig K, Boysen M, Tausjo J. Fistuale following laryngectomy in patients treated with irradiation. J Laryngol Otol 1993;107(12):1136-9.

(11.) Papazoglou G, Doundoulakis G, Terzakis G, Dokianakis G. Pharyngocutaneous fistula after total laryngectomy: Incidence, cause, and treatment. Ann Otol Rhinol Laryngol 1994;103(10):801-5.

(12.) Stell PM, Cooney TC. Management of fistulae of the head and neck after radical surgery. J Laryngol Otol 1974;88(9):819-34.

(13.) Righini C, Lequeux T, Cuisnier O, et al. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005;262(5):357-61.

(14.) Smith TJ, Burrage KJ, Ganguly P, et al. Prevention of postlaryngectomy pharyngocutaneous fistula: The Memorial University experience. J Otolaryngol 2003;32(4):222-5.

(15.) Albirmawy OA. Prevention of postlaryngectomypharyngocutaneous fistula using a sternocleidomastoid muscle collar flap. J Laryngol Otol 2007:121 (3):253-7.

(16.) Akduman D, Naiboglu B, Uslu C, et al. Pharyngocutaneous fistula after total laryngectomy: Incidence, predisposing factors, and treatment [in Turkish]. Kulak Burun Bogaz Ihtis Derg 2008; 18(6):349-54.

(17.) Qureshi SS, Chaturvedi P, Pai PS, et al. A prospective study of pharyngocutaneous fistulas following total laryngectomy. J Can Res Ther 2005;1(1):51-6.

(18.) Cavalot AL, Gervasio CE Nazionale G, et al. Pharyngocutaneous fistula as a complication of total laryngectomy: Review of the literature and analysis of case records. Otolaryngol Head Neck Surg 2000;123(5):587-92.

Masoud Naghibzadeh, MD; Ramin Zojaji, MD; Nematollah Mokhtari Amir Majdi, MD; Morteza Mazloum Farsi Baf, MD

From the Department of Otorhinolaryngology, Mashhad University of Medical Sciences, Mashhad, Iran (Prof. Naghibzadeh and Prof. Mokhtari Amir Majdi); and the Department of Otorhinolaryngology (Dr. Zojaji) and the Faculty of Medicine (Dr. Mazloum Farsi Baf), Mashhad Branch, Islamic Azad University, Mashhad, Iran. The study described in this article was conducted at Ghaem Hospital in Mashhad, Iran.

Corresponding author: Ramin Zojaji, MD, Department of Otorhinolaryngology, Arya Teaching Medical Hospital, Azad Medical University, Jahanbany St., Mashad, Khorasan Razavi, Iran 9185711111. Email: raminzojaji@yahoo.com

Table 1. Demographic characteristics of the study population

                 Flap group     Nonflap group     Total
Variable          (n = 37)        (n = 51)      (n = 88)    p Value

Mean age, yr    61.4 [+ or -]   61.3 [+ or -]     61.35      0.073
  [+ or -] SD        5.9             4.4
Sex, n (%)
  Male            31 (83.8)       49 (96.1)     80 (90.9)    0.09
  Female           6(16.2)         2 (3.9)       8(9.1)      0.065

Table 2. Incidence of fistula development in the two groups

                                   n (%)

                         No fistula   Fistula   p Value

Flap group (n = 37)      36 (97.3)    1 (2.7)
Nonflap group (n = 51)   43 (84.3)    8(15.7)   <0.001
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Title Annotation:ORIGINAL ARTICLE
Author:Naghibzadeh, Masoud; Zojaji, Ramin; Majdi, Nematollah Mokhtari Amir; Baf, Morteza Mazloum Farsi
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Aug 1, 2014
Words:2199
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