Pharyngocutaneous Fistulas after Salvage Laryngectomy ...

“Pharyngocutaneous Fistulas after

Salvage Laryngectomy: Need for

Vascularized Tissue”

Wojciech K. Mydlarz, M.D.

Disclosures

• No Relevant Financial Relationships or

Commercial Interests

Educational Objectives

• Discuss risk factors for fistula after

salvage total laryngectomy

• Discuss prevention of fistulas after

salvage total laryngectomy

• Discuss outcomes and complications of

various surgical management options of

fistulas.

Overview

• Background

• Risk factors for pharyngocutaneous

fistulas (PCF) after Salvage Total

Laryngectomy (TL)

• Prevention of PCF after Salvage TL:

vascularized tissue

• Outcomes

Clinical Background

• Laryngeal Cancer:

• Supraglottis (epiglottis, arytenoids, aryepiglotticfolds, false cords)

• Glottis (true cords, anterior and posterior commissures)

• Subglottis

Clinical Background

2006 ASCO• New cases of laryngeal cancer to be diagnosed

(U.S., 2005): 9,880

• Newly diagnosed cases that will lead to death

(U.S., 2005): 3,770

• 95% of laryngeal cancers are invasive with

squamous cell carcinoma as the predominant

histologic type

• 40% of patients will have stage III or IV laryngeal

cancer (upon first evaluation)

• 25% of healthy people are willing to trade a 20%

absolute difference in survival for the opportunity

to save their voice

Clinical Background

• Tobacco and/or alcohol use are

associated with most cases of laryngeal

cancer

• Continued tobacco and/or alcohol use

complicates treatment and facilitates

medical comorbidity and the

development of second primary

cancers.

Clinical Background

• Larynx-preservation options include:

– Radiation therapy

– Chemoradiation therapy

– Function-preserving partial laryngectomy

procedures

• TL is surgical procedure most feared by

patients. Common sequelae:

– Social isolation

– Job loss

– Depression

Clinical Scenario

• 54 year-old man s/p 35 doses of 2 Gray RT over 7 weeks for a

T3NOMO squamous cell carcinoma of the right vocal cord

• 6 months later undergoes biopsy because of suspicion of

recurrence.

• PMH significant for non–insulin-dependent diabetes mellitus and

hypertension.

• Patient continues to smoke 10 cigarettes per day, which has

decreased from 25 cigarettes per day before diagnosis of

laryngeal cancer. He consumes about 4 beers per day.

• Biopsy histopathology positive for residual tumor.

Multidisciplinary oncology board recommends salvage TL

surgery.

• Potential complications of TL discussed with patient, including

PCF. The patient asks about what are his risks for a fistula?

PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the

Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9





• multivariate logistic regression

analysis: only initial T stage &

tumor site remained as

independent prognostic factors

• Odds ratio (OR) for tumor stage:

– 2.08 (95% confidence interval [CI] =

1.26-3.45)

– T3-4 in comparison to T1-2 for

developing PCF

• OR for tumor site:

– 2.08 (95% CI = 1.25-3.45)

– Non-glottic tumors in comparison with

glottic tumors.

PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous

Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.







Prevention of PCF:

Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery

141, 190-195.

Prevention of PCF:

Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery

141, 190-195.

Prevention of PCF:

Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-

1023.

Prevention of PCF:

Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-

1023.

Prevention of PCF:

Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.

Prevention of PCF:


Prevention of PCF:


Prevention of PCF:


Prevention of PCF:

Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope

117, May 2007.

Prevention of PCF:


117, May 2007.

Prevention of PCF:


117, May 2007.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.









Summary

• PCF can occurr after salvage TL

• Previous radiotherapy, tumor location

and T stage are important risk factors

• Vascularized tissue plays a role in

prevention of PCF after Salvage TL

• Pectoralis major and free flaps can both

be used to help prevent PCF with good

outcomes

Questions?

Pharyngocutaneous Fistulas after Salvage Laryngectomy ...

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