Braz J Otorhinolaryngol. 2019;85(3):351---356 Brazilian Journal of OTORHINOLARYNGOLOGY www.bjorl.org 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 a a Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Otorhinolaryngology Department, Barcelona, Spain b Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Plastic Surgery Department, Barcelona, Spain Received 8 August 2017; accepted 1 March 2018 Available online 5 April 2018 KEYWORDS Abstract Total laryngectomy; Introduction: The pectoralis major flap is a reconstructive option to consider in the treatment Pharyngocutaneous of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing fistula; variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our Pectoralis major flap; objectives were to review the results obtained with this type of treatment when pharyngocu- Bypass salivary tube; taneous fistula appears in laryngectomized patients, and to evaluate variables related to the Pharynx closure results. Methods: We retrospectively reviewed our results using either a myocutaneous or fasciomus- cular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients. Results: There were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed. Conclusions: The pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence. © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). 夽夽 Please cite this article as: Sumarroca A, Rodríguez-Bauzà E, Lop-Gros J, García J, López M, Quer M, et al. Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap. Braz J Otorhinolaryngol. 2019;85:351---6. ∗ Corresponding author. E-mail: annasumarroca@gmail.com (A. Sumarroca). Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. https://doi.org/10.1016/j.bjorl.2018.03.002 1808-8694/© 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). 352 Sumarroca A et al. PALAVRAS-CHAVE Reparo de fístulas faringocutâneas pós-laringectomia utilizando retalho do músculo Laringectomia total; peitoral maior Fístula Resumo faringocutânea; Introdução: O retalho do músculo peitoral maior é uma opção a ser considerada no fechamento Retalho do músculo de fístula faringocutânea pós-laringectomia total. Não há grandes estudos que avaliem as peitoral maior; variáveis relacionadas à recorrência da fístula faringocutânea após esse procedimento. Nos- Tubo de derivação sos objetivos foram avaliar os resultados obtidos com esse tipo de tratamento em pacientes salivar; laringectomizados com fístula faringocutânea e as variáveis relacionadas aos resultados. Fechamento da Método: Revisamos retrospectivamente os nossos resultados em 50 pacientes nos quais um faringe retalho miocutâneo ou fasciomuscular do músculo peitoral maior foram utilizados para reparar a fístula faringocutânea. Resultados: Não houve casos de necrose de retalho. Após o reparo da fístula com um retalho do músculo peitoral maior, a ingestão oral foi restaurada em 94% dos casos. Houve recorrência da fístula em 22 casos (44%), a qual foi associada à duração da hospitalização. O uso do retalho como procedimento de emergência foi associado a um risco significativamente maior de recorrência da fístula. A permanência hospitalar foi significativamente menor quando utilizado um tubo de derivação salivar. Conclusões: O uso do retalho do músculo peitoral maior é uma abordagem útil para reparar a fístula faringocutânea. A colocação de tubos de derivação salivar durante o reparo da fístula reduz significativamente o tempo de hospitalização e a gravidade das complicações em caso de recorrência da fístula faringocutânea. © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/). Introduction repair procedures and the length of hospitalization was increased. The appearance of a pharyngocutaneous fistula (PCF) Treatment for PCF is usually conservative. It consists of remains one of the most common and difficult postoperative medical treatment with antibiotics, enteral nutrition with complications in patients undergoing total laryngectomy. a nasogastric tube, and daily local wound care including This complication increases morbidity, length of hospital- removal of all necrotic tissue, cleaning with an antiseptic ization, and costs associated with treatment. The reported solution, and placement of a compressive dressing. Between incidence of pharyngocutaneous fistulas after total laryn- 62%3 and 86%17 of PCF spontaneously close with medical gectomy is highly variable, ranging between 4% and 65%.1 treatment, particularly those in non-irradiated patients with Several studies have evaluated the risk factors associated small fistulas. Surgical closure of the fistula is indicated with the appearance of PCF after total laryngectomy: previ- when conservative treatment fails, but there is no consensus ous treatment with radiotherapy2---8 or chemoradiotherapy9 ; about waiting time. Several authors consider there is no rea- a shorter interval between the end of radiotherapy son to wait any longer if PCF closure is not obtained in one and laryngectomy7,8,10 ; hemoglobin levels below 125 g/L month with medical management; surgical closure should be preoperative4 as well as postoperative5,6,11 ; comorbidities considered in these patients.2,11,18 such as diabetes, liver disease, or hypothyroidism2---4,12 ; Many surgical techniques are used in the treatment of the and surgical aspects such as neck dissection,2,7,8 prior PCF: direct closure2,11 ; endoscopic repair with a platysmal tracheotomy,6 resection of the pharynx,8,13 or the use flap19 ; axial fasciocutaneous flaps such as the deltopectoral of nonirradiated tissue to reinforce the pharyngeal flap18,20 or the internal mammary artery perforator flap21 ; suture.14 The results of a meta-analysis of 26 studies musculocutaneous flaps such as the sternocleidomastoid,22 conducted by Paydafar et al.15 showed that risk factors pectoralis major flap,18,20,23---25 trapezius26 or latissimus significantly associated with the appearance of PCF were dorsi22 flaps; and free flaps such as the jejunum,23,27 radial hemoglobin level less than 125 g/L, prior tracheostomy, forearm5,12,25,28 and anterolateral thigh flaps.29 preoperative radiotherapy, and concurrent neck dissection. In our center, the method of choice to treat a PCF that The results also showed that PCF was more severe in does not respond adequately to conservative treatment is patients with previous radiotherapy. In a case-control fistula closure using a pectoralis major flap (PMF). Since 1994 study conducted in laryngectomized patients by Venegas we have systematically added placement of a bypass salivary ® et al.,16 no significant differences were found in the tube (Montgomery Salivary Bypass Tube; Boston Medical percentage of PCF between non-irradiated and irradiated Products) in combination with the PMF. patients (12% vs. 18%, p > 0.05). However, patients with The aims of this study were to review the results previous radiotherapy and PCF required more surgical obtained with this type of treatment when PCF appears in Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap 353 Full oral intake restoration after PCF repair using the PMF Table 1 Characteristics of patients included in the study was considered as a successful outcome, as long as no new (n = 50). further PCF repair procedures were needed. Analysis of the Age, years (average, standard 61.4 (9.1) results included the percentage of complications at the cer- deviation) vical surgical wound site and thoracic donor site, and the Sex period of hospitalization after performing the pectoralis flap Male 47 (94%) repair. Female 3 (6%) Qualitative variables were compared using the Chi- square test or Fisher’s exact test. The relationship between Location qualitative and continuous variables was performed using Larynx 35 (70%) the nonparametric Mann---Whitney test. A logistic regression Hypopharynx 15 (30%) was used in the multivariate analysis. Prior radiotherapy This study was approved by the institutional oncologi- No 11 (22%) cal scientific committee of our center, and conducted in Yes 39 (78%) accordance with the Declaration of Helsinki. Previous flap No 44 (88%) Yes 6 (12%) Results Preoperative Hb g/L (average, 109.9 (18.7) A pectoralis myocutaneous flap was performed in 12 cases standard deviation) (24.0%), and a fasciomuscular flap without a skin paddle in Fistula period in days 32 (5---300) 38 cases (76.0%). No signs of flap necrosis were observed in (average, range) any case. The flap was performed within 14 days post-laryngectomy in 13 patients with a pharyngocutaneous fistula and cervical laryngectomized patients and to evaluate variables related bleeding. In these cases, the flap was used in an emergency to the results. context to protect the vascular axis and to reconstruct the pharyngeal defect, performing the suture on a contaminated Methods area. In the remaining patients, the fistula was repaired electively, and no evidence of cervical wound infection was Data were obtained retrospectively from a registry that noted during surgery. prospectively collects information from reconstructive pro- One patient with a PCF had a hemorrhage of the internal cedures performed in our center since 1990. From 1990 to jugular vein on the 12th postoperative day. Following vein 2014, a total of 50 patients were treated with a PMF to close ligation we repaired the fistula using a myocutaneous pec- post-laryngectomy PCF. Table 1 shows the characteristics of toralis flap. The patient died eight days later due to septic patients included in this study. shock associated with complications of the cervical wound; In one case, the fistula appeared due to necrosis of a the fistula persisted at the time of death. Two patients radial free skin flap used in reconstruction of the hypophar- required a second surgery to repair the recurrence of PCF ynx. In two patients a PMF was used after the previous failure after treatment with the PMF. In the two cases, surgical of a repair attempt with an internal mammary artery perfo- treatment consisted of the use of a second PMF to repair rator flap. In six patients treated with a total laryngectomy the defect. and a partial or total pharyngectomy a PMF was used in the Restoration of full oral intake is considered the goal reconstruction of the hypopharynx at the primary surgery. of treatment. Post-laryngectomy PCF surgical repair using The decision for elective surgical closure of PCF with a CMPM was successful in 94% of patients (47/50). PCF recur- PMF was carried out after a failed conservative management rence occurred in 22 of the 50 procedures (44%). Table 2 of at least four weeks duration and was based on clinical shows the percentage of patients with fistula recurrence in parameters such fistula size and cervical soft tissue status. relation to patient age, hemoglobin levels, the number of Treatment involved the use of a myocutaneous or fas- days before repair, the location of the primary tumor, pre- ciomuscular flaps. The criteria to use a myocutaneous flap vious radiotherapy, the use of PMF at the primary surgery, or a fasciomuscular flap depended basically on the size of the type of flap, the use of a salivary bypass tube, and the the defect to be reconstructed and the morphology of the context of the repair surgery (elective or emergency with patient. We chose a muscle flap without skin paddle when a cervical bleeding). There were no significant differences fistula repair required reconstruction of less than a third of in fistula recurrence after completion of the pectoralis flap the hypopharynx, or when the thickness of the skin pad- for any of the analyzed variables. We found a correlation dle was considered excessive. In these cases, we directly for fistula recurrence when surgery was carried out as an sutured the superficial fascia of the pectoralis muscle to emergency procedure. Two of the patients operated in an the defect margins. In the case of large pharyngocutaneous emergency situation needed a second reconstructive proce- fistulas requiring reconstruction of more than a third of the dure with a contralateral PMF in order to a close recurrent hypopharynx, we used myocutaneous flaps, suturing the skin PCF. paddle to the margins of the pharyngeal defect. Since 1994, We performed a multivariate study considering fistula we routinely place a bypass salivary tube simultaneously recurrence as the dependent variable and including those with pharyngocutaneous fistula repair. variables with a p < 0.20 in the univariate analysis as the 354 Sumarroca A et al. Table 2 Fistula recurrence after repair with a pectoral flap in relation to clinical and operative variables. 120 Fistula recurrence p No Yes 100 Age in years 60.8 62.7 0.453 Hospitalization stay (days) (median) Period of 32.0 33.0 0.692 80 previous fistula days (median) Preoperative 114.1 106.0 0.140 Hb in g/L 60 (median) Location Larynx 21 (57%) 16 (43%) 0.757 40 Hypopharynx 8 (53%) 7 (47%) Radiotherapy No 6 (55%) 5 (45%) 0.927 20 Yes 23 (56%) 18 (44%) Previous flap 0 No 26 (57%) 20 (43%) 0.762 No Yes Yes 3 (50%) 3 (50%) Flap Figure 1 Length of hospitalization stay in days in relation to 8 (67%) 4 (33%) 0.386 the use of salivary bypass tube. Myocutaneous Fasciocuta- 21 (53%) 19 (47%) neous Salivary Three patients were discharged from hospital with a No 8 (42%) 11 (58%) 0.132 nasogastric tube due to the persistence of a small fistula Yes 21 (64%) 12 (36%) that was resolved on an outpatient basis. With the excep- Emergency tion of the patient who died during the postoperative period, No 25 (64%) 14 (37%) 0.054 all patients achieved successful oral intake. The median Yes 4 (31%) 9 (69%) length of hospitalization after completion of the pectoralis flap was 24.5 days (range 9---120 days). Length of hospi- talization after completion of a pectoralis flap differed significantly depending on fistula recurrence (p = 0.001). The Table 3 Results of multivariate analysis considering fistula median hospitalization for patients who were treated with recurrence as a dependent variable. the pectoralis flap was 16.0 days (range 9---31 days) for those HR 95% CI p who achieved primary closure of the fistula, and 45 days (range 13---120 days) for patients with fistula recurrence. Salivary Periods of hospitalization after completion of the PMF were Yes 1 analyzed considering the location of the primary tumor, pre- No 3.42 0.94---12.37 0.060 vious radiotherapy, type of flap, the use of a shunt salivary Emergency tube, and whether the flap was performed as elective or No 1 emergency surgery. Placement of a salivary bypass tube was Yes 4.68 1.05---20.83 0.043 the only variable significantly related to the length of stay (Fig. 1). The median hospitalization was 20.5 days (range Preoperative Hb 0.984 0.951---1.01 0.356 9---90 days) for patients in whom a salivary tube was placed, and 40.0 days (range 13---120) for patients in whom no tube was placed (p = 0.013). Considering only patients with fistula independent variables (Table 3). The only variable asso- recurrence (n = 22), the median length of hospitalization was ciated with a significant risk of fistula recurrence was 41.5 days (range 13---90 days) for patients in whom a sali- undergoing flap surgery as an emergency procedure. In this vary tube was placed (n = 12) and 66 days (range 40---120 situation, the risk of fistula recurrence was 4.68 times days) for patients in whom no tube was placed (n = 10) higher (95% CI 1.05---20.83, p = 0.043). Patients in whom (p = 0.036). salivary tube bypass was not used had an increased risk Five patients (9.6%) had a chest wound infection in the of recurrence, but in this case the hazard ratio did not donor area and 2 (3.8%) had a hematoma. All 7 cases reach statistical significance (HR = 3.42, 95% CI 0.94---12.37, of chest level complication resolved with local wound p = 0.060). care. Repair of post-laryngectomy pharyngocutaneous fistulas using a pectoralis major flap 355 Discussion excessive bulk depending on the phenotype of the patient, especially in cases where a myocutaneous flap is used. It should be kept in mind, however, that as all our patients Several studies have shown the efficiency of the PMF in clos- were operated by the same surgical team, the learning curve ing the pharynx during a laryngectomy and hence reducing using the PMF in the closure of PCF could have played a role the frequency of postoperative PCF.30,31 However, to our in the better results achieved over time. knowledge no studies have been performed in a large series An alternative to pectoralis flaps are microanastomosed of patients to examine the usefulness of PMF to treat post- free flaps.27 The advantages of this type of repair are the operative PCFs or to determine the variables related to the availability of different donor sites and their adaptability to appearance of fistula recurrence. the specific requirements of each type of defect. Free flaps, According to our results, fasciomuscular and myocuta- however, also have disadvantages. These include increased neous pectoralis flaps for the closure of post-laryngectomy complexity of the microsurgical technique and problems PCF are safe and effective. With the exception of the patient arising from a lack of viable vascular neck structures in who died due to complicated postoperative wound infection patients with a history of neck dissection, radiotherapy, or and secondary septic shock, oral intake was restored in all cervical infection. In the series of Bohannon and cols27 in patients, although a second procedure using contralateral which free flaps were used to repair 20 cases of PCF, the PMF was needed in two of them. Despite the usefulness and authors chose to use recipient vessels from areas other than efficacy of this technique, 44% of patients developed fis- the neck in 45.5% of cases, anastomosing the free flap to the tula recurrence. Performing this surgery in an emergency internal mammary vessels. situation due to postoperative local bleeding was the vari- able most strongly associated with the recurrence of PCF, with a 67% rate of fistula recurrence. In contrast, when Conclusions surgery was performed as elective non-emergency surgery, the frequency of fistula recurrence was 37%, a rate similar The myocutaneous or fasciomuscular PMF is a useful to that reported by other authors. McLean et al.23 analyzed reconstructive tool for the repair of PCFs after laryngec- the results obtained in 17 cases of post-laryngectomy PCF tomy. Placing salivary by-pass tubes during fistula repair repaired with PMF in a group of patients in which 82.4% had significantly reduces hospital stay and the severity of received pre-operative irradiation. These patients had 58.8% complications of PCF recurrence. of complications associated with PMF reconstruction, with a 35.3% rate of fistula recurrence. In Magdy et al.25 study, the rate of fistula recurrence in 10 patients using PMF to repair Conflicts of interest post-laryngectomy PCF was 30%. The results of a multivariate analysis showed that the The authors declare no conflicts of interest. use of the PMF in an emergency situation increased the risk of fistula recurrence almost nine-fold. In our opinion, the increased risk of fistula recurrence when PMF reconstruc- tion is carried out in an emergency background is justified by References the precarious systemic and local context in which surgery is 1. Sarra LD, Rodríguez JC, García Valea M, Bitar J, Da performed. When cervical bleeding is associated with phar- Silva A. Fistula following total laryngectomy. Retrospective ynx and cervical dehiscence the pectoralis flap is sutured study and bibliographical review. Acta Otorrinolaringol Esp. on infected tissue. Cervical bleeding means, furthermore, 2009;60:186---9. that we are working on hemodynamically unstable patients. 2. 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