JAMA Otol Logo Orlando 2013 AHNS Meeting Location
American Head & Neck Society
Annual Meeting, April 10-11, 2013
JW Marriott Grande Lakes
Orlando, Florida

During the
Combined Otolaryngology Spring Meeting
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Presentation: S002
Topic: Clinical - Plastic & Reconstructive Surgery
Type: Oral Presentation
Date: Wednesday, April 10, 2013
Session: 10:30 AM - 11:30 AM Discussions
Authors: Urjeet A Patel, MD, Brian Moore, MD, Mark Wax, MD, Eben Rosenthal, MD, Larissa Sweeny, MD, Oleg Militsakh, MD, Joseph A Califano, MD, Alice C Lin, MD, Christine P Hasney, MD, R B Butcher, MD, Jamie Flohr, MD, Demetri Arnaoutakis, MD, Matthew Huddle, MD, Jeremy D Richmon, MD
Institution(s): Departments of Otolaryngology–Head & Neck Surgery, Northwestern University, Chicago, Illinois (Drs Patel and Lin), Ochsner Health System, New Orleans, Louisiana (Drs Moore, Hasney, and Butcher), Oregon Health Science University, Portland (Dr Wax), University of Alabama, Birmingham (Drs Rosenthal and Sweeny), University of Nebraska Medical Center, Omaha (Drs Militsakh and Flohr), Nebraska Methodist Hospital, Omaha (Dr Militsakh), Greater Baltimore Medical Center, Baltimore, Maryland (Drs Califano and Arnaoutakis), and Johns Hopkins Hospital, Baltimore (Drs Califano, Huddle, and Richmon)

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.

JAMA Otolaryngol Head Neck Surg.
Published online April 10, 2013.

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