BACKGROUND: Salvage total laryngectomy following chemoradiation is associated with increased wound healing complications, specifically pharyngocutaneous fistula. Thus, many surgeons choose to reconstruct salvage laryngectomy defects with a free tissue transfer in order to incorporate non-radiated, healthy tissue. The decision to tube the flap versus suture to a strip of intact posterior pharyngeal wall is dependent on the surgical defect. We question whether the remaining pharyngeal mucosa displays microscopic radiation damage, resulting in increased risk of fistula formation.
METHODS: This is a retrospective review of patients who underwent either primary or salvage total laryngectomy. Laryngectomy margins were re-reviewed by a single pathologist blinded to patient outcome.
RESULTS: Sixty patients who underwent total laryngectomy had their margins re-reviewed; 10 underwent primary laryngectomy and 50 had salvage laryngectomy. Pharyngocutaneous fistula was more common in those who underwent salvage laryngectomy (44%) compared to no prior radiation (20%). Laryngectomy margins were assessed for presence of fibrosis, dilated lymphatics, thinned epithelium, atypical stromal cells, abnormal mucous cells, presence of telangiectatic capillaries, and hyalinized arterioles. Odds-ratios were calculated to examine the relationship between each histologic characteristic and fistula. Patients who have mucosal margins displaying telangiectatic capillaries may be at increased risk of post-operative fistula (OR 3.72, 95% CI 1.06 – 13.049). The presence of hyalinized arterioles was also associated with fistula (OR 9.21, 95% CI 1.002 – 84.668).
CONCLUSIONS: Telangiectatic capillaries or hyalinized arterioles may indicate severe post-radiation changes and decreased healing potential. The ability to assess this intraoperatively may assist the surgeon in deciding whether to resect the remaining posterior pharyngeal wall strip, tube the free flap, and thus close the wound with healthy, non-irradiated, and well-vascularized tissue.