What Is the Role of Flap Reconstruction in Salvage Total Laryngectomy?

Trio Best Practice
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Given the results of the Department of Veterans Affairs Laryngeal Cancer Study Group investigations in the 1990s and the subsequent publication of the Radiation Therapy Oncology Group 91-11 (RTOG 91-11) study in 2003, treatment for advanced staged laryngeal carcinoma has focused on organ preservation strategies involving chemotherapy and radiation. Analysis of these studies reveals that pharyngocutaneous fistula occurred in at least 30% of patients undergoing salvage laryngectomy, and other series have reported even higher fistula rates after organ preservation treatment. Development of a postoperative fistula is a multifactorial process, and the surgeon’s assessment of the patient’s clinical situation could help select those patients who are at a higher risk for fistula development. Fistula development results in increased hospitalization, time before initiation of an oral diet, and use of healthcare resources.

Investigators have reported decreased fistula rates following salvage laryngectomy when using flap reconstruction. In addition, patients with primary flap reconstructions who did develop fistulas healed at a faster rate than those without primary flap reconstruction. Reconstructions in these salvage laryngectomy surgeries have involved free flaps or pedicled myocutaneous flaps. This review will seek to answer the question of best practice with regard to flap reconstruction of laryngectomy defects for salvage laryngectomy following failed organ preservation treatment.

Best Practice

In the situation of salvage total laryngectomy, when it is deemed that there is adequate tissue to afford a primary pharyngeal closure, the question is: Should a flap reconstruction be used to reinforce the pharyngeal closure in order to avoid the development of a pharyngocutaneous fistula? Given recent reports, it would appear that there is evidence supporting the use of onlay flap reconstruction in high-risk patients to decrease the rate of fistula development. High-risk patients include those who have previously received chemoradiation therapy. Further investigation is necessary to elucidate a more refined definition of high-risk patients; not all salvage total laryngectomy patients who have had previous chemoradiation therapy develop fistulas. Other variables such as nutritional status, recent smoking history, diabetes, thyroid function, or quality of the remaining tissues at the time of surgery likely play a role. The choice of flap used in onlay reconstruction depends on patient factors, donor site morbidity, and the availability of technical expertise for microvascular anastomosis. However, the onlay pectoralis myofascial flap is relatively more advantageous given the time and ease of execution to include donor site repair, less invasive nature, and cost. (Laryngoscope. 2014;124:2441-2442).