Onlay Prophylactic Flaps Help Reduce Fistula Incidence after STL

What is the impact of organ preservation protocols on pharyngo-cutaneous fistula (PCF) incidence following total laryngectomy (TL), and what role do “onlay” prophylactic tissue flaps play in reducing PCF in salvage total laryngectomy (STL)?

Background: Nonsurgical approaches to laryngeal carcinoma management fail in some patients, necessitating STL. The most common major wound complication is PCF. Several studies have investigated prophylactic vascularized flaps to aid pharyngeal closure following STL, with variable results. Radiotherapy has been associated with higher PCF incidence compared to primary total laryngectomy (PTL). The emergence of chemoradiotherapy protocols for locally advanced laryngeal cancer has heightened concern regarding post-operative wound complications.

Study design: Study review of 33 English language literature from Jan. 1, 2000, to Sept. 1, 2013.

Setting: PUBMED and EMBASE databases.

Synopsis: Included studies reported data from at least one of three categories: PTL, STL with primary pharyngeal closure, and/or STL with primary pharyngeal closure with a reinforcing tissue flap. In total, 326 of 2177 patients undergoing PTL developed a fistula. After STL with primary pharyngeal closure (following either radiotherapy alone, induction chemotherapy with radiotherapy, or concurrent chemoradiotherapy), the estimated overall fistula incidence was 27.6%, double that in the PTL group. In total, 443 of 1,721 patients undergoing STL developed a fistula. STL following chemoradiotherapy was associated with a significantly higher risk of fistula compared to PTL, but not compared with STL following radiotherapy alone. Overall fistula incidence in patients receiving a vascularized tissue flap was 10.3%; 24 of 188 STL patients receiving a prophylactic flap developed a fistula. A prophylactic flap for STL patients significantly reduced fistula incidence, however. The study has some limitations: There is a risk of selection bias due to small study size and the often retrospective nature of the studies. Also, data on induction and concurrent chemotherapy protocols are inseparable. There may be publication bias because the addition of smaller studies to some cumulative meta-analyses resulted in a progressive drift toward higher PCF incidence.

Bottom line: Prophylactic tissue flaps placed over the pharyngeal suture at the time of STL following failed organ preservation protocols reduce the risk of PCF, particularly in STL patients.

Citation: Sayles M, Grant DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope. 2014;124:1150-1163.