Vascularized Flaps Useful in Reducing PCF

Does using vascularized tissue from outside the radiation field reduce the risk of pharyngocutaneous fistula (PCF) following salvage total laryngectomies (STL)?

Background: Chemoradiation therapy (CRT) is effective in managing locally advanced tumors of the larynx. With organ preservation rates between 60% and 80% at five years for patients completing the therapy, a substantial proportion of patients need STL. Generally, STLs performed after radiation failure are more prone to complications than those performed up front, with PCF the most significant complication. Transferring healthy vascularized tissue from outside the radiation field may enhance wound healing and reduce wound complication incidence.

Study design: Retrospective study analysis and data pooling.

Setting: Seven Medline English-language studies from 2004 to 2013.

Synopsis: There are three usual choices of donor tissue for flaps: pectoralis major myofascial flap (PMMF), pectoralis major myocutaneous flap (PMMC), or free flaps from various sites. Generally, surgeons have adopted two distinct techniques when using vascularized tissue following laryngectomy: 1) using vascularized tissue in a patch graft to augment the pharyngeal circumference and 2) using vascularized tissue to reinforce the pharyngeal repair. For the first technique, studies found a lower PCF rate and fewer leaks in groups that had a flap compared with primary closure groups. For the second technique, studies found a lower leak rate and incidence of major wound complications for patients who received a flap compared to those who received no flap, as well as a higher need for a second surgical procedure for fistula closure in patients with PCF who did not receive a flap. Any limitations stem from the nature of the retrospective pooling of case series. Other outcomes, such as donor site morbidity, extra costs involved in the flap reconstruction, and a description of the fistula as major or minor, were not analyzed.

Bottom line: There is currently retrospective but clear evidence to support the routine use of vascularized flaps to augment or bolster the pharyngeal closure following STL as a strategy to reduce PCF.

Citation: Paleri V, Drinnan M, van den Brekel MW, et al. Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review. Laryngoscope. 2014;124:1848-1853.