Pharyngocutaneous fistula after salvage laryngectomy

Conclusion: Preoperative chemoradiotherapy (CRT) was associated with a significantly higher rate of pharyngocutaneous fistula (PCF). Objective: PCF is the most frequent complication following total laryngectomy. Although organ-preserving radiotherapy (RT) or CRT offer good locoregional control, many patients still require salvage laryngectomy. The aim of this study was to evaluate the factors that predispose patients to PCF, with a focus on preoperative RT, induction chemotherapy (ICT), and CRT. Methods: This was a retrospective case series; 151 patients who underwent TL were reviewed. Preoperative RT, ICT, CRT, and some surgical parameters were analyzed as potential risk factors. Results: The overall PCF rate was 13%. CRT was the only preoperative treatment that had a significant effect on PCF (35.3%, p = 0.004, odds ratio (OR) = 10.75). Surgery extended to the pharynx (p = 0.005, OR = 8.34) and vacuum drain duration (p = 0.012, OR = 5.16) were observed to be associated with PCF.     

Pharyngocutaneous fistula following total laryngectomy

Pharyngocutaneous fistula (PCF) is the most common complication after total laryngectomy.ObjectivesTo establish the incidence of this complication and to analyze the predisposing factors.MethodThis is a cross-sectional study of a historical cohort including 94 patients who underwent total laryngectomy. The following aspects were correlated to the occurrence of PCF: gender, age, tumor site, TNM staging, type of neck dissection, previous radiation therapy, previous tracheotomy, and use of stapler for pharyngeal closure. The following were considered in PCF cases: the day into postoperative care when the fistula was diagnosed, duration of occurrence, and proposed treatment.ResultsTwenty (21.3%) patients had PCF. The incidence of PCF was statistically higher in T4 tumors when compared to T2 and T3 neoplasms (p = 0.03). The other analyzed correlations were not statistically significant. However, 40.9% of the patients submitted to tracheostomy previously had fistulae, against 21.1% of the patients not submitted to this procedure.ConclusionAdvanced primary tumor staging is correlated with higher incidences of PCF.     

Pharyngocutaneous fistula following total laryngectomy and post-operative vomiting

The significance of post-operative vomiting as a risk factor in the development of a pharyngocutaneous fistula was examined. The case records of 50 consecutive patients undergoing laryngectomies (39 men, 11 women, average age 64 years) were examined. 17 also underwent a simulataneous radical neck dissection. A fistula developed in eight patients (16%) and the median time to its diagnosis was 11 days (range 3–15 days). Several potential risk factors were examined including age, gender, previous radiotherapy. TNM stage, differentiation of tumour, simultaneous radical neck dissection and also the occurrence of vomiting post-operatively. In this series of patients only vomiting in the early post-operative period appeared to be related to the development of a fistula (regression summary: R2 = 0.6, t-value 5.6. P < 0.0001). An episode of vomiting was recorded in eight patients and of these six (75%) subsequently developed a fistula. The median time of post-operative vomiting was 7.5 days (range 1–10 days) and the diagnosis of a fistula occurred at a mean of 1.2 ± 0.4 days after the episode of vomiting. In a study of this nature it is not possible to conclude that a causal relationship exists between vomiting. In a study of this nature it is not possible to conclude that a causal relationship exists between vomiting and fistula development. However, if this is the case a pottential means of decreasing the incidence of fistulae following laryngectomy may be available.     

Pharyngocutaneous fistula following total laryngectomy: multivariate analysis of risk factors

The objective of this study is to establish the role of risk factors in the etiology of pharyngocutaneous fistula formation after total laryngectomy. A retrospective study was performed for patient, disease and treatment-related factors, and also factors related to pathology specimen. Logistic regression analysis revealed that fistula development ratio was 4.955 times higher in patients with fistula than in the control group when the preoperative hemoglobin value was below 12.2 g/dL, 3.653 times higher when the postoperative hemoglobin value was below 12.2 g/dL, 3.471 times higher in the presence of an accompanying systemic disease, 3.23 times higher when the postoperative albumin level was below 3.5 g/dL, 3.1 times higher when ipsilateral lymph node was positive, 2.05 times higher when erythrocyte suspension is used as transfusion material, and 1.048 times higher when contralateral lymph node was positive. Proper concomitant systemic disease control, maintenance of hematologic values in the pre- and postoperative periods, provision of adequate nutrition, preference of erythrocyte suspensions for transfusion are the key points for the prevention of pharyngocutaneous fistula development. Preoperative detection of positive cervical lymph nodes should alert the physician about the potential development of fistula.     

晚期喉咽癌和喉癌全喉切除术后咽皮肤瘘

目的:探讨晚期喉咽癌和喉癌患者施行全喉切除术后咽皮肤瘘的位置、易患因素、处置及其结果.方法:回顾性分析因喉咽癌或喉癌施行全喉切除术的198例患者的资料,分析多因素对咽皮肤瘘形成的影响.结果:发生咽皮肤瘘患者33例(16.7%),内瘘口位于黏膜吻合口上段23例(69.7%),下段7例(21.2%),中段3例(9.1%);喉咽癌与喉癌的咽皮肤瘘发生率分别为24.7%和11.6%,其差异具有统计学意义(P<0.05);术后持续发热>5 d与≤5 d者咽皮肤瘘的发生率差异具有统计学意义(P<0.01);28例通过保守治疗痊愈,5例手术修复.结论:全喉切除术后咽皮肤瘘内瘘口多发生于舌根处和气管造瘘后上方,肿瘤部位和术后发热是咽皮肤瘘形成的重要易患因素.     

Pharyngocutaneous fistula following total laryngectomy: a single institution’s 10-year experience

The etiology of postoperative pharyngocutaneous fistula (PCF) formation following major head and neck surgery is multifactorial and the incidence varies greatly. We reviewed retrospectively the records of 108 consecutive patients who underwent a total laryngectomy during the period from December 1992 to December 2002 at the Helsinki University Central Hospital, Helsinki, Finland. PCF occurred postoperatively in 19 (18%) patients. Two additional patients (2%) developed a PCF later than 30 days after laryngectomy. Nineteen percent of these patients with fistula formation had received previous radiation therapy and laryngectomy was performed for local recurrence. Eighteen (86%) of the all fistulae closed spontaneously and surgical closure of the fistula was performed in three (14%) cases. We conclude that the PCFs in our patient population occurred both in radiated and nonirradiated patients. Although most fistulae close spontaneously without surgical intervention this complication leads to prolonged hospitalization and increased patient morbidity.This paper has been presented at the American Laryngological Association Annual Meeting, Phoenix, Arizona, April 30–May 1, 2004.     

Pharyngocutaneous fistula and total laryngectomy: possible predisposing factors, with emphasis on pharyngeal myotomy

Ninety-two total laryngectomy cases were investigated with reference to post-laryngectomy fistula formation. Fistula was observed in eight cases (8.69 per cent). There were no statistically significant differences between the fistula group and the non-fistula group with regard to pre-operative tracheotomy, tumour differentiation, positive surgical margins, concurrent neck dissection, previous radiotherapy, T stage of the tumour, presence of extended hypopharyngeal mucosal excision, and placement of nasogastric tube. The only statistically significant positive association was found with primary pharyngeal myotomy. Myotomy was performed in six of the fistula patients and in two cases a technical error was observed. In these cases myotomy was performed adjacent to the edge of hypopharyngeal mucosa resulting in a weakened area of pharyngeal closure, possibly contributing to the fistula. This should be kept in mind and avoided at all costs during the performance of myotomy. Since it was not possible to find out any specific causal relationship with myotomy in four other cases, further studies are needed to establish the association of myotomy with pharyngocutaneous fistula.     

Pharyngocutaneous fistulae following total laryngectomy

Postoperative pharyngocutaneous fistula formation is a troublesome complication in head and neck surgery and occurred in 8 out of 53 patients following a total laryngectomy (15%). The incidence falls within the lower range of that reported in the literature (6–66%). Different factors which may influence the formation of fistulae were analysed. Factors which seem to increase fistula formation are previous full dose radiotherapy (Co⁶⁰), residual carcinoma and surgical technique.     

Pharyngocutaneous fistulae following total laryngectomy.

Postoperative pharyngocutaneous fistula formation is a troublesome complication in head and neck surgery and occurred in 8 out of 53 patients following a total laryngectomy (15%). The incidence falls within the lower range of that reported in the literature (6-66%). Different factors which may influence the formation of fistulae were analysed. Factors which seem to increase fistula formation are previous full dose radiotherapy (Co60), residual carcinoma and surgical technique.     

Effectiveness of Recombinant Human Growth Hormone for Pharyngocutaneous Fistula Closure

Objectives

In laryngeal cancer, which comprises 25% of head and neck cancer, chemotherapy has come into prominence with the increase in organ-protective treatments. With such treatment, salvage surgery has increased following recurrence; the incidence of pharyngocutaneous fistula has also increased in both respiratory and digestive system surgery. We investigated the effects of recombinant human growth hormone on pharyngocutaneous fistula closure in Sprague-Dawley rats, based on an increase in amino acid uptake and protein synthesis for wound healing, an increase in mitogenesis, and enhancement of collagen formation by recombinant human growth hormone.

Methods

This study was experimental animal study. Forty Sprague-Dawley rats were separated into two groups, and pharyngoesophagotomy was performed. The pharyngoesophagotomy was sutured with vicryl in both groups. Rats in group 1 (control group) received no treatment, while those in group 2 were administered a subcutaneous injection of recombinant human growth hormone daily. On day 14, the pharynx, larynx, and upper oesophagus were excised and examined microscopically.

Results

Pharyngocutaneous fistula exhibited better closure macroscopically in the recombinant human growth hormone group. There was a significant difference in collagen formation and epithelisation in the recombinant human growth hormone group compared to the control group.

Conclusion

This study is believed to be the first in which the effect of recombinant human growth hormone on pharyngocutaneous fistula closure was evaluated, and the findings suggest the potential of use of growth hormone for treatment of pharyngocutaneous fistula.     

Pharyngocutaneous fistulae following total laryngectomy comparison between manual and mechanical sutures

The extension of the surgery and closure type of the pharynx can be the determinants in the pharyngocutaneous fistula development. The objective of the study is to evaluate the incidence of pharingocutaneous salivary fistulae after total laryngectomies comparing manual and mechanical sutures. The study is designed as non-randomized, prospective clinical study. Sixty patients with squamous cell carcinoma were submitted to total laryngectomies. In 30 cases, the linear stapler (75 mm) closure (surgical technique described in details) and in other 30 cases manual suture was used. The cases of mechanical suture were prospective and consecutive and the cases of manual suture were a review series of patients who underwent a manual suture of pharynx, in the same period of time. The statistical analysis between the two groups concluded that both were comparable. Fistulae incidence was 6.7% (2/30) in the group with the mechanical suture and 36.7% (11/30) in the group with manual suture closure, presenting a significant difference (p = 0.0047). The total laryngectomy with mechanical closure is an easy and fast learning technique, allowing watertight closure of the pharynx with a low risk of contamination of the surgical field. It is an assured method, even in previously irradiated patients, since we respect the limits of its indication regarding the extension of primary tumor that must be confirmed by previous suspension laryngectomy performed in the operating room.