Dr. Erami M.D.ENT Resident

Department Of ENTShahid Sadoghi Hospital

Yazd Iran

Pharyngocutaneous fistula after total laryngectomy

high risk for fistula development:

• Patients with poor preoperative nutritional status • advanced tumor stage• Diabetes• preoperative RT (Early studies did not show a significantly increased)• RT (particularly + chemoradiation ) + acquired hypothyroidism

may occur :

• 1 to 6 weeks postoperatively, depending the presence or absence of previous irradiation

confirmed by :

• methylene blue swallow test• Gastrografin swallow radiograph

always be ruled out :

• Persistent tumor• Recurrent tumor

Initial management :

• regular antiseptic gauze fistulatract packing• Dressings• antibiotic therapy• giving the patient nothing by mouth• A pressure dressing is sometimes useful• Control of esophageal reflux (preventing and managing)• Sterilize :

10 mL of 0.25% acetic acid by mouth or an antibiotic or other antiseptic (3 to 4 times daily)

Spontaneous closure :

• up to 6 weeks after onset (most patients more rapid )

operative closure :

• pedicled muscle flap(before complete epithelialization an excellent option)

pectoralistrapeziuslatissimus dorsi

• 158 patients were included.• previous surgical interventions

the more extensive, the higher the risk• previous RT (the data in the literature are inconsistent)

not higher incidence of PCF in irradiated patientsHowever, if previously irradiated patients develop PCF, these are often• Extensive• Persistent• usually require surgical intervention

• Previous RCTwe found a strong association

• surgical prophylactic regimenAmoxicillin/Clavulanic acid over Clindamycinno significant advantagethe efficiency of one day and prolonged antibiotic prophylaxis is similar

• interesting observation in our series is the timing of surgical wound Infection

In the PCF group , 5th postoperative dayIn the control group on the 7th postoperative day

(neopharyngeal suture line might be mature enough)

controversy about which factors are most significant for PCF

Sixteen studies involving 2598 patients were included

• smoking and alcohol (history of consumption)did not show any significant association

• not influenced by age and gender (>60 years had higher rate, but no statistical correlation was found)

• comorbid illness was not a risk factor (In this study)• low Hb value (<12.5 g/L )• transfusion (any correlation )

preoperative build-up and blood loss might be important to help reduce fistula formation in clinical practice

• Malnutritionnot well documentedvalues of malnutrition are various in many studies

• tumor locationsupraglottic tumor > glottic tumor more extensive resection(pharyngeal wall), more tension on the pharyngeal suture

• previous RT (significantly)• interval from the end of RT to surgery

(short interval > longer interval)• high-dose radiation was not the risk factor

(Only one study )• preoperative tracheostomy

(advanced tumors?! )

• neck dissection( did not find any statistical relation )

• Positive surgical margins (significant correlation )

significantly associated

• Diabetes• pre-operative radiotherapy• pre-operative chemotherapy• pre-operative tracheostomy

• only pre-operative radiotherapy was highly associatedwith the formation of PCF

77 patients with total laryngectomy (2000 to 2008)

most significant risk factors :

• hemoglobin pre- and post-surgery < 12.5 g/dL• pre- and postsurgery albumin < 3.7 g/L• presence of comorbidities• Performance of previous RT or CRT• long duration of surgery• blood transfusion during operation

• no appropriate classification for stratifying the risk factors

• Type of suture materialMost studies did not consider as a significant factor

• tracheoesophageal puncture for voice prosthesis in the initial procedure

not a significant factor• NGT and oral feeding

absence or its removal without replacement with premature early oral feeding (<14 days after operation)

does not cause an increase in the rate of fistula

Treatment

conservative management

• Parenteral nutrition• nasogastral feeding• reduce drooling and secretion parasympatholytics

(glycopyrronium bromide and scopolamine)• botulinum toxin A : intraglandular injection can be useful

Besides a pharmacological therapy• antimicrobiotic wound dressings and a systemic application of

antibiostics

• Rates of 70 % for PCF closure by conservative approaches

reconstructive approach

• local flaps• regional flaps• free flaps

• in case of previous radiationregional and free flaps are advantageous to local flaps

reconstructive approach

• local flaps• regional flaps• free flaps

• in case of previous radiationregional and free flaps are advantageous to local flaps

• The average period of conservative treatment was 1 month before admittance to our department

• Closure of the POPCF was proved by a barium swallow test in seven patients

• high rate of successful closure(87.5 %)

• POPCFs will close with conservative management (62–86 %)• Includes

• antibiotic treatment• no oral feeding• wound cleansing and debridement

• in our study :All the patients had failed an attempt of an average of 2 weeks of conservative treatment.

• very high rate of success (seven out of eight,87.5 %) with average of 1 month of HBOT

Materials and methods :

• Debridement daily (removal of non-healing granulation tissue)

• HBOT was performed in a multi-place chamber• Each session was

90 min longincluded three phases:

compressionoxygen breathingdecompression

• Compression and decompressionperformed with room air at a rate of 0.1 kPa atmospheres absolute pressure (ATA) per minute

• oxygen breathing phase:breathed 100 % oxygen under 2 ATA (203 kPa) for 90 minthrough a face mask that fit well

• HBOT sessions daily from Sunday to Friday with a break of 1 day (a total of 30 sessions)

Methods

• control group (23 patients without IHMFF cover after laryngectomy)PCF developed in 6 of 23 patientsAll the 6 patients with fistula required additional closure surgery

• Case group (11 patients who were at a high risk of developing PCF)PCF developed in 2 of the 11 patientsclosed conservatively and did not require additional surgery

Surgical procedure

• The skin of flap was spared and only the muscle portion was used• Included

sternohyoidsternothyroidomohyoid

feeding vessels of this flap :superior thyroid artery and vein

• The flaps were elevated before total (pharyngo) laryngectomy

• Mostly, the contralateral side of the malignant tumour was selected for flap harvest

• If tumour did not invade the thyroid cartilage, bilateral flaps were used for coverage

myocutaneous flap

• U-shaped incision• superior to the fistula• using this as a turnover flap in 10–14 days• re-sutured in its normal anatomic position

using three 5–0 nylon sutures

• Two weeks later, the patient returned for the second and final part of the procedure.

Two weeks later

• sutures were removed • released and undermined toward the fistula• The circumference of the turnover flap was denuded of epithelium

approximately 3 mm from the edge of the flap itself• circumferential incision was made surrounding the fistula• epithelium was dissected out toward the edge of the fistula• The skin surrounding the fistula was also denuded 360 degrees• The fistula itself was then closed with interrupted 5-0 Maxon sutures

for a watertight seal

• the remnants of the PMF were then elevated• The PMF muscle flap was then advanced over the turnover flap• The surrounding skin was undermined and the remaining defect was

closed to make a new laryngectomy stoma

The outline delay flap was released and underminedtoward the fistula. Itwas then flipped inferiorly to cover the PCF after the surrounding skin had been denuded.

The originally placed PMF was then lifted and layered over the turnover flap toreinforce it. The neckincision was then extended laterally andundermined. The defect was then closed, sutured and a Penrose drain was placed