Skip to main content
SpringerLink
Log in

Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis

  • Head and Neck
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Purpose

To compare the efficacy of different reconstructive techniques in preventing pharyngocutaneous fistula (PCF) after salvage total laryngectomy (STL).

Methods

An arm-based network analysis was conducted using a Bayesian hierarchical model according to the PRISMA-NMA guidelines.

Results

A total of 1694 patients with a median age of 64 years (n = 1569, 95% CI: 62–66 years) were included. If compared to primary pharyngeal closure alone, only a pedicled flap onlay (PFO) showed a statistically significant reduction in PCF rate (OR: 0.35, CI: 0.20–0.61). PFO seemed to perform better than other treatments according to the rank probabilities test (39.9% chance of ranking first).

Conclusions

A pedicled flap placed with an overlay technique might be preferred over a patch reconstruction to prevent PCF after STL.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Nocini R, Molteni G, Mattiuzzi C, Lippi G (2020) Updates on larynx cancer epidemiology. Chin J Cancer Res 32(1):18–25

    Article  CAS  Google Scholar 

  2. Steuer CE, El-Deiry M, Parks JR, Higgins KA, Saba NF (2017) An update on larynx cancer. CA Cancer J Clin 67(1):31–50

    Article  Google Scholar 

  3. National Comprehensive Cancer Network (2021) Head and neck cancers (version 3.2021). https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

  4. Department of Veterans Affairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG et al (1991) Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 324(24):1685–1690

  5. Forastiere AA, Ismaila N, Lewin JS et al (2018) Use of larynx-preservation strategies in the treatment of laryngeal cancer: American Society of Clinical Oncology Clinical Practice guideline update. J Clin Oncol 36(11):1143–1169

    Article  Google Scholar 

  6. Verma SP, Mahboubi H (2014) The changing landscape of total laryngectomy surgery. Otolaryngol Head Neck Surg 150(3):413–418

    Article  Google Scholar 

  7. Cheraghlou S, Kuo P, Mehra S, Yarbrough WG, Judson BL (2018) Salvage surgery after radiation failure in T1/T2 larynx cancer: outcomes following total versus conservation surgery. Otolaryngol Head Neck Surg 158(3):497–504

    Article  Google Scholar 

  8. Dedivitis RA, Aires FT, Cernea CR, Brandão LG (2015) Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors. Head Neck 37(11):1691–1697

    Article  Google Scholar 

  9. Trotti A (2000) Toxicity in head and neck cancer: a review of trends and issues. Int J Radiat Oncol Biol Phys 47(1):1–12

    Article  CAS  Google Scholar 

  10. Hasan Z, Dwivedi RC, Gunaratne DA, Virk SA, Palme CE, Riffat F (2017) Systematic review and meta-analysis of the complications of salvage total laryngectomy. Eur J Surg Oncol 43(1):42–51

    Article  CAS  Google Scholar 

  11. Paleri V, Drinnan M, van den Brekel MWM et al (2014) Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review. Laryngoscope 124(8):1848–1853

    Article  Google Scholar 

  12. Sayles M, Grant DG (2014) Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope 124(5):1150–1163

    Article  Google Scholar 

  13. Guimarães AV, Aires FT, Dedivitis RA et al (2016) Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: a systematic review. Head Neck 38(Suppl 1):E2317-2321

    Article  Google Scholar 

  14. Cabrera CI, Joseph Jones A, Philleo Parker N, Emily Lynn Blevins A, Weidenbecher MS (2021) Pectoralis major onlay vs interpositional reconstruction fistulation after salvage total laryngectomy: systematic review and meta-analysis. Otolaryngol Head Neck Surg 164(5):972–983

  15. Hutton B, Salanti G, Caldwell DM et al (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162(11):777–784

    Article  Google Scholar 

  16. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S (2014) PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 14:579

    Article  Google Scholar 

  17. National Institute for Health and Care Excellence (2012) Methods for the development of NICE Public Health Guidance. National Institute for Health and Care Excellence (NICE), London

    Google Scholar 

  18. McGrath S, Zhao X, Qin ZZ, Steele R, Benedetti A (2019) One-sample aggregate data meta-analysis of medians. Stat Med 38(6):969–984

    Article  Google Scholar 

  19. Veroniki AA, Jackson D, Viechtbauer W et al (2016) Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth Methods 7(1):55–79

    Article  Google Scholar 

  20. Cowles MK, Carlin BP (1996) Markov chain Monte Carlo convergence diagnostics: a comparative review. J Am Stat Assoc 91(434):883–904

    Article  Google Scholar 

  21. Biondi-Zoccai G (2014) Network meta-analysis: evidence synthesis with mixed treatment comparison. Nova Science Publishers, Hauppauge, NY

    Google Scholar 

  22. Cochran WG (1954) The combination of estimates from different experiments. Biometrics 10(1):101–129

    Article  Google Scholar 

  23. Jackson D, White IR, Riley RD (2012) Quantifying the impact of between-study heterogeneity in multivariate meta-analyses. Stat Med 31(29):3805–3820

    Article  Google Scholar 

  24. Baujat B, Mahé C, Pignon J-P, Hill C (2002) A graphical method for exploring heterogeneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med 21(18):2641–2652

    Article  Google Scholar 

  25. Sterne JAC, Sutton AJ, Ioannidis JPA et al (2011) Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 343:d4002

    Article  Google Scholar 

  26. Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L (2006) Comparison of two methods to detect publication bias in meta-analysis. JAMA 295(6):676–680

    Article  CAS  Google Scholar 

  27. Almadori G, De Corso E, Visconti G et al (2019) Impact of internal mammary artery perforator propeller flap in neck resurfacing and fistula closure after salvage larynx cancer surgery: our experience. Head Neck 41(11):3788–3797

    Article  Google Scholar 

  28. Anschütz L, Nisa L, Elicin O, Bojaxhiu B, Caversaccio M, Giger R (2016) Pectoralis major myofascial interposition flap prevents postoperative pharyngocutaneous fistula in salvage total laryngectomy. Eur Arch Otorhinolaryngol 273(11):3943–3949

    Article  Google Scholar 

  29. Chiesa Estomba CM, González García JA, Sistiaga Suarez JA, Thomas Arrizabalaga I, Larruscain Sarasola E, Altuna MX (2018) Efficacy of the myofascial pectoralis major flap in the reduction of salivary fistulas after salvage total laryngectomy. Acta Otorrinolaringol Esp (Engl Ed) 69(2):99–104

    Article  Google Scholar 

  30. Cömert E, Tunçel Ü, Torun MT et al (2014) Pectoralis major myofascial flap in salvage laryngectomy. J Laryngol Otol 128(8):714–719

    Article  Google Scholar 

  31. Crosetti E, Arrigoni G, Sprio AE, Succo G (2021) “Fistula Zero” project after total laryngectomy: the Candiolo Cancer Institute experience. Front Oncol 11:690703

    Article  Google Scholar 

  32. Fung K, Teknos TN, Vandenberg CD et al (2007) Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 29(5):425–430

    Article  Google Scholar 

  33. Gendreau-Lefèvre A-K, Audet N, Maltais S, Thuot F (2015) Prophylactic pectoralis major muscle flap in prevention of pharyngocutaneous fistula in total laryngectomy after radiotherapy. Head Neck 37(9):1233–1238

    Article  Google Scholar 

  34. Gil Z, Gupta A, Kummer B et al (2009) The role of pectoralis major muscle flap in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 135(10):1019–1023

    Article  Google Scholar 

  35. Gilbert MR, Sturm JJ, Gooding WE, Johnson JT, Kim S (2014) Pectoralis major myofascial onlay and myocutaneous flaps and pharyngocutaneous fistula in salvage laryngectomy. Laryngoscope 124(12):2680–2686

    Article  Google Scholar 

  36. Hayden RE, Chang BA, Mullin DP et al (2021) Bipedicled submental musculofascial “hammock” flap for salvage laryngectomy closure reinforcement. Head Neck 43(1):198–202

    Article  Google Scholar 

  37. Higgins KM, Ashford B, Erovic BM, Yoo J, Enepekides DJ (2012) Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy. Laryngoscope 122(3):523–527

    Article  Google Scholar 

  38. Iglesias-Moreno M-C, Sarrió-Solera P, López-Salcedo MA et al (2019) Use of pectoralis major myofascial flap on the prevention of pharyngocutaneous fístula in salvage laryngectomy after chemoradiotherapy. Acta Otolaryngol 139(10):926–929

    Article  Google Scholar 

  39. Khan NA, Medina JE, Sanclement JA, Krempl GA (2014) Fistula rates after salvage laryngectomy: comparing pectoralis myofascial and myocutaneous flaps. Laryngoscope 124(7):1615–1617

    Article  Google Scholar 

  40. Mizrachi A, Zloczower E, Hilly O et al (2016) The role of pectoralis major flap in reducing the incidence of pharyngocutaneous fistula following total laryngectomy: a single-centre experience with 102 patients. Clin Otolaryngol 41(6):809–812

    Article  CAS  Google Scholar 

  41. Naghibzadeh M, Zojaji R, Mokhtari Amir Majdi N, Mazloum Farsi Baf M (2014) Using a sternocleidomastoid muscle flap to prevent postoperative pharyngocutaneous fistula after total laryngectomy: a study of 88 cases. Ear Nose Throat J 93(8):362–365

  42. Nguyen S, Thuot F (2017) Functional outcomes of fasciocutaneous free flap and pectoralis major flap for salvage total laryngectomy. Head Neck 39(9):1797–1805

    Article  Google Scholar 

  43. Okamoto I, Tsukahara K, Shimizu A, Sato H (2019) Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps. Acta Otolaryngol 139(2):167–171

    Article  Google Scholar 

  44. Oosthuizen JC, Leonard DS, Kinsella JB (2012) The role of pectoralis major myofascial flap in salvage laryngectomy: a single surgeon experience. Acta Otolaryngol 132(9):1002–1005

    Article  CAS  Google Scholar 

  45. Patel UA, Moore BA, Wax M et al (2013) Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg 139(11):1156–1162

    Article  Google Scholar 

  46. Patel UA, Keni SP (2009) Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 141(2):190–195

    Article  Google Scholar 

  47. Pellini R, Zocchi J, Pichi B et al (2020) Prevention of fistulas after salvage laryngectomy using temporoparietal fascia free flap. Acta Otorhinolaryngol Ital 40(3):181–189

    Article  Google Scholar 

  48. Piazza C, Paderno A, Del Bon F et al (2021) Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy. Eur Arch Otorhinolaryngol 278(1):219–226

    Article  Google Scholar 

  49. Powell J, Ullal UR, Ahmed O, Ragbir M, Paleri V (2014) Tissue transfer to post-chemoradiation salvage laryngectomy defects to prevent pharyngocutaneous fistula: single-centre experience. J Laryngol Otol 128:365–367

    Article  Google Scholar 

  50. Sharma S, Chaukar DA, Laskar SG et al (2016) Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy. J Laryngol Otol 130(9):860–864

    Article  CAS  Google Scholar 

  51. Sittitrai P, Srivanitchapoom C, Reunmakkaew D (2018) Prevention of pharyngocutaneous fistula in salvage total laryngectomy: role of the pectoralis major flap and peri-operative management. J Laryngol Otol 132(3):246–251

    Article  CAS  Google Scholar 

  52. Sousa AA, de Castro SMO, Porcaro-Salles JM et al (2012) The usefulness of a pectoralis major myocutaneous flap in preventing salivary fistulae after salvage total laryngectomy. Braz J Otorhinolaryngol 78(4):103–107

    Article  Google Scholar 

  53. Teknos TN, Myers LL, Bradford CR, Chepeha DB (2001) Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications. Laryngoscope 111(7):1192–1196

    Article  CAS  Google Scholar 

  54. Withrow KP, Rosenthal EL, Gourin CG et al (2007) Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope 117(5):781–784

    Article  Google Scholar 

  55. Spriano G, Piantanida R, Maffioli M (1989) Salvage surgery after unsuccessful radiotherapy of cancer of the larynx. Acta Otorhinolaryngol Ital 9(2):161–168

    CAS  Google Scholar 

  56. Mueller CK, Schultze-Mosgau S (2009) Radiation-induced microenvironments—the molecular basis for free flap complications in the pre-irradiated field? Radiother Oncol 93(3):581–585

    Article  CAS  Google Scholar 

  57. Costantino A, Festa BM, Ferreli F et al (2022) Circumferential pharyngeal reconstruction after total laryngopharyngectomy: a systematic review and network meta-analysis. Oral Oncol 127:105809

    Article  Google Scholar 

  58. Ferreli F, Mercante G, De Virgilio A et al (2020) Lateral cervical approach for salvage total laryngectomy without pharyngeal reinforcement with pedicled or free flaps: our preliminary experience in six patients. Eur Arch Otorhinolaryngol 277(6):1837–1841

    Article  Google Scholar 

  59. Lin L, Zhang J, Hodges JS, Chu H (2017) Performing arm-based network meta-analysis in R with the pcnetmeta package. J Stat Softw 80:5

    Article  Google Scholar 

  60. De Virgilio A, Costantino A, Russo E et al (2021) Different surgical strategies in the prevention of frey syndrome: a systematic review and meta-analysis. Laryngoscope 131(8):1761–1768

    Article  Google Scholar 

Download references

Acknowledgements

None.

Funding

None.

Author information

Author notes

  1. Armando De Virgilio and Andrea Costantino contributed equally as first authors. Giuseppe Mercante and Fabio Ferreli contributed equally as last authors.

Authors and Affiliations

  1. Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy

    Armando De Virgilio, Andrea Costantino, Bianca Maria Festa, Elena Russo, Giuseppe Spriano, Giuseppe Mercante & Fabio Ferreli

  2. Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy

    Armando De Virgilio, Andrea Costantino, Bianca Maria Festa, Elena Russo, Luca Malvezzi, Giovanni Colombo, Giuseppe Spriano, Giuseppe Mercante & Fabio Ferreli

  3. Department of Otolaryngology-Head and Neck Surgery, IRCCS Regina Elena National Cancer Institute, 00144, Rome, Italy

    Raul Pellini

Authors
  1. Armando De Virgilio
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andrea Costantino
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bianca Maria Festa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Elena Russo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Luca Malvezzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Raul Pellini
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Giovanni Colombo
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Giuseppe Spriano
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Giuseppe Mercante
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Fabio Ferreli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bianca Maria Festa.

Ethics declarations

Conflict of interest

None.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 15201 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

De Virgilio, A., Costantino, A., Festa, B. et al. Surgical prevention of pharyngocutaneous fistula in salvage total laryngectomy: a systematic review and network meta-analysis. Eur Arch Otorhinolaryngol 279, 5839–5849 (2022). https://doi.org/10.1007/s00405-022-07490-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00405-022-07490-9

Keywords

Search

Navigation