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Pharyngocutaneous Fistula Following Primary and Salvage Laryngectomy: Aetiology and Predictive Factors

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Abstract

Laryngeal cancer treatment is often wrought with challenges, pharyngocutaneous fistula formation (PCF) in patients undergoing either primary or salvage laryngectomy for laryngeal and hypopharyngeal for squamous cell carcinoma is an important one. We aimed to study the factors before and at the surgery that are associated with PCF formation in a South Indian tertiary care hospital. A retrospective chart review of 127 patients who underwent total laryngectomy (TL) between May 2014 and April 2019 at our centre were done. Data was collected, including patient age and gender, comorbidities (Diabetes mellitus, COPD and hypothyroidism), smoking, tumor stage and site, prior tracheostomy, prior radiation, concurrent neck dissection and type of pharyngoplasty, Preoperative hemoglobin and albumin levels, surgical margin status and development of a PCF was also done. Further details specific to the development of a PCF were recorded for that subset of patients including the length of time to fistula, mode of closure, time of closure and modality of management. The overall incidence of PCF was 16.5% (21 of 127 patients), and the median time from TL to the diagnosis of PCF was 6 days (range, 3–20 days). The analysis was done separately for laryngectomies without any pharyngeal reconstruction (112/127 patients). In patients treated with a primary TL, the incidence of PCF was 12.20% (10 of 82) and 26.66% (8 of 30) after salvage TL. Subset analysis for type of pharyngoplasty repair showed 12% (15/127) underwent different types of vascularised/muscular flap for smaller residual pharyngeal mucosa, of which 20% (3/15) developed PCF and one patient developed haematoma needing exploration and re-suturing. The predictive factors for PCF were hypopharynx cancer (P < 0.05), surgical margin positivity (P < 0.0001), female gender (P < 0.05), absence of prior tracheostomy (P < 0.05) and tumor extension into pyriform sinus mucosa (P < 0.05). Preoperative patient factors of gender and site of primary along with histological margin positivity and extension of tumor to the pyriform sinus mucosa were significant risk factors for PCF formation. Pre-Op radiotherapy remains a strong clinical suspicion but not statistically significant.

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Abbreviations

PCF:

Pharyngocutaneous fistula

OR:

Odds Ratio

CI:

Confident interval

TL:

Total laryngectomy

RT:

Radiation therapy

CTRT:

Chemotherapy and radiation therapy

COPD:

Chronic obstructive pulmonary disease

TNM:

Tumor node metastasis system

POD:

Postoperative day

PO:

Postoperative

SCC:

Squamous cell carcinoma

References

  1. Bobdey S, Jain A, Balasubramanium G (2015) Epidemiological review of laryngeal cancer: an Indian perspective. Indian J Med Paediatr Oncol. 36:154–160. https://doi.org/10.4103/0971-5851.166721

    Article  PubMed  PubMed Central  Google Scholar 

  2. National Cancer Registry Programme (2013) Three-Year Report of Population Based Cancer Registries 2009–2011. Indian Council of Medical Research. https://main.icmr.nic.in/sites/default/files/reports/Preliminary_Pages_Printed.pdf. Accessed 29 Feb 2020

  3. IARC Publications—PDFs online—Cancer Epidemiology—Cancer Survival in Africa, Asia, the Caribbean and Central America—SurvCan [Internet]. [cited 2020 Feb 29]. Available http://survcan.iarc.fr/indexsurvcan1.php

  4. Vainshtein JM, Wu VF, Spector ME, Bradford CR, Wolf GT, Worden FP (2013) Chemoselection: a paradigm for optimization of organ preservation in locally advanced larynx cancer. Expert Rev Anticancer Ther 13:1053–1064. https://doi.org/10.1586/14737140.2013.829646

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Sullivan CB, Ostedgaard KL, Al-Qurayshi Z, Pagedar NA, Sperry SM (2020) Primary laryngectomy versus salvage laryngectomy: a comparison of outcomes in the chemoradiation era. The Laryngoscope. https://doi.org/10.1002/lary.28343

    Article  PubMed  PubMed Central  Google Scholar 

  6. Goepfert RP, Hutcheson KA, Lewin JS, Desai NG, Zafereo ME, Hessel AC, Lewis CM, Weber RS, Gross ND (2017) Complications, hospital length of stay, and readmission after total laryngectomy. Cancer 123:1760–1767. https://doi.org/10.1002/cncr.30483

    Article  PubMed  Google Scholar 

  7. Galli J, De Corso E, Volante M, Almadori G, Paludetti G (2005) Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy. Otolaryngol Head Neck Surg 133:689–694. https://doi.org/10.1016/j.otohns.2005.07.025

    Article  PubMed  Google Scholar 

  8. Liang J-W, Li Z-D, Li S-C, Fang F-Q, Zhao Y-J, Li Y-G (2015) Pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis of risk factors. Auris Nasus Larynx 42:353–359. https://doi.org/10.1016/j.anl.2015.04.002

    Article  PubMed  Google Scholar 

  9. Sayles M, Grant DG (2014) Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope. 124:1150–1163. https://doi.org/10.1002/lary.24448

    Article  PubMed  Google Scholar 

  10. Boscolo-Rizzo P, De Cillis G, Marchiori C, Carpenè S, Da Mosto MC (2008) Multivariate analysis of risk factors for pharyngocutaneous fistula after total laryngectomy. Eur Arch Otorhinolaryngol 265:929–936. https://doi.org/10.1007/s00405-007-0562-z

    Article  PubMed  Google Scholar 

  11. Lebo NL, Caulley L, Alsaffar H, Corsten MJ, Johnson-Obaseki S (2017) Peri-operative factors predisposing to pharyngocutaneous fistula after total laryngectomy: analysis of a large multi-institutional patient cohort. J Otolaryngol Head Neck Surg. 46:54. https://doi.org/10.1186/s40463-017-0233-z

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wang M, Xun Y, Wang K, Lu L, Yu A, Guan B et al (2020) Risk factors of pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 277:585–599. https://doi.org/10.1007/s00405-019-05718-9

    Article  PubMed  Google Scholar 

  13. Benson EM, Hirata RM, Thompson CB, Ha PK, Fakhry C, Saunders JR et al (2015) Pharyngocutaneous fistula after total laryngectomy: a single-institution experience, 2001–2012. Am J Otolaryngol 36:24. https://doi.org/10.1016/j.amjoto.2014.08.017

    Article  PubMed  Google Scholar 

  14. White HN, Golden B, Sweeny L, Carroll WR, Magnuson JS, Rosenthal EL (2012) Assessment and incidence of salivary leak following laryngectomy. Laryngoscope 122:1796–1799. https://doi.org/10.1002/lary.23443

    Article  PubMed  PubMed Central  Google Scholar 

  15. Ganly I, Patel S, Matsuo J, Singh B, Kraus D, Boyle J et al (2005) Postoperative complications of salvage total laryngectomy. Cancer 103:2073–2081. https://doi.org/10.1002/cncr.20974

    Article  PubMed  Google Scholar 

  16. Mimica X, Hanson M, Patel SG, McGill M, McBride S, Lee N et al (2019) Salvage surgery for recurrent larynx cancer. Head Neck 41:3906–3915. https://doi.org/10.1002/hed.25925

    Article  PubMed  PubMed Central  Google Scholar 

  17. Patel UA, Moore BA, Wax M, Rosenthal E, Sweeny L, Militsakh ON et al (2013) Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg. 139:1156–1162. https://doi.org/10.1001/jamaoto.2013.2761

    Article  PubMed  Google Scholar 

  18. Grau C, Johansen LV, Hansen HS, Andersen E, Godballe C, Andersen LJ et al (2003) Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA. Head Neck 25:711–716. https://doi.org/10.1002/hed.10237

    Article  PubMed  Google Scholar 

  19. Qureshi SS, Chaturvedi P, Pai PS, Chaukar DA, Deshpande MS, Pathak KA et al (2005) A prospective study of pharyngocutaneous fistulas following total laryngectomy. J Cancer Res Ther 1:51–56. https://doi.org/10.4103/0973-1482.16092

    Article  CAS  PubMed  Google Scholar 

  20. Hui Y, Wei WI, Yuen PW, Lam LK, Ho WK (1996) Primary closure of pharyngeal remnant after total laryngectomy and partial pharyngectomy: how much residual mucosa is sufficient? Laryngoscope. 106:490–494. https://doi.org/10.1097/00005537-199604000-00018

    Article  CAS  PubMed  Google Scholar 

  21. Sharma S, Chaukar DA, Laskar SG, Kapre N, Deshmukh A, Pai P et al (2016) Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy. J Laryngol Otol 130:860–864. https://doi.org/10.1017/s0022215116008501

    Article  CAS  PubMed  Google Scholar 

  22. Basheeth N, O’Leary G, Sheahan P (2014) Pharyngocutaneous fistula after salvage laryngectomy: impact of interval between radiotherapy and surgery, and performance of bilateral neck dissection. Head Neck 36:580–584. https://doi.org/10.1002/hed.23337

    Article  PubMed  Google Scholar 

  23. Wulff NB, Kristensen CA, Andersen E, Charabi B, Sørensen CH, Homøe P (2015) Risk factors for postoperative complications after total laryngectomy following radiotherapy or chemoradiation: a 10-year retrospective longitudinal study in Eastern Denmark. Clin Otolaryngol 40:662–671. https://doi.org/10.1111/coa.12443

    Article  CAS  PubMed  Google Scholar 

  24. Nitassi S, Belayachi J, Chihab M, Rkain I, Benayad J, Benbouzid MA et al (2016) Evaluation of post laryngectomy pharyngocutaneous fistula risk factors. Iran J Otorhinolaryngol. 28:141–147 PMID: 27280101

    PubMed  PubMed Central  Google Scholar 

  25. Scotton WJ, Nixon IJ, Pezier TF, Cobb R, Joshi A, Urbano TG et al (2014) Time interval between primary radiotherapy and salvage laryngectomy: a predictor of pharyngocutaneous fistula formation. Eur Arch Otorhinolaryngol 271:2277–2283. https://doi.org/10.1007/s00405-013-2726-3

    Article  PubMed  Google Scholar 

  26. Aires FT, Dedivitis RA, de Castro MAF, Ribeiro DA, Cernea CR, Brandão LG (2012) Pharyngocutaneous fistula following total laryngectomy. Braz J Otorhinolaryngol. 78:94–98. https://doi.org/10.5935/1808-8694.20120040

    Article  PubMed  Google Scholar 

  27. Markou KD, Vlachtsis KC, Nikolaou AC, Petridis DG, Kouloulas AI, Daniilidis IC (2004) Incidence and predisposing factors of pharyngocutaneous fistula formation after total laryngectomy. Is there a relationship with tumor recurrence? Eur Arch Otorhinolaryngol 261:61–67. https://doi.org/10.1007/s00405-003-0643-6

    Article  PubMed  Google Scholar 

  28. González-Ballester D (2016) The tissue shrinkage phenomenon on surgical margins in oral and oropharyngeal squamous cell carcinoma. Plast Aesthet Res 3:150–157. https://doi.org/10.20517/2347-9264.2016.23

    Article  Google Scholar 

  29. Upile T, Fisher C, Jerjes W, El Maaytah M, Searle A, Archer D, Michaels L, Rhys-Evans P, Hopper C, Howard D, Wright A (2007) The uncertainty of the surgical margin in the treatment of head and neck cancer. Oral Oncol 43:321–326. https://doi.org/10.1016/j.oraloncology.2006.08.002

    Article  CAS  PubMed  Google Scholar 

  30. Erdag MA, Arslanoglu S, Onal K, Songu M, Tuylu AO (2013) Pharyngocutaneous fistula following total laryngectomy: multivariate analysis of risk factors. Eur Arch Otorhinolaryngol 270:173–179. https://doi.org/10.1007/s00405-012-2111-7

    Article  PubMed  Google Scholar 

  31. Aydoğan LB, Kiroğlu M, Tuncer U, Soylu L (2003) The wound amylase concentration in the prediction of pharyngocutaneous fistula. Otolaryngol Head Neck Surg 129:414–416. https://doi.org/10.1016/S0194-59980300714-9

    Article  PubMed  Google Scholar 

  32. Patel UA, Keni SP (2009) Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 141:190–195. https://doi.org/10.1016/j.otohns.2009.03.024

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Head and Neck Surgery, Christian Medical College, Vellore, 6320004, India

    Rajiv C. Michael, Sukamal Das & Suresh Mani

  2. Department of ENT, Christian Medical College, Vellore, India

    Sabarinath Arunagiri, Regi Thomas & Rajan Sundaresan Vediappan

  3. Department of Biostatistics, Christian Medical College, Vellore, India

    Dona Maria Philip

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Michael, R.C., Das, S., Mani, S. et al. Pharyngocutaneous Fistula Following Primary and Salvage Laryngectomy: Aetiology and Predictive Factors. Indian J Otolaryngol Head Neck Surg 74 (Suppl 2), 2139–2148 (2022). https://doi.org/10.1007/s12070-020-02046-x

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