“Pharyngocutaneous Fistulas after

Salvage Laryngectomy: Need for

Vascularized Tissue”

Wojciech K. Mydlarz, M.D.

Disclosures

• No Relevant Financial Relationships or

Commercial Interests

Educational Objectives

• Discuss risk factors for fistula after

salvage total laryngectomy

• Discuss prevention of fistulas after

salvage total laryngectomy

• Discuss outcomes and complications of

various surgical management options of

fistulas.

Overview

• Background

• Risk factors for pharyngocutaneous

fistulas (PCF) after Salvage Total

Laryngectomy (TL)

• Prevention of PCF after Salvage TL:

vascularized tissue

• Outcomes

Clinical Background

• Laryngeal Cancer:

• Supraglottis (epiglottis, arytenoids, aryepiglotticfolds, false cords)

• Glottis (true cords, anterior and posterior commissures)

• Subglottis

Clinical Background

2006 ASCO• New cases of laryngeal cancer to be diagnosed

(U.S., 2005): 9,880

• Newly diagnosed cases that will lead to death

(U.S., 2005): 3,770

• 95% of laryngeal cancers are invasive with

squamous cell carcinoma as the predominant

histologic type

• 40% of patients will have stage III or IV laryngeal

cancer (upon first evaluation)

• 25% of healthy people are willing to trade a 20%

absolute difference in survival for the opportunity

to save their voice

Clinical Background

• Tobacco and/or alcohol use are

associated with most cases of laryngeal

cancer

• Continued tobacco and/or alcohol use

complicates treatment and facilitates

medical comorbidity and the

development of second primary

cancers.

Clinical Background

• Larynx-preservation options include:

– Radiation therapy

– Chemoradiation therapy

– Function-preserving partial laryngectomy

procedures

• TL is surgical procedure most feared by

patients. Common sequelae:

– Social isolation

– Job loss

– Depression

Clinical Scenario

• 54 year-old man s/p 35 doses of 2 Gray RT over 7 weeks for a

T3NOMO squamous cell carcinoma of the right vocal cord

• 6 months later undergoes biopsy because of suspicion of

recurrence.

• PMH significant for non–insulin-dependent diabetes mellitus and

hypertension.

• Patient continues to smoke 10 cigarettes per day, which has

decreased from 25 cigarettes per day before diagnosis of

laryngeal cancer. He consumes about 4 beers per day.

• Biopsy histopathology positive for residual tumor.

Multidisciplinary oncology board recommends salvage TL

surgery.

• Potential complications of TL discussed with patient, including

PCF. The patient asks about what are his risks for a fistula?

PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the

Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9

PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the

Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9

PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the

Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9

• multivariate logistic regression

analysis: only initial T stage &

tumor site remained as

independent prognostic factors

• Odds ratio (OR) for tumor stage:

– 2.08 (95% confidence interval [CI] =

1.26-3.45)

– T3-4 in comparison to T1-2 for

developing PCF

• OR for tumor site:

– 2.08 (95% CI = 1.25-3.45)

– Non-glottic tumors in comparison with

glottic tumors.

PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous

Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.

PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous

Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.

PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous

Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.

PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous

Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.

Prevention of PCF:

Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery

141, 190-195.

Prevention of PCF:

Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery

141, 190-195.

Prevention of PCF:

Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-

1023.

Prevention of PCF:

Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-

1023.

Prevention of PCF:

Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope

117, May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope

117, May 2007.

Prevention of PCF:

Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope

117, May 2007.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.

Outcomes of Vascularized

Tissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.

Summary

• PCF can occurr after salvage TL

• Previous radiotherapy, tumor location

and T stage are important risk factors

• Vascularized tissue plays a role in

prevention of PCF after Salvage TL

• Pectoralis major and free flaps can both

be used to help prevent PCF with good

outcomes

Questions?