Salvage total laryngectomy: is a flap necessary?

Gonzalez-Orús Álvarez-Morujo, Ricardo; Martinez Pascual, Paula; Tucciarone, Manuel; Fernández Fernández, Mario; Souviron Encabo, Rosalia; Martinez Guirado, Tomás

doi:10.1016/j.bjorl.2018.11.007

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Brazilian Journal of Otorhinolaryngology

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Original articles • Braz. j. otorhinolaryngol. 86 (2) • Mar-Apr 2020 • https://doi.org/10.1016/j.bjorl.2018.11.007 copy

Salvage total laryngectomy: is a flap necessary?^☆ ☆ Please cite this article as: Gonzalez-Orus Alvarez-Morujo R, Pascual PM, Tucciarone M, Fernández MF, Encabo RS, Guirado TM. Salvage total laryngectomy: is a flap necessary? Braz J Otorhinolaryngol. 2020;86:228-36.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy.

Objective:

Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors.

Methods:

We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed.

Results:

We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes.

Conclusions:

Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy.

KEYWORDS
Salvage total laryngectomy; Pectoralis major flap; Pharyngocutaneous fistula; Radiotherapy

Characteristic	n	%
Sex
Male	25	92.5
Female	2	7.5

Prior treatment
Radiotherapy alone	13	48.1
Chemo-radiotherapy	12	44.4
Bio-radiotherapy^a a Radiotherapy plus cetuximab.	2	7.5

Localization
Supraglottis	12	44.4
Glottis	15	55.6

Pathological tumour stage
T1	4	14.8
T2	7	25.9
T3	13	48.1
T4	3	11.1

Pathological node status
N0	23	85.2
N1	2	7.5
N2	1	3.7
N3	1	3.7

Tumor stage
I	3	11.1
II	7	25.9
III	13	48.1
IVa	3	11.1
IVb	1	3.7

Tumour grade
Well differentiated	7	25.9
Moderately differentiated	16	59.3
Poorly differentiated	4	14.8

Associated diseases
Coronary artery disease	4	14.8
Chronic obstructive pulmonary disease	8	29.6
Hypertension	10	37
Diabetes mellitus	8	29.6
Chronic renal failure	2	7.5

Anesthetic assessment
ASA II	13	48.1
ASA III	10	37
ASA IV	4	14.8

Prior tracheostomy
Yes	10	37
No	17	63

Neck dissection
Yes	4	14.8
No	23	85.2

Tracheoesophageal puncture
Yes	5	18.5
No	22	81.5

Characteristic	With fistula	Without fistula	p-Value
Mean age	65.7 ± 11.2	665 ± 1049	0.8

Sex
Male	11 (44%)	14 (56%)	0.7
Female	1 (50%)	1 (50%)

Coronary artery disease
No	10 (43.5%)	13 (56.5%)	0.6
Yes	2 (50%)	2 (50%)

Chronic obstructive pulmonary disease
No	8 (42.1%)	11 (57.9%)	0.5
Yes	4 (50%)	4 (50%)

Hypertension
No	8 (47.1%)	9 (52.9%)	0.5
Yes	4 (40%)	6 (60%)

Diabetes mellitus
No	7 (36.8%)	12 (63.2%)	0.2
Yes	5 (62.5%)	3 (37.5%)

Chronic renal failure
No	11 (44%)	14 (6%)	0.2
Yes	1 (50%)	1 (50%)

Haemoglobin
>12 g/dL	5 (41.6%)	7 (58.4%)	0.6
<12 g/dL	7 (46.6%)	8 (53.4%)

Creatinin
<1.3 mg/dL	11 (47.8%)	12 (57.2%)	0.3
>1.3 mg/dL	1 (25%)	3 (75%)

Total proteins
>7 mg/dL	5 (38.5%)	8 (61.5%)	0.4
<7 mg/dL	7 (50%)	7 (50%)

Anesthetic assessment
ASA II	5 (28.5%)	8 (61.5%)	0.5
ASA III	4 (40%)	6 (60%)
ASA IV	3 (75%)	1 (25%)

Chemotherapy
Yes	5 (41.6%)	7 (58.4%)	0.6
No	7 (46.6%)	8 (53.4%)

Tumour grade
Well	1 (25%)	3 (75%)	0.5
Moderately	7 (43.7%)	9 (56.3%)
Poorly	4 (57.1%)	3 (42.9%)

Time until salvage laryngectomy
<12 months	4 (40%)	6 (60%)	0.5
>12 months	8 (47.1%)	9 (52.9%)

Localization
Supraglottis	6 (50%)	6 (50%)	0.4
Glottis	6 (40%)	9 (60%)

Tumour size
T1-T2	4 (36.4%)	7 (63.6%)	0.3
T3-T4	8 (50%)	8 (50%)

Node status
N0	11 (47.8%)	12 (52.2%)	0.3
N +	1 (25%)	3 (75%)

Tumour stage
I-II	4 (40%)	6 (60%)	0.5
III-IV	8 (47.1%)	9 (52.9%)

Prior tracheostomy
Yes	2 (20%)	8 (80%)	0.057
No	10 (58.8%)	7 (41.2%)

Neck dissection
Yes	2 (40%)	3 (60%)	0.6
No	10 (45.5%)	12 (54.5%)

Tracheoesophageal puncture
Yes	2 (40%)	3 (60%)	0.6
No	10 (45.5%)	12 (54.5%)

Variable	Without PMF (n = 14)	With PMP (n = 13)	p-Value
Global PCF rate
Yes	11 (78.6%)	4 (30.8%)	0.016
No	3 (21.4%)	9 (69.2%)

PCF rate with surgical repair
Yes	9 (64.3%)	1 (7.7%)	0.003
No	5 (35.7%)	12 (92.3%)

Great pharyngostomas
Yes	9 (64.3%)	0 (0%)	0.0004
No	5 (35.5%)	13 (100%)

FLAP	Mean	SD	Range	p-Value
Mean surgical time (minutes)				0.0075
With PMF (n = 13)	291.5	108.84	190-335	0.0075
Without PMF (n = 14)	199.28	45.81	165-280

Mean surgical time including additional procedures to reconstruct pharyngostomes (minutes)				0.17
With PMF (n = 13)	299.23	110.33	190-340	0.17
SIN Without PMF (n = 14)	385.21	192.58	165-985

Oral diet initiation (days)				0.039
With PMF (n = 13)	21.53	14.64	7-61	0.039
Without PMF (n = 14)	84	69.25	11-203

Length of hospitalization (days)				0.0041
With PMF (n = 13)	27.23	14.48	10-63	0.0041
Without PMF (n = 14)	98.38	79.76	14-204

Reference/year	Pharyngocutaneous fistula		Surgical treatment of fistula
	CMPM	Nº CMPM	CMPM	Nº CMPM
Righini et al., 2005	6/26 (23.1%)	17/34 (50%)	4/6 (66.6%)	14/17 (82.4%)
Gil et al., 2009	3/11 (27.3%)	16/89 (18%)	0/3	14/17 (82.4%)
Patel et al., 2009	0/10 (0%)	4/7 (57.1%)	-	-
Sakai et al., 2012	1/13 (77.7%)	12/39 (30.7%)	0/1 (0%)	10/12 (83.3%)
Sousa et al., 2012	3/19 (15.8%)	7/12 (58.3%)	-	-
Cömert et al., 2014	9/21 (42.8%)	14/24 (58.3%)	0/9 (0%)	10/14 (71.4%)
Sayles at al. 2014	6/13 (46.2%)	17/47 (36.2%)	-	-
Gilbert et al., 2014	6/35 (17.1%)	17/38 (44.7%)	-	-
Gendreau-Lefevre et al., 2014	7/51 (13.7%)	41/115 (35.6%)	4/7 (57.1%)	26/41 (63.41%)
Present study	4/13 (30.7%)	11/14 (78.6%)	1/4 (7.7%)	9/11 (64.3%)

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] * Corresponding author. E-mail: ricardomorujo@hotmail.com (R. Gonzalez-Orús Álvarez-Morujo).

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Salvage total laryngectomy: is a flap necessary?☆ ☆ Please cite this article as: Gonzalez-Orus Alvarez-Morujo R, Pascual PM, Tucciarone M, Fernández MF, Encabo RS, Guirado TM. Salvage total laryngectomy: is a flap necessary? Braz J Otorhinolaryngol. 2020;86:228-36.

Abstract

Introduction:

Objective:

Methods:

Results:

Conclusions:

Salvage total laryngectomy: is a flap necessary?^☆ ☆ Please cite this article as: Gonzalez-Orus Alvarez-Morujo R, Pascual PM, Tucciarone M, Fernández MF, Encabo RS, Guirado TM. Salvage total laryngectomy: is a flap necessary? Braz J Otorhinolaryngol. 2020;86:228-36.