Closure of post-laryngectomy pharyngocutaneous fistulae

Closure of salvage laryngectomy defects with vascularized tissue remains controversial.

We evaluate outcomes in patients who required repair of a fistula after attempted primary closure of salvage laryngectomy defect and assess risk factors for persistent fistula. Between 2001 and 2010, 20 patients were treated for pharyngocutaneous fistulae after primary closure of a salvage laryngectomy. All patients required free flap repair for definitive fistula management.

Patients presented with fistulae from one to 18 months in duration; median time to closure was seven days. Radial forearm free flap was used in 86% of patients. With free flap alone 50% of patients achieved fistula closure. Additional procedures improved closure rate to 85%. Recipient vessels were used in the neck in 54.5%, compared to internal mammary vessels in 45.5%. Hypothyroidism was identified as a risk factor for persistent fistula (p = 0.01). Chronic steroid use (p = 0.08) did not reach significance as a risk factor for fistula closure. Gastroesophageal reflux disease was newly diagnosed or noted as a comorbidity in 14 patients (70%) in this study. It did not reach statistical significance as a risk factor in refistulization (p = 0.12). Complications included leak, carotid blowout, infection, free flap loss, and late refistulization. Overall flap failure in this study was 4.5%.

Delayed secondary repair of pharygocutaneous fistulas after salvage laryngectomy is associated with a higher complication rate and poor success rates compared to use of vascularized tissue at the time of salvage laryngectomy. Prolonged wound healing in these patients is associated with hypothyroidism.