Risk Factors for Esophageal Stricturing Status Post Total Laryngectomy: A Systematic Review and Meta-analysis

Esophageal strictures are a common and morbid complication following total laryngectomy, associated with high recurrence rates and reduced quality of life. This systematic review and meta-analysis aimed to identify risk factors for stricture formation to inform preventative strategies and guide multidisciplinary decision-making. A systematic review was conducted following PRISMA guidelines. Searches of Embase, MEDLINE, and Web of Science identified studies of head and neck cancer patients undergoing total laryngectomy who developed esophageal strictures. The screening and data extraction processes were performed by two independent reviewers. A one-sample meta-analysis for binary outcomes was conducted using a random-effects model with restricted maximum likelihood estimation. The Freeman-Tukey double-arcsine transformation was applied to stabilize variance, and pooled proportions with 95% confidence and prediction intervals were calculated. A meta-regression was used to evaluate study-level covariates. Forty-eight studies (4,919 total laryngectomies, 996 strictures) yielded an overall stricture rate of 20.25%. Prior radiation or chemoradiation was associated with higher stricture rates compared to no radiation (23% vs. 15%, p = 0.029). Laryngopharyngectomy was linked to increased stricture frequency relative to laryngectomy alone (26% vs. 18%, p = 0.017). Hypopharyngeal tumors, advanced nodal disease (N2/N3), and mechanical closure were each associated with higher stricture prevalence (p < 0.01). Tobacco/nicotine use was modestly associated with increased stricture rates (19% vs. 12%, p = 0.042). This analysis identified several clinicopathologic and technical factors associated with post-laryngectomy esophageal strictures. Substantial between-study heterogeneity was observed across analyses, with meta-regression variably explaining this heterogeneity and sensitivity analyses suggesting that a small number of influential studies contributed to variability. While the data from this analysis do not imply causation, consistent associations were observed across multiple studies. Recognition of these patterns may help guide risk counseling, surgical technique selection, and postoperative surveillance, but prospective studies are needed to clarify underlying mechanisms and assess potential interventions.