Dead Space Prevention: a Technique for Preventing Pharyngocutaneous Fistula After Salvage Laryngectomy

Pharyngocutaneous fistula (PCF) is the most common and challenging complication after salvage total laryngectomy, particularly in patients with prior chemoradiation. This prospective study aimed to evaluate the effectiveness of a novel multilayer closure technique utilizing vascularized muscle flaps designed to obliterate residual pharyngeal dead space and reinforce neopharyngeal healing, with the goal of preventing PCF formation. A prospective single-arm cohort study was conducted on 25 consecutive patients with stage III or IV laryngeal cancer, or recurrent disease following chemoradiation, who underwent total laryngectomy with concurrent neck dissection between 2017 and 2025. The modified technique involved vertical multilayer suturing of the posterior pharyngeal wall combined with tailored vascularized muscle flaps (local, distant, or free) to fill dead space and support the neopharynx. Postoperative care included nutritional optimization, targeted antibiotic prophylaxis, and close monitoring for complications. The primary outcome was the incidence of PCF, compared to the institutional historical baseline rate of 18%. Of the 25 patients (mean age 58 years; 96% male), 60% had prior chemoradiation and 48% were underweight preoperatively. Local muscle flaps, predominantly sternocleidomastoid, were used in 68% of cases; pedicled flaps were used in 88%. Transient hypoalbuminemia occurred in 12% of patients and was corrected with intravenous albumin supplementation. Over a 3-year follow-up, no patient developed PCF or major wound complications. Statistical analysis confirmed a significantly lower PCF rate compared to the institutional baseline (0% vs. 18%, p = 0.007; 95% CI: 0-11.3%). This modified multilayer closure technique with vascularized muscle flap reinforcement demonstrated complete prevention of PCF in a high-risk cohort undergoing salvage laryngectomy. By addressing pharyngeal dead space and employing tension-free vertical closure, this approach aligns with biomechanical principles of improved perfusion and healing. Although promising, these findings warrant validation in larger multicenter controlled trials to confirm its efficacy over standard reconstructive techniques.