A Novel and Simple Technique to Reduce the Rate of Pharyngocutaneous Fistula Formation Following a Total Laryngectomy - our Initial Results

Abstract

Objective: Pharyngocutaneous fistula (PCF) is a common and often devastating complication of total laryngectomy. Patients undergoing a total laryngectomy need enhancement of the neopharynx to reduce the risk of PCF formation. Our study aimed to evaluate the formation of a PCF following a total laryngectomy in patients that underwent a modified closure technique of their neopharynx. This technique included the recruitment of a flap of the muscular division of the pretracheal fascia that invests the strap muscles as a protective blanket. We called this surgical technique the ‘curtain call’. Methods: We conducted a retrospective study for patients who underwent a total laryngectomy in our department between May 2022 and May 2023. Results: Twelve patients were identified. Our results demonstrated that the recruitment of this modified closure technique to cover the neopharynx resulted in a very low rate of postoperative PCF formation (8.3%). Conclusion: The ‘curtain call’ technique is an excellent method to support the neopharynx with extremely low rates of postoperative chronic dysphagia and with no evidence of impairing the development of esophageal speech. It could sometimes substitute much more time-consuming techniques like major pectoralis flap and supraclavicular flap.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04343-7.

Introduction

Surgical treatment of squamous cell laryngeal carcinoma (SCC) ranges from a single cordectomy to a total laryngectomy. Although a lot of conservative surgical techniques that spare a part of the larynx have been developed, a total laryngectomy is often unavoidable. Total laryngectomy is strongly indicated for moderately advanced tumor disease (T4a) or as a salvage procedure for recurrent cases where conservative treatment options, such as radiation therapy or chemotherapy, have failed [1–4].

Total laryngectomy is associated with major limitations in patients’ postoperative quality of life that mainly include aphonia and the presence of a permanent stoma [5]. In addition, surgical excision of the larynx is a demanding surgical procedure with both early and late complications. The formation of a pharyngocutaneous fistula (PCF) - usually on the 9th postoperative day - remains the major factor that prolongs the hospital stay and delays the start of oral feeding and adjuvant radiotherapy [6]. The frequency of PCF ranges from about 7% for primary total laryngectomies to 61% for salvage cases [7–9].

According to the literature, the most common risk factors for the development of a PCF are preoperative irradiation, haemoglobin levels below 12.55 g/dL, prior tracheotomy, and poor surgical technique in the closure of the neopharynx [7]. Some authors suggest that the prophylactic use of a major pectoralis flap or a supraclavicular flap and the administration of perioperative antibiotics reduce the rate of postoperative PCF formation [8–12].

Aim of the Study

The aim of our study is to examine the rate of postoperative PCF formation with the recruitment of a flap of the muscular division of the pretracheal fascia that invests the strap muscles as a modified closure technique to cover the neopharynx in patients undergoing a total laryngectomy.

Methods

The study was conducted in accordance with the declaration of Helsinki and all its subsequent amendments. It was also approved by the Institutional Review Board (IRB) of ‘G. Papanikolaou’ General Hospital of Thessaloniki in Greece with the review number 371/30.05.2023. This is a retrospective study examining the cases of SCC laryngeal cancer treated in the Department of Otorhinolaryngology-Head and Neck Surgery of ‘G. Papanikolaou’ General Hospital of Thessaloniki between May 2022 and May 2023.

All the patients who underwent a total laryngectomy (primary or salvage) were eligible for inclusion in our study. Patients with neoplasms that infiltrated the strap muscles or with significant extralaryngeal extension were excluded. All the laryngectomies were performed with the same surgical technique and by the same surgeon (AP). Neck dissection was performed in positive neck cases or in cases with advanced primary tumors. Every patient due for laryngectomy followed a preoperative MRSA eradication protocol with chlorhexidine mouthwash and mupirocin nasal ointment 7 days prior to surgery.

Prophylactic flap coverage of the pharyngotomy with a major pectoralis flap was not performed. In contrast, the muscular division of the pretracheal fascia of the strap muscles was recruited to cover as a second layer the primary closure of the neopharynx. Specifically, after the elevation of the Apron flap, the investing fascia of the omohyoid and sternohyoid muscle was divided in the midline. Then, the fascia was dissected bilaterally from the midline to the lateral border of the carotid sheath as shown in Fig. 1. In cases of unilateral neck dissection, this fascia was the medial border of the ipsilateral specimen of the neck dissection and was sacrificed. On the opposite side, the fascia was employed at the end of the operation to cover the neopharynx. It should be noted, that the neopharynx was not covered by the incised lower and middle pharyngeal constrictors muscles in order to avoid potential postoperative dysphagia and restrictions in the development of esophageal speech. We called this modified closure technique of the neopharynx the ‘curtain call’. In all cases, other flaps like major pectoralis flap or supraclavicular flap were not recruited.

Fig. 1.

Division of the investing fascia of the omohyoid and sternohyoid muscle in the midline and bilateral dissection from the midline to the lateral border of the carotid sheath

The medical charts of the patients were retrieved and analyzed by two authors (PK and EF). A data extraction template (Microsoft Office Excel, Bellevue, Washington) was prepared including patients’ demographics, the reason for a total laryngectomy (primary or salvage), the comorbidities, the presence of preoperative tracheotomy, the incidence of PCF formation, and the presence of postoperative dysphagia. The primary endpoint of interest was to determine the effectiveness of the ’curtain call’ technique in the prevention of postoperative PCF in patients undergoing a total laryngectomy.

The statistical analysis was conducted using the Statistical Program for Social Science (SPSS) 21.0 (IBM Corporation, Armonk, NY). All the data were expressed as frequencies +/- percentage. The data were analyzed using contingency tables. A p-value of less than 0.005 was considered to be statistically significant.

Results

Our results indicated 9 cases of primary total laryngectomy and 3 cases of salvage total laryngectomy. The average age of our patients was 66 years. 10 out of 12 (83.3%) patients were males and 2 (16.7%) were females. Patients’ characteristics are summarized in Table 1.

Table 1.

Patients’ characteristics and the type of surgical procedure

Age groups	≥ 60 years 9 (75%)	< 60 years 3 (25%)
Sex	Female 2 (16.7%)	Male 10 (83.3%)
BMI	< 18.5 kg/m2 0	18.5–24.9 kg/m2 8 (66.6%)	> 25-29.9 kg/m2 1 (8.3%)	> 30 kg/m2 3 (25%)
Abuse habits	Tobacco 9 (75%)	Alcohol 6 (50%)
Medical comorbidity	Present 10 (83.3%)	Absent 2 (16.7%)
Type of treatment	PTL 9 (75%)	STL 3 (25%)	SND 3 (25%)	ART 6 (50%)	CMRT 0

BMI: Body Mass Index, PTL: Primary Total Laryngectomy, STL: Salvage Total Laryngectomy, SND: Selective Neck Dissection, ART: Adjuvant Radiotherapy, CMRT: Chemoradiotherapy

Two (16.7%) patients had a prior tracheotomy performed and the majority of them (83.3%) had comorbidities that affect the healing procedure. 75% of the patients were smokers and 50% of them reported heavy alcohol consumption. In addition, 33.3% of the patients had Body Mass Index (BMI) above 25 kg/m² and 33.3% had diabetes mellitus II. One patient had a synchronous hematologic malignancy and one patient reported a history of esophageal cancer. In one patient a total thyroidectomy was also performed due to goiter. The concomitant histology report revealed the presence of a synchronous papillary thyroid carcinoma.

PCF formation was observed only in one patient (8.3%). The risk factors for PCF formation are shown in Table 2. Two patients reported postoperative dysphagia. One patient was re-operated the same day because of significant postoperative bleeding. Data about the postoperative complications are summarized in Table 3. The average hospital stay of the patients who did not develop a PCF was 11.7 days. No patient has developed a peristomatic recurrence, while one patient developed distant metastases (brain and liver).

Table 2.

Risk factors for pharyngocutaneous fistula formation

Comorbidities	Diabetes mellitus II 4 (33.3%)	Hypertension 6 (50%)	COPD 5 (41.6%)	Coronary artery disease 2 (16.7%)
Radiotherapy	Previous 3 (25%)	Postoperative 6 (50%)
Prior tracheotomy	Yes 2 (16.7%)	No 10 (83.3%)
Haemoglobin levels < 12.2 g/dl ≥ 12.2 g/dl	Preoperative 7 (58.3%) 5 (41.6%)	Postoperative 10 (83.3%) 2 (16.7%)
Albumin levels* < 3.5 g/dl ≥ 3.5 g/dl	Preoperative 4 (40%) 6 (60%)	Postoperative 4 (40%) 6 (60%)

COPD: Chronic Obstructive Pulmonary Disease, * data about albumin levels available for 10 out of 12 patients

Table 3.

Postoperative complications after a total laryngectomy

Type of complication	Total sample (n = 12) (%)	PTL (n = 3)	PTL/Post-RT (n = 6)	STL (n = 3)
Dysphagia Yes No	2 (16.7%) 10 (83.3%)	0 3	1 5	1 2
PCF Yes No	1 (8.3%) 11 (91.7%)	1 2	0 6	0 3
Local complications* Yes No	4 (33.3%) 8 (66.7%)	2 3	1 5	1 2
Length of hospitalization Mean (SD)	13.25 5.44

PCF: Pharyngocutaneous fistula, PTL: Primary Total Laryngectomy, PTL/Post-RT: Primary Total Laryngectomy/ Postoperative Radiotherapy, STL: Salvage Total Laryngectomy, SD: Standard Deviation, *Local complications include wound infection and haemorrhage

Discussion

Our results demonstrate that the ’curtain call’ technique is an effective technique for preventing postoperative PCF formation in patients undergoing a total laryngectomy. Patients in need of a salvage laryngectomy are considered high-risk groups and avoiding a PCF formation is crucial for their recovery. PCF formation affects the initiation of oral feeding, and the overall hospital stay, and also delays the postoperative radiation treatment when needed. Thus, minimizing the incidence of this complication is of paramount importance [13].

There is still neither consensus nor uniform practice for the closure of the neopharynx following a total laryngectomy and several surgical techniques have been considered through the years. The use of a flap to prevent PCF formation is a common practice and major pectoralis flap remains the workhorse [14]. The use of vascularized non-irradiated flaps has been suggested as necessary by some authors, because of concerns about the vascularization of the covering tissue. The major pectoralis is out of the irradiated field and thus is considered an excellent choice [15]. Guimarães et al. [16] conducted a systematic review that demonstrated the necessity of a major pectoralis flap in every case of salvage laryngectomy. Specifically, the results of their study showed a decrease of 22% in the incidence of PCF in patients who underwent prophylactic flap reinforcement. Our study showed no PCFs in salvage laryngectomies, although the patients had undergone therapeutic radiotherapy at the time of the initial diagnosis.

Pretracheal fascia also known as the middle portion of the deep cervical fascia has two divisions. The visceral division that encircles the larynx, trachea, thyroid gland, and esophagus, and the muscular division that invests the infrahyoid muscles. The latter is attached superiorly in the hyoid bone and inferiorly in the clavicle and the manubrium of the sternum. According to some authors, its natural extension inferiorly is the clavicopectoral fascia that encircles the subclavius, serratus anterior, and minor pectoralis muscles [17, 18]. Pretracheal fascia is characterized by dense connective tissue and is considered relatively avascular. The small vessels that vascularize the fascia are derived superiorly from the branches of the external carotid artery and inferiorly from the branches of the thyrocervical trunk and internal thoracic artery [19]. Therefore, it is strongly suggested to avoid the ligation of the superior thyroid artery during laryngectomy to avoid restricting the vascularization of our suggested flap. Finding the superior thyroid artery is sometimes challenging due to its inconsistent point of origin [20].

Dysphagia is another major limitation in the quality of life of patients who underwent a total laryngectomy. They often complain of halitosis, globus sensation, and very prolonged mealtime. The main pathologies of neopharynx that impair the normal flow of meals include stricture formation, pseudodiverticulum formation, fistulae, and tumor recurrence [21]. Total blockage of the neopharynx is another relevant common phenomenon in these patients that needs urgent management. According to the literature, dysphagia is more prevalent in patients who underwent a primary closure compared to those where a flap was recruited [22]. Dysphagia is also combined with tracheoesophageal speech failure due to pharyngeal or esophageal muscle spasms and hypertonicity [23]. We made some adjustments to our closure plan, in order to avoid these long-term complications. Firstly, we did not use pharyngeal muscles to cover the mucosa of the primary closure as a second layer. We used the ’curtain call’ technique that does not contain muscle fibers. Secondly, we performed a myotomy of the smooth muscles of the esophagus to avoid secondary esophageal hypertonicity. Only two patients reported dysphagia and no patient mentioned any impairment in his effort to develop tracheoesophageal speech.

The present study has to be seen in the light of certain limitations. It is a retrospective study and data were extracted from patients’ medical charts and hospital records. The retrospective nature of the study might introduce selection bias. Additionally, the sample of our study includes only 12 patients treated over a time span of 12 months by the same surgeon. Therefore, the presence or not of statistical significance cannot be reported and the relevant conclusions should be interpreted with caution.

Conclusion

The use of this technique for pharyngeal closure following a total laryngectomy seems to be promising. The ’curtain call’ technique is an easier, less time-consuming, and less invasive technique that demonstrated excellent initial results. Postoperative PCF formation, hospitalization, and postoperative dysphagia were reduced in our patients. Future randomized control trials (RCTs) are necessary to validate the results of the present study.

Electronic Supplementary Material

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Funding

The authors received no financial support for this study’s research, authorship, and/or publication.

Declarations of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this study.