Abstract
Background
Salvage total laryngectomy (STL) remains a difficult procedure in patients with recurrent or persistent laryngeal neoplasms after radiotherapy and chemoradiotherapy. The choice of the most appropriate method for pharyngeal closure continues to be debated, especially in relation to the possible associated postoperative complications and functional recovery.
Objective
To compare postoperative complications and functional outcomes between primary pharyngeal closure and pectoralis major flap reconstruction in patients undergoing salvage total laryngectomy.
Materials and methods
A retrospective study was conducted on 62 patients treated between January 2022 and December 2025 at Coltea Clinical Hospital. All patients underwent salvage total laryngectomy following failure of organ preservation therapy. Pharyngeal closure was performed by primary suture in 27 patients and reconstruction with a pectoralis major flap in 35 patients. Postoperative complications, such as pharyngocutaneous fistula (PCF), wound infection, bleeding and wound dehiscence, were analyzed. We analyzed functional outcomes by determining the time required to resume eating and the length of hospital stay. The need for surgical reintervention was additionally analyzed according to closure technique and complication type. Fisher’s exact test was used for statistical analysis because of the small sample size and we considered the results to be statistically significant if p < 0.05.
Results
There were more patients with pharyngocutaneous fistulas in the primary pharyngeal closure group than in the pectoralis major flap reconstruction group (63.0% vs. 28.6%, p = 0.0099). Wound infection was also more frequent in the primary closure group although this difference did not reach statistical significance. Postoperative haemorrhage and skin flap dehiscence occurred significantly more frequently in the primary closure group compared to the pectoralis major flap reconstruction group. The presence of complications, especially pharyngocutaneous fistulas, was associated with a delayed return to oral feeding and a longer recovery. Although patients undergoing pectoralis major flap reconstruction had fewer complications and lower surgical reintervention rates, they also had a prolonged hospital stay in patients without postoperative complications.
Conclusions
Pharyngeal reconstruction with pectoralis major flap was associated with lower rates of postoperative complications and reduced need for surgical reintervention compared with primary closure in salvage total laryngectomy patients. Pharyngocutaneous fistula, postoperative hemorrhage and skin flap dehiscence occurred more frequently in the primary closure group and were associated with higher rates of surgical reintervention. Functional recovery was strongly influenced by postoperative complications, particularly PCF, which was associated with delayed oral feeding initiation and prolonged hospitalization. These findings support an individualized surgical approach based on patient risk factors and anticipated postoperative morbidity.
Keywords: salvage laryngectomy, primary closure, pectoralis major flap, pharyngocutaneous fistula, postoperative complications, functional outcomes
INTRODUCTION
Salvage total laryngectomy (STL) remains an important part of treating recurrent or persistent laryngeal cancer after primary non-surgical treatment, which is usually radiotherapy alone or chemoradiotherapy (1, 2). While this method is more effective for treating cancer, it also has a higher rate of complications after surgery compared to primary laryngectomy. This is mainly due to the damage to blood vessels, formation of scar tissue and slower healing of wounds, which are all caused by previous treatments.
The technique for closing the pharynx is one of the most important parts of STL (3). The choice between primary pharyngeal closure and reconstruction using vascularised tissue has led to considerable debate.
Primary closure has a number of benefits, such as a faster surgery time, less pain at the donor site and a simpler process. Nevertheless, in irradiated tissues, this approach may be associated with an elevated incidence of complications, particularly pharyngocutaneous fistula (PCF), which remains the most prevalent and clinically significant postoperative complication.
Conversely, free flap reconstruction, including methods like forearm or anterolateral thigh free flaps, has become a common approach for treating pharyngeal defects (4). These techniques aim to incorporate well-vascularized non-irradiated tissue into the surgical area, potentially promoting healing and reducing the probability of adverse outcomes. However, free flap reconstruction is linked to extended surgical time, greater resource demands and the possibility of donor-site complications, raising concerns about its widespread applicability in all patients undergoing salvage procedures.
Functional outcomes, encompassing the ability to swallow and the restoration of speech, represent crucial considerations in the selection of optimal reconstructive surgical techniques (5). While primary closure can preserve the original tissue's structure, reconstructive techniques might improve structural integrity in larger lesions, which could affect how well things work after surgery.
Given these factors, the best way to close the pharynx after a STL is still debated. The choice of the optimal treatment is always in relation with the tumor characteristics, the surgeon’s experience and the individual clinical condition of the patient.
Therefore, this study aims to compare flap reconstruction with primary pharyngeal closure in patients undergoing STL, focusing on postoperative complications and functional results, and to contribute to current discussions by examining clinical cases and providing practical information to help with surgical decisions.
MATERIALS AND METHODS
Patient selection and study design
This retrospective case series, which was conducted at Coltea Clinical Hospital from January 2022 to December 2025, included patients who underwent STL. They had recurrent or persistent laryngeal carcinoma after having received prior radiotherapy or chemoradiotherapy. A total of 62 patients were included in the analysis.
Inclusion criteria consisted of patients with histologically confirmed laryngeal squamous cell carcinoma who underwent STL after failure of organ-preservation therapy and whose complete clinical and follow-up data were available.
Patients with other head and neck cancers, those with distant metastases and those with incomplete clinical data were excluded from the study.
Data acquisition
We gathered retrospective clinical data from patient records, including demographic details like age and sex. We also recorded risk factors such as smoking and alcohol use. In addition, we noted previous treatments, specifically radiotherapy or chemoradiotherapy, along with the disease status, which was classified as either recurrent or persistent.
Surgical technique
All patients underwent STL. Pharyngeal closure was performed either by primary suture or by reconstruction using a pectoralis major flap. In 27 patients, primary closure was used, while 35 subjects underwent reconstruction using a pectoralis major flap.
Outcome measures
After surgery, we assessed the outcomes by tracking the occurrence of PCF, wound infections and dehiscence, and hemorrhage postoperatively. Functional outcomes, specifically the time until oral feeding began and the need for enteral nutrition as well as rate of surgical reintervention for management of complications, were also evaluated.
Statistical analysis
Descriptive statistics were used to summarize patient characteristics and postoperative outcomes. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean values and ranges. Fisher’s exact test was used to compare categorical variables because of the small sample size. A p-value < 0.05 was considered statistically significant.
Follow-up
Patients were followed postoperatively for the assessment of complications, functional outcomes and surgical reintervention.
RESULTS
The present study comprised 62 patients with a mean age of roughly 67 years (range 49-85). The group was primarily male. The majority of patients had a history of tobacco and alcohol intake. Primary pharyngeal closure was performed in 27 patients, whereas 35 subjects received reconstruction utilizing a pectoralis major flap.
Postoperative progression
Postoperative complications were observed in both groups, with a higher incidence being seen in the primary closure group. Pharyngocutaneous fistula was the most common complication (Table 1).
Postoperative problems noted by us included PCF, wound infections, skin flap dehiscence and bleeding affecting the common or external carotid artery.
Pharyngocutaneous fistula developed in 17 of 27 patients (63%) in the primary closure group and in 10 of 35 cases (28.6%) in the pectoralis major flap reconstruction group.
Wound infections, which developed later in the postoperative course, were observed in eight cases (29.6%) within the primary closure group; all affected patients had previously experienced a PCF. In the reconstruction group, wound infection occurred in 11.4% of cases.
Postoperative bleeding was seen in 12 cases (44.4%) in the primary closure group and two cases (5.7%) in the reconstruction group.
Skin flap dehiscence was noted in 14 of 27 cases (51.9%) in the primary closure group and in two of 35 (5.7%) patients of the ones with major flap reconstruction.
TABLE 1.
Postoperative complications according to pharyngeal closure technique in salvage total laryngectomy patients
Functional outcomes
Functional outcomes were evaluated by comparing oral feeding initiation time and duration of hospital stay according to postoperative complication status and closure technique. The results are summarized in Figures 1 and 2.
Patients without PCF demonstrated earlier initiation of oral feeding in both reconstruction groups. In the primary closure group without PCF, oral feeding was initiated after a mean period of 13.5 days, whereas patients who developed PCF resumed oral intake significantly later, with a mean time of 27.2 days. Similarly, in the pectoralis major flap reconstruction group, patients without PCF resumed oral feeding after a mean of 15.7 days, compared to 18.6 days in those who developed PCF. Delayed oral feeding initiation was therefore more pronounced in patients with postoperative fistula, particularly in the primary closure group.
Hospital stay was also prolonged in patients who developed postoperative complications. In the primary closure group without complications, the mean hospital stay was 13.5 days, compared to 31.9 days in patients with postoperative complications. In the pectoralis major flap reconstruction group, patients without complications had a mean hospitalization period of 16.4 days, whereas patients with complications required a longer postoperative stay, with a mean duration of 24.4 days.
Overall, patients reconstructed with pectoralis major flap demonstrated improved postoperative functional recovery, characterized by earlier oral feeding initiation and shorter hospitalization periods, particularly among subjects who developed postoperative complications.
FIGURE 1.
Mean oral feeding initiation time according to pharyngocutaneous fistula status and closure technique
FIGURE 2.
Mean hospital stay according to postoperative complication status and closure technique
Surgical reintervention
Postoperative complications were managed according to their severity and clinical evolution. While a proportion of patients responded successfully to conservative treatment, more severe complications required surgical reintervention. Conservative management consisted of local wound care, compressive dressing, prolonged nasogastric feeding, antibiotic therapy and close clinical observation. Surgical intervention was reserved for patients with persistent or severe complications and included procedures such as fistula closure, flap revision, vascular ligature and neck exploration. The need for surgical reintervention was evaluated according to closure technique and complication type in order to assess the severity of postoperative morbidity following STL.
Surgical reintervention was required in 15 of 27 patients (55.6%) in the primary closure group and in three out of 35 patients (8.6%) in the pectoralis major flap group, as shown in Figure 3. This difference was statistically significant (p=0.000068, Fisher’s exact test). When only patients with postoperative complications were considered, surgical reintervention was needed in 15 of 21 patients (71.4%) in the primary closure group compared with 3 of 10 patients (30.0%) in the pectoralis major flap group, showing a trend toward lower reintervention rates in the flap group (p=0.0515).
Distribution of complications requiring surgical reintervention is illustrated in Figure 4. Among patients requiring surgery, PCF was present in all cases. Hemorrhage and skin flap dehiscence were also frequent among surgically managed patients, occurring in 14 of 18 cases (77.8%) each. Wound infection was present in six of 18 surgically managed cases (33.3%). In patients with PCF, surgical reintervention was significantly more common after primary closure than after pectoralis major flap reconstruction (88.2% vs 30.0%, p=0.00365).
FIGURE 3.
Surgical reintervention rates in primary closure versus pectoralis major flap reconstruction groups
FIGURE 4.
Distribution of postoperative complication types requiring surgical reintervention according to closure technique
DISCUSSION
Total salvage laryngectomy remains a procedure with many potential complications, especially in patients who had previously undergone radiotherapy or chemoradiotherapy, due to impaired tissue vascularization and reduced healing capacity in patients previously treated with radio/radio-chemotherapy (6). For this reason, choosing the correct technique for pharyngeal closure is important for postoperative outcomes and avoiding possible complications that may occur after surgery.
In the present study, a significantly higher incidence of pharyngocutaneous fistula was observed in the primary closure group compared with the pectoralis major flap reconstruction group (63.0% vs. 28.6%, p = 0.0099). These findings are consistent with previous meta-analyses and systematic reviews demonstrating increased fistula rates following primary closure in previously irradiated tissues (7, 8). In addition, prior radiotherapy and impaired tissue vascularization remain major risk factors for the development of postoperative complications, particularly PCF formation (9).
The use of tissue that is not vascularized by prior irradiation, such as the pectoralis major flap, has been recommended to reduce fistula development in the salvage surgery setting. Several studies have demonstrated that pectoralis major flap reconstruction favors tissue healing and reduces postoperative complications (10, 11).
Wound infections were more frequent in the primary closure group compared with the pectoralis major flap reconstruction group (29.6% vs. 11.4%, p = 0.106), although this difference did not reach statistical significance. Similar findings have been reported in previous studies evaluating postoperative morbidity following STL (12, 13).
Postoperative hemorrhage occurred significantly more frequently in the primary closure group compared with the pectoralis major flap reconstruction group (44.4% vs. 5.7%, p = 0.0005). In our study, all bleeding events occurred in patients with previous wound dehiscence or PCF. These findings suggest that in previously irradiated tissues, persistent salivary leakage secondary to pharyngocutaneous fistula or wound dehiscence may contribute to vascular wall erosion and carotid blowout syndrome, as previously described in the literature (10).
Skin flap dehiscence occurred significantly more frequently in the primary closure group compared with the pectoralis major flap reconstruction group (51.9% vs. 5.7%, p < 0.0001). In both groups, several cases of dehiscence were associated with PCF. Previous studies have suggested that wound dehiscence may occur secondary to impaired pharyngeal healing and local tissue breakdown following STL (14).
The current study demonstrated that patients without postoperative complications resumed oral feeding earlier in both groups, whereas the occurrence of PCF was associated with delayed oral feeding initiation and prolonged recovery. Patients from the primary closure group who developed PCF experienced the greatest delay in oral feeding resumption. These findings are supported by previous studies demonstrating that fistula formation complicates postoperative recovery and delays the reintroduction of oral nutrition (15, 16).
Patients reconstructed with pectoralis major flap demonstrated lower rates of postoperative complications despite a slightly prolonged hospital stay in uncomplicated cases compared with the primary closure group. This difference may be related to the increased complexity of flap reconstruction and the need for closer postoperative monitoring. However, in patients who developed postoperative complications, the pectoralis major flap group showed shorter hospitalization periods and lower rates of surgical reintervention compared with the primary closure group. Similar findings have been reported in studies evaluating reconstructive techniques in head and neck surgery (17, 18). Furthermore, previous studies support the protective role of pectoralis major flap reconstruction in high-risk patients undergoing STL (19).
The findings of this study suggest that pectoralis major flap reconstruction following STL may be advantageous, particularly in high-risk patients with previous radiotherapy. This technique was associated with lower rates of severe postoperative complications, including PCF, postoperative hemorrhage and skin flap dehiscence, as well as reduced need for surgical reintervention. Although flap reconstruction was associated with slightly prolonged hospitalization in uncomplicated cases, it contributed to improved postoperative recovery and lower overall postoperative morbidity (20, 21).
Among the limitations of this study we highlight its retrospective design and the relatively small number of included patients. In addition, some functional outcomes were assessed using cumulative data, which may have limited statistical precision. Further prospective studies including larger patient cohorts are necessary to validate these findings and better identify the risk factors associated with postoperative complications following STL.
CONCLUSIONS
Patients undergoing salvage total laryngectomy represent a high-risk category that requires careful selection of the reconstructive technique. In the present study, pectoralis major flap reconstruction was associated with lower rates of postoperative complications, particularly pharyngocutaneous fistula, postoperative hemorrhage and skin flap dehiscence, as well as reduced need for surgical reintervention compared with primary pharyngeal closure. These findings may be explained by the use of well-vascularized non-irradiated tissue, which contributes to improved wound healing and reduced postoperative morbidity.
Postoperative recovery and oral feeding resumption were strongly influenced by the occurrence of complications, especially pharyngocutaneous fistula. Although patients reconstructed with pectoralis major flap demonstrated slightly prolonged hospitalization in uncomplicated cases, they experienced fewer severe postoperative complications and lower reintervention rates.
Free flap reconstruction also represents an important reconstructive option in selected patients, particularly in extensive pharyngeal defects, offering favorable functional and oncological outcomes. However, pectoralis major flap reconstruction remains a reliable, accessible and effective technique, especially in high-risk patients or in centers with limited microsurgical resources.
These findings highlight the importance of individualized surgical planning in salvage total laryngectomy patients. Patient-related risk factors, tissue quality, defect extent and intraoperative findings should all be considered when selecting the optimal pharyngeal closure technique in order to achieve improved postoperative outcomes.
Conflicts of interest
none declared.
Financial support
none declared.
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