Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy

Authors: Moreno MA, Wax MK, Gardner JR, Cannady SB, Graboyes EM, Bewley AF, Dziegielewski PT, Khaja SF, Bayon R, Ryan J, Al-Khudari S, El-Deiry MW, Ghanem TA, Huang A, Patel R, Higgins KM, Jackson RS, Patel UA

Affiliation: 17 academic tertiary head and neck centers in the United States and Canada, led by University of Arkansas for Medical Sciences.

Journal: JAMA Otolaryngology-Head & Neck Surgery, June 2024

PMID: 38635282

Key Takeaways

• In salvage laryngectomy defects amenable to primary closure, free tissue transfer (FTT) had the lowest pharyngocutaneous fistula (PCF) rate: 22.4% vs 34.5% with primary closure (PC) and 39.1% with regional closure (RC).

• Adjusted PCF risk was about twice as high with PC or RC versus FTT; estimated number needed to treat with FTT was 7.

• The key signal may be cutaneous interposition (skin paddle sewn into the suture line) rather than free flap reconstruction itself. Pectoralis myocutaneous cutaneous-paddle interposition was not associated with higher PCF risk than interpositional FTT.

• Closure technique was not associated with clinically meaningful differences in 1- or 2-year functional outcomes.

Background

Previously irradiated salvage laryngectomy carries substantial PCF risk. Many institutions have begun adopting FTT for these defects, but there is not strong evidence to support this change.

Objective

Assess the association of pharyngeal closure technique with perioperative complications and long-term function after salvage laryngectomy with no or limited pharyngectomy.

Methods

• Retrospective cohort from 17 academic centers, 2011-2016; 309 patients, minimum 1-year follow-up. Mean age 64.7 years; 82.8% male; 57.1% had prior chemoradiotherapy.

• Inclusion criteria: salvage laryngectomy performed for oncologic indication or laryngeal dysfunction, completion of full course of radiation or chemoradiation, no associated pharyngectomy defect that would allow for tension-free PC.

• Exclusions: Extended pharyngectomy, >1 cm tongue-base extension, skin involvement, reirradiation, uncertain defect extent, and salivary bypass tube use

• Reconstruction: FTT 161 (52.1%), RC 64 (20.7%), PC 84 (27.2%). FTT was mainly radial forearm (79) or anterolateral thigh (73); RC included pectoralis myofascial onlay and cutaneous interposition.

• Outcomes included PCF rate, 30-day reoperation, need for delayed reconstruction, dilation, diet, gastrostomy use, and communication.

• Multivariable generalized estimating equations adjusted for smoking, chemoradiotherapy, pharyngectomy, and neck dissection. Formal power and alpha were not reported.

Results

• Overall PCF rate: 90/309 (29.1%), 13.3% subclinical (detected on routine videofluoroscopy). All but one subclinical fistula occurred in patient closed by PC + pectoralis onlay

• PCF rate:

  • Free Tissue (FTT) 36/161 (22.4%)

  • Regional Closure (RC) 25/64 (39.1%)

  • Primary Closure (PC) 29/84 (34.5%).

• Adjusted PCF risk vs FTT: PC RR 2.2 (95% CI, 1.1-4.4); RC RR 2.5 (1.3-4.8). FTT vs no FTT: RR 0.6 (0.4-0.9), NNT 7.

• Skin-paddle interposition reduced PCF risk (RR 0.7, 95% CI, 0.5-0.9). Versus interpositional FTT, PC and pectoralis myofascial onlay had higher PCF risk; pectoralis myocutaneous interposition did not.

• Thirty-day reoperation was 13.6%; 9.4% required delayed pharyngeal reconstruction. These did not differ between groups

• Among 249 patients without disease at 1 year, closure technique was not associated with dilation, diet, gastrostomy use, or communication strategy.

Conclusion

For salvage laryngectomy defects amenable to primary closure, pharyngeal cutaneous interposition, most commonly with FTT, was associated with lower PCF risk. Closure technique had no measurable association with longer-term swallowing outcomes.

Strengths

• Large multicenter cohort focused on the clinically important "could close primarily" salvage defect.

• Center clustering and established PCF risk factors were incorporated into adjusted analysis.

• Distinguishes muscle-only onlay from true cutaneous interposition.

Limitations

• Retrospective, nonrandomized design with surgeon and center selection bias.

• FTT patients had more chemoradiotherapy, pharyngectomy, and neck dissection at baseline.

• Comorbidity severity was incompletely captured.

• Functional endpoints were coarse; patients with disease at 1 year were excluded from long-term analysis.

  
  

Clinical relevance

For a previously irradiated salvage laryngectomy that can technically be closed primarily, these data favor vascularized cutaneous interposition, whether with free flap or myocutaneous pectoralis flap, over primary closure or pectoralis myofascial onlay. They do not prove that a free flap is mandatory if a reliable regional flap can provide true cutaneous interposition.