Risk Factors for Post Laryngectomy Pharyngocutaneous Fistula and Impact of Pharyngeal Suture Type on Fistula Characteristics

Document Type : Original

Authors

1 Otolaryngology Department, Rafael Mendez University Hospital, Lorca, Spain.

2 Otolaryngology Department, Hospital Comarcal de la Línea de La Concepción, Cádiz, Spain.

3 Doctoral School UAM, Graduate Studies Center, Autonomous University of Madrid. Calle Francisco Tomás y Valiente, No. 2. Cantoblanco University City, 28049 Madrid, Spain. Allergy and Clinical Immunology Research Unit, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.

4 Otorhinolaryngology Department, University Hospital of Heraklion, University of Crete, School of Medicine. Crete, Greece.

5 Otolaryngology Department, San Antonio Catholic University of Murcia. Murcia, Spain.

10.22038/ijorl.2024.83054.3798

Abstract

Introduction:
Pharyngocutaneous fistula (PCF) is the most common complication following total laryngectomy (TL). The factors contributing to its occurrence are still a matter of debate. The impact of suture type has been relatively underexplored. This study aimed to analyze the risk factors associated with PCF and understand how the type of suture influences PCF characteristics.
 
Materials and Methods:
An observational study encompassing all TL procedures was performed between 2005 and 2022 at a secondary care hospital. Sociodemographic and clinical variables widely studied in the literature to identify PCF risk factors were considered. Additionally, the characteristics of fistulas were examined to assess the influence of the suture type.
 
Results:
Seventy TL cases were included. The incidence of PCF was 56.0%. Identified risk factors for PCF included pharyngeal closure type (p=0.001) (RR=13.09), nutritional support type (p=0.001) (RR=13.54), the need for reintervention due to postoperative bleeding (p=0.001) (RR=1.13), and the need for blood transfusion after surgery (p=0.015) (RR=1.20). Regarding the suture type, Modified Connell Suture (MCS) was associated with a later onset of fistula (p=0.014), shorter hospital stay (p=0.001), and early initiation of oral feeding (p=0.009).
 
Conclusion:
PCF occurrence is associated with nasogastric tube use, Lambert closure, postoperative bleeding, and reintervention for bleeding after TL. Moreover, MCS sutures are linked to a shorter hospital stays and early initiation of oral feeding.
 

Keywords

Main Subjects

References

  1. Medina JE, Khafif A. Early oral feeding following total laryngectomy. Laryngoscope. 2001 Mar; 111(3): 368-72. doi: 10.1097/00005537-200103000-00002. PMID: 11224763.
  2. Wang M, Xun Y, Wang K, Lu L, Yu A, Guan B, Yu C. Risk factors of pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2020 Feb; 277(2):585-99. doi: 10.1007/s00405-019-05718-9.
  3. Iglesias-Moreno MC, Gimeno-Hernández J, Gómez-Serrano M, Carricondo F, Gil-Loyzaga P, Poch-Broto J. Pharyngo-cutaneous fistula: an old problem revisited. Acta Otolaryngol. 2011 Dec; 131(12):1311-8. doi: 10.3109 /00016489. 2011.611532. Epub 2011 Sep 22. PMID: 21939383.
  4. Haksever M, Akduman D, Aslan S, Solmaz F, Ozmen S. Modified Continuous Mucosal Connell Suture for the Pharyngeal Closure After Total Laryngectomy: Zipper Suture. Clin Exp Otorhinolaryngol. 2015 Sep;8(3):281-8. doi: 10.3342/ceo.2015.8.3.281. Epub 2015 Aug 13. PMID: 26330925; PMCID: PMC4553361.
  5. Chotipanich A. Total Laryngectomy: A Review of Surgical Techniques. Cureus. 2021 Sep 22; 13(9): e18181. doi: 10.7759/cureus.18181. PMID: 34707956; PMCID: PMC8531883.
  6. Aarts MC, Rovers MM, Grau C, Grolman W, van der Heijden GJ. Salvage laryngectomy after primary radiotherapy: what are prognostic factors for the development of pharyngocutaneous fistulae? Otolaryngol Head Neck Surg. 2011 Jan;144(1):5-9. doi: 10.1177/0194599810390914.
  7. Van Bokhorst-de van der Schueren MA, van Leeuwen PA, Sauerwein HP, Kuik DJ, Snow GB, Quak JJ. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications. Head Neck. 1997 Aug; 19(5):419-25. doi: 10.1002/(sici)1097-0347 (199708) 19: 5<419::aid-hed9>3.0.co;2-2.
  8. Singh R, Karantanis W, Fadhil M, Dow C, Fuzi J, Robinson R, Jacobson I. Meta-analysis on the rate of pharyngocutaneous fistula in early oral feeding in laryngectomy patients. Am J Otolaryngol. 2021 Jan-Feb;42(1):102748. doi: 10. 1016/j. amjoto.2020. 102748.
  9. Busoni M, Deganello A, Gallo O. Pharyngocutaneous fistula following total laryngectomy: analysis of risk factors, prognosis and treatment modalities. Acta Otorhinolaryngol Ital. 2015 Dec;35(6):400-5. doi: 10.14639/0392-100X-626.
  10. Boscolo-Rizzo P, De Cillis G, Marchiori C, Carpenè S, Da Mosto MC. Multivariate analysis of risk factors for pharyngocutaneous fistula after total laryngectomy. Eur Arch Otorhinolaryngol. 2008 Aug; 265(8):929-36. doi: 10.1007/s00405-007-0562-z.
  11. Thompson CSG, Asimakopoulos P, Evans A, Vernham G, Hay AJ, Nixon IJ. Complications and predisposing factors from a decade of total laryngectomy. J Laryngol Otol. 2020 Mar; 134(3): 256-62. doi: 10.1017/S0022215120000341.
  12. Casasayas M, Sansa A, García-Lorenzo J, Venegas MDP, Quer M, León X. Pharyngocutaneous fistula in irradiated patients: systematic review and our experience. J Laryngol Otol. 2022 Nov; 136(11): 1027-33. doi: 10.1017/S0022215121004370.
  13. Fernández-Prada M, Palomeque-Vera JM, Gómez-Hervás J, Guillén Solvas J, Sainz Quevedo M, Revelles Suárez H. Incidencia, estancia hospitalaria y factores de riesgo asociados a la aparición de fístula faringocutánea poslaringectomía. Acta Otorrinolaringol Esp. 2014 Jan-Feb;65(1):22-6. Spanish. doi: 10.1016/j.otorri.2013.08.003.
  14. Jack DR, Dawson FR, Reilly JE, Shoaib T. Guideline for prophylactic feeding tube insertion in patients undergoing resection of head and neck cancers. J Plast Reconstr Aesthet Surg. 2012 May; 65(5):610-5. doi: 10.1016/j.bjps.2011.11.018.
  15. Riera L, Sandiumenge A, Calvo C, Bordas JM, Alobid I, Llach J, Bernal M. Percutaneous endoscopic gastrostomy in head and neck cancer patients. ORL J Otorhinolaryngol Relat Spec. 2002 Jan-Feb;64(1):32-4. doi: 10.1159/000049265.
  16. Locher JL, Bonner JA, Carroll WR, Caudell JJ, Keith JN, Kilgore ML, Ritchie CS, Roth DL, Tajeu GS, Allison JJ. Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine. JPEN J Parenter Enteral Nutr. 2011 May;35(3):365-74. doi: 10. 1177/ 0148607110377097. PMID: 21527598.
  17. Talwar B, Donnelly R, Skelly R, Donaldson M. Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016 May;130(S2): S32-S40. doi: 10.1017/S0022215116000402.
  18. Cristian D, Poalelungi A, Anghel A, Burcoş T, Grigore R, Berteşteanu S, Richiteanu G, Grama F. Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) - The Importance of Nutritional Support in Patients with Head and Neck Cancers (HNCs) or Neurogenic Dysphagia (ND). Chirurgia (Bucur). 2015 Mar-Apr;110(2):129-36.
  19. Bojaxhiu B, Shrestha BK, Luterbacher P, Elicin O, Shelan M, Macpherson AJS, Heimgartner B, Giger R, Aebersold DM, Zaugg K. Unplanned hospitalizations in patients with locoregionally advanced head and neck cancer treated with (chemo)radiotherapy with and without prophylactic percutaneous endoscopic gastrostomy. Radiat Oncol. 2020 Dec 14;15(1):281. doi: 10.1186/s13014-020-01727-9.
  20. Barie P, Eachempati S. Surgical site infections. Surg Clin North Am. 2005;85:1115-35.
  21. Haga Y, Yasunaga Y, Araki J, Nakao J, Mori H, Nakagawa M, Mukaigawa T. Perioperative Factors Aggravating Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Center Retrospective Analysis Using the Clavien-Dindo Classification. Ann Plast Surg. 2023 Jul 1;91(1):84-9. doi: 10.1097/SAP.0000000000003627. PMID:37450865.
  22. Dedivitis RA, Aires FT, Cernea CR, Brandão LG. Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors. Head Neck. 2015 Nov; 37(11):1691-7. doi: 10.1002/hed.23804. Epub 2015 Jun 26. PMID: 24958209.
  23. Liang JW, Li ZD, Li SC, Fang FQ, Zhao YJ, Li YG. Pharyngocutaneous fistula after total laryngectomy: A systematic review and meta-analysis of risk factors. Auris Nasus Larynx. 2015 Oct; 42(5):353-9. doi: 10.1016/j.anl.2015.04.002. Epub 2015 Apr 29. PMID: 25933584.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Chotipanich A, Wongmanee S. Incidence of Pharyngocutaneous Fistula After Total Laryngectomy and Its Relationship With the Shapes of Mucosa Closure: A Meta-Analysis. Cureus. 2022 Sep 6;14(9):e28822. doi: 10.7759/cureus.28822. PMID: 36225453; PMCID: PMC9535618.
  2. Van der Kamp MF, Rinkel RNPM, Eerenstein SEJ. The influence of closure technique in total laryngectomy on the development of a pseudo-diverticulum and dysphagia. Eur Arch Otorhinolaryngol. 2017 Apr;274(4):1967-73. doi: 10.1007/s00405-016-4424-4.
  3. Avci H, Karabulut B. Is It Important Which Suturing Technique Used for Pharyngeal Mucosal Closure in Total Laryngectomy? Modified Continuous Connell Suture May Decrease Pharyngocutaneous Fistula. Ear Nose Throat J. 2020 Dec;99(10):664-70. doi: 10. 1177/ 01455613209389 18. Epub 2020 Jul 23. PMID: 32703029.
  4. Lemaire E, Schultz P, Vergez S, Debry C, Sarini J, Vairel B, de Bonnecaze G, Takeda-Raguin C, Cabarrou B, Dupret-Bories A. Risk Factors for Pharyngocutaneous Fistula After Total Pharyngolaryngectomy. Ear Nose Throat J. 2021 Sep;100(5_suppl):746S-752S. doi: 10. 1177/ 0145 5613 19901035.

 

Iranian Journal of Otorhinolaryngology
Volume 37, Issue 1
January and February 2025
Pages 11-17

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