Surgical closure of postlaryngectomy pharyngocutaneous fistula: a defect-based approach

ABSTRACT

Postlaryngectomy pharyngocutaneous fistula [PCF] is a serious potentially life-threatening complication. Although most can be managed conservatively, some persist requiring surgical repair that can be sometimes challenging. Several studies describe separate reconstruction methods, however, only few address the variability in defect characteristics and hence appropriate flap selection. This study was conducted on 19 patients who underwent surgical repair of persistent PCFs, over a three-year period. Patients included 18 males [94.7%] and only one female [5.3%] with a mean age of 61 +/- 10 years. Nine patients had previous unsuccessful attempts for surgical closure. All patients had more than one comorbid condition predisposing to PCF development as ivell as preventing its healing. Previous neck irradiation was the most common [52.6%], followed by low hemoglobin level [47.4%], hepatic disease [36.8%] and diabetes mellitus [31.6%]. According to defect characteristics; 6 patients received a local cervical skin procedure [cervical skin turn-in [Z-plasty], 10 patients had reconstructions using the pectoralis major musculocutaneous flap with or without cervical skin turn-in hinge flaps for mucosal closure reinforcement and 3 patients required a radial forearm free flap repair in which its central part was de-epithelialized and the flap was folded on itself for both mucosal defect closure and external skin coverage. All PCFs were eventually successfully closed with no major complications. Acceptable oral swallowing results were achieved in all but one patient. This article describes the author's approach for surgical management of persistent PCFs with special emphasis on defect characteristics that affect reconstruction choice and hence closure outcome: