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Pharyngocutaneous fistula is one of the most common and serious complications associated with total laryngectomy. Numerous studies tried to evaluate causative and predisposing factors associated with this complication, but data are considerably variable and there is still no international consensus. Incidence rate varies considerably between studies, with reported rates from 3% to 65%. This 4K video presents our T‐shaped four‐step technique (FST) for closing the pharyngeal mucosa after total laryngectomy in a step‐by‐step manner. All sutures were performed by braided absorbable 3/0 26 mm 1/2c (Vicryl plus 3.0; Ethicon, Somerville, NJ, USA). Recordings were performed using a Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany). We have been described this technique through a high‐definition video, showing each step, and tips from the authors. Our T‐shaped pharyngoplasty closure technique can be divided into four steps: 1. "Key Stitches"; 2. "Area Refinement Stitches"; 3. "Modified Connell Suture"; 4. "Modified Purse String Suture." Our T‐shaped FST closure technique proved to be an effective and reproducible method, which we feel could be the preferred choice for primary pharyngoplasty closure. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this retrospective study was to assess the efficacy of Salivary Bypass Tube (SBT) for preventing pharyngo-cutaneous fistula (PCF) in a recent cohort of patients who underwent primary and salvage total laryngectomy (TL). Methods: A consecutive series of 133 patients who underwent total laryngectomy between 1997 and 2019 was reviewed. The incidence of PCF was compared between patients who did not receive SBT (nSBT group; n = 55) and those preventively receiving SBT (SBT group; n = 78) in both primary and salvage TL. Risk factors for PCF were evaluated in a univariate and multivariate analyses. Results: The overall PCF rate was 30%. Preoperative characteristics were similar between the nSBT and SBT groups, except for older age (p = 0.016), lower preoperative hemoglobin (p = 0.043), and lesser neoadjuvant chemotherapy (p = 0.015) in the SBT group. The rate of PCF the nSBT group, was 41.5%, compared to 21.8% in the SBT group (p = 0.020). In multivariate analysis, only the use of SBT was associated with lower risk of PCF (OR = 0.41 (95% CI 0.19–0.89), p = 0.026). This effect was verified only in the subgroup of patient operated for salvage TL (OR = 0.225; 95% CI 0.09–0.7; p = 0.008). Conclusion: The use of SBT in our series in salvage TL, appears to be associated with a decreased risk of PCF. [ABSTRACT FROM AUTHOR]

Gabriele Molteni, Andrea Sacchetto, Luca Sacchetto, Daniele Marchioni Otolaryngology –Head and Neck Surgery, Department of Surgery, University of Verona, Verona, ItalyCorrespondence: Andrea SacchettoOtolaryngology-Head and Neck Surgery, Department of Surgery, University of Verona, Verona, ItalyTel +39-45-8122330Fax +39-45-8122313Email andrea.sacchetto89@gmail.comAbstract: The pharyngocutaneous fistula (PCF) is one of the most common post-operative complications in patients undergoing laryngectomy. Up till now, there is no universally accepted algorithm for managing of PCFs and several treatment modalities are used for wound healing. The English language literature was searched using PUBMED databases with the keywords “laryngectomy”, “pharyngocutaneous”, “fistula”, “treatment”, and “management” from January 1, 1999 to June 1, 2019; we selected 35 studies according to inclusion criteria and we conducted a systematic review of the articles. The analysis of the international literature shows a high variability of treatment approaches; there is no consensus about conservative treatment and waiting time, and neither about the indication for surgical treatment or the ideal surgical technique. A first attempt of a conservative measure is mandatory in all cases of PCF. In case of failure of conservative measures surgical treatment should be considered: direct closure and local flap are suitable for small defects, pedicled or free flaps showed good to excellent results in closure of large and complex cervical defects. Other non-invasive treatment such as hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT) showed promising results but in limited case series.Keywords: laryngectomy, pharyngo-cutaneous fistula, reconstructive surgery, hyperbaric oxygen therapy, negative pressure wound therapy, laryngeal cancer

Background: Pharyngo-cutaneous fistula is a major complication of total laryngectomy. Despite its significant impact on the patients’ nutrition and management outcome, there is lack of consensus for recognising high-risk patients and factors associated with fistula formation. Hence, this study was aimed at determining the incidence of pharyngo- cutaneous fistula and factors associated with fistula formation. Methods: A retrospective collection of data on all cases of laryngeal cancer diagnosed histologically and had total laryngectomy, in the Otorhinolaryngology Department of a tertiary centre in Southwestern, Nigeria, from 2007 - 2016. The data collected includeage, gender, tumour stage, tracheostomy, adjuvant therapy extent of laryngectomy procedure and factors for pharyngo-cutaneous fistula. Results: Forty-two patients had total laryngectomy, male to female ratio was 7.4:1 and mean age was 52.3 ± 2.1 years. All patients had pathologicaldiagnosis of stage 3 (83.3%) and stage 4 (16.7%) laryngeal cancer, respectively. The incidence of pharyngo-cutaneous fistula was 11.9% and the factors related to fistula formation were prior radiotherapy treatment and diabetes. Age, gender, neck dissection procedures, site of primary tumor and emergency tracheostomy did not contribute to fistula formation. Spontaneous fistula closure was achieved in all cases except one patient who had surgical closure. Conclusion: Pharyngo-cutaneous fistula formation post-surgery is related to the presence of co-morbidities. The high percentage of spontaneous closure underscores the need for a conservative management approach.

Purpose: Pharyngocutaneous fistula (PCF) formation and swallowing difficulties are common and troublesome complications following total laryngectomy (TL). Prior (chemo)radiotherapy ((C)RT) is thought to be a risk factor for these complications, but there is conflicting evidence as to whether the time interval between (C)RT and TL is important. The impact of time interval on these complications and also its impact on overall survival are investigated. Methods: This is a retrospective case note review of all patients undergoing TL at the University Medical Center, Utrecht, The Netherlands over the 10-year period from January 2008 to December 2017. The cohort was split into those who underwent TL within a year of finishing (C)RT and those longer than 1 year. Results: One hundred and twenty-six patients (108 males, 18 females), with a mean age of 66 underwent total laryngectomy after prior (C)RT in the study period. Overall 5-year survival was 35% with a median follow-up of 30 months. Fifty-four patients underwent laryngectomy within a year of their (C)RT versus 72 patients who had a time interval of more than one year. No differences in PCF rate, risk of dilatation or overall survival could be found between the two groups. Conclusions: In this modern cohort, time interval between (C)RT and surgery did not impact PCF rate, risk of dilatation or overall survival. [ABSTRACT FROM AUTHOR]

Introduction: Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol. Methods: Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent. Results: Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%). Conclusion: The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature. [ABSTRACT FROM AUTHOR]

Pharyngo-cutaneous fistula is a well-known complication following total laryngectomy in case of carcinoma larynx, however it is a very rare entity to present as an initial and sole presentation of carcinoma glottis. Here we are reporting case of glottic carcinoma presented to us with pharyngo-cutaneous fistula as an initial presentation.

Advanced glottic cancer (T3,N+ & T4) is usually treated in the majority of centres by total laryngectomy. Carcinoma of the larynx is one of the very few subsets of all cancers which have shown a decrease in the 5 year survival rate and this phenomenon has been attributed to a Pharyngo-cutaneous fistula is the most common complication after total laryngectomy. Comparative study between double layered repair of pharyngeal mucosa against routine single layered repair in cases of 'total laryngectomy with partial pharyngectomy'. All patients with the principal procedure of 'total laryngectomy with partial pharyngectomy' in department of otorhinolaryngology and head-neck surgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India were included in this study. Out of the 20 patients who had undergone total laryngectomy irrespective of the type of mucosal repair, 5 (25 %) patients developed pharyngocutaneous fistula. Out of the 8 patients, with double layered mucosa repair, 1 (12.5 %) patient developed pharyngocutaneous fistula. Out of the 12 patients, with single layered mucosa repair, 4 (33 %) patients developed pharyngocutaneous fistula. Double layered repair of pharyngeal mucosa is associated with a lower incidence of pharyngocutaneous fistula formation and no increased incidence of dysphagia after complete radiotherapy as compared to single layered repair. [ABSTRACT FROM AUTHOR]

Pharyngo-cutaneous fistula is a well-known complication following total laryngectomy in case of carcinoma larynx, however it is a very rare entity to present as an initial and sole presentation of carcinoma glottis. Here we are reporting case of glottic carcinoma presented to us with pharyngo-cutaneous fistula as an initial presentation. [ABSTRACT FROM AUTHOR]

Pharyngo-cutaneous fistula is a serious complication of laryngectomy, with a significant associated morbidity and mortality. The oncologic success of organ-preservation protocols with radiotherapy or chemo-radiotherapy for laryngeal carcinoma means laryngectomy is increasingly reserved for surgical salvage in the event of persistent or recurrent disease. A retrospective review of fistula incidence after laryngectomy in 171 patients in a UK tertiary referral centre over the last decade was conducted to identify trends in this complication in the epoch of non-surgical organ preservation. The overall fistula incidence following laryngectomy is 29.2 % (50/171). Fistula incidence following salvage total laryngectomy is significantly higher than after primary total laryngectomy [19/51 (37.3 %) vs. 8/47 (17.0 %), χ = 5.02, p = 0.03]. There is no significant effect of prior treatment on fistula incidence following laryngo-pharyngectomy or pharyngo-laryngo-oesophagectomy [14/39 (35.9 %) vs. 9/27 (33.3 %), χ = 0.05, p = 0.83]. Prophylactic vascularised tissue flaps to reinforce the pharyngeal suture line may reduce fistula incidence and fistula severity in salvage total laryngectomy. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis Concurrent chemoradiotherapy is the gold-standard nonsurgical organ-preservation treatment for advanced laryngeal carcinoma. Total laryngectomy (TL) is increasingly reserved for surgical salvage. Salvage surgery is associated with more complications than primary surgery. A systematic review and meta-analysis was undertaken to establish the impact of organ preservation protocols on pharyngo-cutaneous fistula incidence following TL, and to synthesize evidence on the role of 'onlay' prophylactic tissue flaps in reducing this complication in salvage TL. Data Sources The English language literature (January 1, 2000, to September 1, 2013) was searched, using PUBMED and EMBASE databases, for the terms 'laryngectomy' and 'fistula.' Of 522 studies identified from database searches, 33 were included in the quantitative synthesis. Review Methods Studies reporting fistula incidence following primary TL (PTL), salvage TL (STL), and STL with 'onlay' flap-reinforced pharyngeal closure were included. Data were extracted by the first author ( M.S.). Meta-analysis of fistula incidence was performed. Results PTL fistula incidence is 14.3% (95% CI 11.7-17.0), STL 27.6% (23.4-31.8), and STL with flap-reinforced closure 10.3% (4.6-15.9). Chemoradiotherapy is associated with a pooled fistula incidence of 34.1% (22.6-45.6), compared to 22.8% (18.3-27.4) for radiotherapy alone. Relative risk of fistula is 0.566 (0.374-0.856, P = 0.001) for STL with flap-reinforced closure compared to STL alone. The number needed to treat (NNT) to prevent one fistula is 6.05. Conclusion Prophylactic flaps used in an 'onlay' technique reduce fistula incidence in STL. Chemoradiotherapy increases fistula incidence more than radiotherapy alone. Prophylactic flaps should be offered in salvage cases after failed chemoradiation protocols. Level of Evidence 3A. Laryngoscope, 124:1150-1163, 2014 [ABSTRACT FROM AUTHOR]

Summary: Background: The free jejunal flap is a widely spread method of pharyngo-oesophageal reconstruction and can also be used in patients presenting with aspiration tendency following treatment for head and neck cancers or caustic injury of the upper aero-digestive tract to create a separate food pathway, the free jejunal diversionary conduit. Methods: Sixteen patients, 13 males and 3 females, aged between 32 and 66 years, undergoing pharyngo-oesophageal reconstruction with a free jejunal flap between October 2005 and July 2011, were included in this study. An extra length of jejunum was used in 10 patients for widening of the upper portion of a prefabricated free jejunal flap, in three patients who developed a leak at the jejuno-oesophageal junction during the follow-up for creation of a seromuscular flap that was used to seal off the leak and in three patients with aspiration tendency for simultaneous creation of a free jejunal diversionary conduit and a separate pharyngo-cutaneous fistula. Results: All flaps survived completely. No complication was observed at the pharyngo-jejunal junction during the follow-up in patients reconstructed with the prefabricated free jejunal flap. No recurrence of the leak was observed in patients treated with a seromuscular flap during the follow-up period. Patients with a free jejunal diversionary conduit did not experience episodes of aspiration and no obstruction of the pharyngo-cutaneous fistula was noted in the postoperative period. Conclusions: We want to encourage the use of an extra length of jejunum in pharyngo-oesophageal reconstruction with a free jejunal flap because it helps to manage postoperative complications, such as leakage and stricture, and it does not increase the morbidity related to the reconstruction. Furthermore, we believe that the creation of a separate pharyngo-cutaneous fistula represents another step forward in the improvement of pharyngo-oesophageal reconstruction with a free jejunal diversionary conduit. [Copyright &y& Elsevier]

The formation of pharyngo-cutaneous fistula (PCF) is controversial and various predisposing factors have been proposed. This study aimed to compare different suture materials in the closure of pharyngeal wounds in experimental animals. Fifty-two Sprague-Dawley rats were divided into three groups. Artificial pharyngotomy was performed and was then repaired with Vicryl, polypropylene, and Vicryl plus fibrin glue, respectively. Outcome measurements included gross wound inspection and histological examination. There was a significant difference in the rates of PCF formation between group I and group II (Fisher’s exact test, p = 0.046). In addition, minimal inflammatory response was found in the polypropylene group when compared to the other groups. The fibrin glue-treated group had the highest fibroblast activity and collagen deposition. Polypropylene produced minimal tissue reaction, which facilitated the healing process. Therefore, proper selection of suture material can probably reduce the rate of PCF but should not be substituted for proper aseptic and meticulous surgical techniques. [ABSTRACT FROM AUTHOR]

Objectives The time to begin oral feeding after total laryngectomy remains a subject of debate among head and neck surgeons. The prevailing assumption is that early initiation of oral feeding may cause pharyngocutaneous fistula; thus, the common practice of initiating oral feeding after a period of 7 to 10 days. The objective of the study was to demonstrate the feasibility and safety of oral feeding 48 hours after total laryngectomy. Study Design Two-part study includes, first, a sequential study and, second, a prospective analysis of our practice. Methods Patients undergoing total laryngectomy without partial pharyngectomy or radiation treatment (except irradiation through small ports for a T1 or T2 glottic carcinoma) were included. In the first, sequential part of the study (part I), a group of 18 patients who were fed 7 to 10 days after total laryngectomy (control group) was compared with a group of 20 patients who received oral feeding within 48 hours. To confirm the results of part I, a prospective analysis of this practice was conducted (part II) in which 35 additional patients who met the above criteria were fed within 48 hours after surgery. Results In part I, pharyngocutaneous fistula occurred in one patient (5%) in the early feeding group and in two patients (11%) in the control group. In part II, pharyngocutaneous fistula occurred in one patient (2.8%). Overall, fistula occurred in two patients in the combined early feeding group (3.6%). This rate of pharyngocutaneous fistula compares favorably with the fistula rate in the control group of 18 patients. Pharyngeal stricture that required dilation occurred in three of our patients in the study group and two in the control group (5.5% vs. 11%, respectively). The length of hospital stay was significantly shortened from 12 to 7 days. Conclusion Our results indicate that in this patient population initiation of oral feeding 48 hours after total laryngectomy is a safe clinical practice. [ABSTRACT FROM AUTHOR]

A 26-year-old man who underwent anterior cervical fusion for a compressed fracture of the C5 vertebra developed postoperatively partial extrusion of the bone graft, followed by progressive dysphagia and retropharyngeal emphysema. Although no definite perforation of the oesophagus or pharynx was detected at reoperation, an extensive pharyngocutaneous fistula formed subsequently through the operative wound. Open drainage in association with broad spectrum antibiotics, continuous nasopharyngeal suctioning, stopping of oral intake and gastrostomy feeding resulted in closure of the fistula. However, the fistula recurred twice soon after resumption of the oral feeding. The diagnostic difficulties in determining when the healing of a pharyngo-cutaneous fistula is complete are underlined. In addition, the importance of continued treatment for 4-6 weeks after first radiological evidence of closure of the fistula is emphasized. [ABSTRACT FROM AUTHOR]

Malignancy larynx usually presents early, the common symptoms being hoarseness, pain throat, cough and irritation of throat. An advanced malignancy is likely to be complicated by a pharyngocutaneous fistula. However it is an occurrence towards the end stage of the disease. Here we present a case of malignancy larynx primarily presenting as pharyngo-cutaneous fistula without any other symptoms. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Patients with advanced cancers of the larynx and hypopharynx have been treated with total laryngectomy at the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney in the past. Increasingly, these patients are being managed with organ-sparing protocols using chemo­therapy and radiotherapy. The aim of the present study was to review complication, recurrence and survival rates following total laryngectomy. Methods: Patients who had total laryngectomy for squamous carcinomas of the larynx or hypopharynx between 1987 and 1998 and whose clinicopathological data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, were reviewed. Patients whose laryngectomy was a salvage procedure for failed previous treatment were included. Results: A total of 147 patients met the inclusion criteria for the study, including 128 men and 19 women with a median age of 63 years. Primary cancers involved the larynx in 90 patients and hypopharynx in 57. There were 30 patients who had recurrent (n = 24) or persistent disease (n = 6) after previous treatment with radiotherapy (26 larynx cases and four hypopharynx cases). Pharyngo-cutaneous fistulas occurred in 26 cases (17.7%) and, using multivariate analysis, the incidence did not correlate with T stage, previous treatment or concomitant neck dissection. Local control rates were 86% for the larynx and 77% for the hypo­pharynx groups and neck control was 84% and 75%, respectively. Five-year survival for the larynx cancer group was 67% and this was significantly influenced by T stage and clinical and pathological N stage. Survival in the hypopharynx group was 37% at 5 years and this did not significantly correlate with T or N stage. There was a non-significant trend to improved survival among previously treated patients whose laryngectomy was a salvage procedure. Conclusion: Patients with cancer of the larynx had a significantly better survival following total laryngectomy than patients with hypopharyngeal cancer. Those whose laryngectomy was carried out as a salvage procedure following failed previous treatment did not have a worse outcome than previously untreated patients. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Pharyngo-cutaneous fistula (PCF) is one of the main problems for patients undergoing total laryngectomy. There are many risk factors described and associated with the appearance of PCF; however, some of these are currently under discussion. The aim of this work is to analyse the incidence of PCF, hospital stay and associated risk factors in patients undergoing total laryngectomy in a secondary hospital., Methods: This was an observational study in a retrospective cohort. We included all patients who underwent total laryngectomy between 2006 and 2011. We considered sociodemographic and clinical items, and most of the risk factors studied in the literature by other authors (tracheostomy, tumour stage, chemotherapy or radiotherapy before surgery, etc.). Statistical analyses were performed using SPSS(®) 15.0 and Epidat(®) 3.1., Results: We analysed 70 total laryngectomies. The incidence of PCF in the time period studied was 48.6%. There were significant differences between the mean hospital stay of patients with and without PCF. Affected locoregional lymph nodes were found to be the only risk factor for the occurrence of PCF [RR=1.60 (1.006-2.54)]., Conclusion: The incidence of PCF is associated with the presence of affected locoregional lymph nodes. It is not associated with tracheostomy, administration of radio/chemotherapy before surgery or tumour location., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)