Prevention of wound complications following salvage laryngectomy using free vascularized tissue

Background. Total laryngectomy following radia- tion therapy or concurrent chemoradiation therapy is asso- ciated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techni- ques to minimize postoperative complications in salvage lar- yngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complica- tions in this difficult patient population. The purpose of this study was to outline our technique and determine the effec- tiveness of this new approach. Methods. We conducted a retrospective review of a pro- spective cohort and compared it with a historical group (surgical patients of Radiation Therapy Oncology Group (RTOG)-91-11 trial). Eligibility criteria for this study included patients under- going salvage total laryngectomy following failed attempts at organ preservation with either high-dose radiotherapy or concur- rent chemo/radiation therapy regimen. Patients were excluded if the surgical defect required a skin paddle for pharyngeal clo- sure. The prospective cohort consisted of 14 consecutive patients (10 males, 4 females; mean age, 58 years) who under- went free tissue reinforcement of the pharyngeal suture line fol- lowing total laryngectomy. The historical comparison group con- sisted of 27 patients in the concomitant chemoradiotherapy arm of the RTOG-91-11 trial who met the same eligibility criteria (26 males, 1 female; mean age, 57 years) but did not undergo free tissue transfer or other form of suture line reinforcement. Mini- mum follow-up in both groups was 12 months. Results. The overall pharyngocutaneous fistula rate was similar between groups—4/14 (29%) in the flap group, com- pared with 8/27 (30%) in the RTOG-91-11 group. There were no major wound complications in the flap group, compared with 4 (4/27, 14.8%) in the RTOG-91-11 group. There were no major fistulas in the flap group, compared with 3/27 (11.1% )i n the RTOG-91-11 group. The rate of pharyngeal stricture requir- ing dilation was 6/14 (42%) in the flap group, compared with 7/ 27 (25.9%) in the RTOG-91-11 group. In our patients, the rate of tracheoesophageal speech was 14/14 (100%), and complete oral intake was achieved in 13/14 (93%) patients. Voice-Related Quality of Life Measure (V-RQOL) and Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) scores suggest that speech and swallowing functions are reasonable following free flap reinforcement. Conclusions. Free vascularized tissue reinforcement of pri- mary pharyngeal closure in salvage laryngectomy following failed organ preservation is effective in preventing major wound complications but did not reduce the overall fistula rate. Fistulas that developed following this technique were relatively small, did not result in exposed major vessels, and were effectively treated with outpatient wound care rather than readmission to the hospi-