Pharyngeal reconstruction after total laryngectomy with sliding epiglottis: technical aspects with retrospective review

To summarize the potential risk factors for postlaryngectomy pharyngocutaneous fistula. Observational studies in the English-language literature about postlaryngectomy pharyngocutaneous fistula from January 1, 1970, to March 31, 2003. Studies were identified through a MEDLINE search with relevant key words; additional studies were identified through references. We included studies about the site of primary malignancy, type of procedure, and type of closure; studies had to have been based on individual-level data, with a comparison group for each risk factor evaluated. Data required to calculate the relative risk of fistula associated with commonly reported risk factors were abstracted from the studies, and a meta-analysis using a random-effects approach was performed to estimate a summary relative risk of fistula for each risk factor. The statistical significance of heterogeneity of effects among studies was assessed. Of 65 studies identified, 26 met the inclusion criteria. Significant risk factors identified in the pooled analysis included postoperative hemoglobin level less than 12.5 g/dL, prior tracheotomy, preoperative radiotherapy, and preoperative radiotherapy and concurrent neck dissection. The degree of heterogeneity of effects among studies was significant for postoperative hemoglobin level, preoperative radiotherapy, concurrent neck dissection, and comorbid illness. The severity of fistula was greater in patients with a history of radiotherapy. This meta-analysis identified several significant risk factors for postlaryngectomy pharyngocutaneous fistula. The clinical implications of these findings and the potential sources of heterogeneity of effects among studies are discussed.

One-hundred patients undergoing radial forearm flap reconstruction in the head and neck over a 2-year period were followed prospectively to assess complications and morbidity associated with the radial flap donor site. Eighty-six patients were available follow-up at 3 months and 74 at 1 year (49 fasciocutaneous, 25 composite). Partial loss of the donor-site skin graft occurred in 14 patients (16 percent), with exposure of tendons in 11 patients (13 percent). Delay in healing of the split-thickness skin graft at the donor site occurred in 19 patients (22 percent). Fracture of the radius occurred in 6 of 35 patients with composite flaps (17 percent). Superficial radial nerve sensation was reduced in 24 patients (32 percent) at 1 year. Ten patients (14 percent) reported cold intolerance, and 21 patients (28 percent) complained of poor aesthetic result. Function of the donor arm was restricted in 8 patients (16 percent) in the fasciocutaneous group, in 7 patients (36 percent) in the composite group without fracture, and in all patients who had a fracture of the radius following harvesting of composite flaps. Detailed measurements of forearm circumference, grip strength, pinch strength, and wrist movements showed greater reduction in these parameters in patients reporting restricted function compared with those reporting normal function. It is concluded that there is a low incidence of long-term morbidity associated with fasciocutaneous flaps and a higher incidence with composite flaps. Fracture of the radius results in reduced function in all cases.