Risk factors and healing factors for pharyngocutaneous fistula after total laryngectomy for laryngeal cancer: An epidemiological study.

To analyse the risk factors and healing factors of pharyngocutaneous fistula (PCF) in patients with laryngeal cancer after total laryngectomy, and to explore the relevant epidemiology. A retrospective analysis was conducted on laryngeal cancer patients who underwent total laryngectomy in our hospital from January 2010 to December 2022. The 349 patients included in the study were divided into a PCF group of 79 and a non-PCF group of 270. Perform one-way analysis of variance and multivariate logistic analysis on various data of patients included in the statistics, and analyse the risk factors and healing factors of PCF. Smoking, history of radiation therapy for laryngeal cancer, history of chemotherapy for laryngeal cancer, tumour location (larynx, pharynx, oesophagus), preoperative albumin, postoperative proteinaemia, <99 haemoglobin, postoperative haemoglobin, postoperative C-reactive protein (CRP) level are the risk factors for PCF. Also, radiation therapy and postoperative proteinaemia were the main reasons for preventing PCF healing. Smoking history, laryngeal cancer, radiation therapy, albumin, haemoglobin and CRP are risk factors for postoperative PCF after total laryngectomy, while radiation therapy and postoperative hypoalbuminaemia are key factors affecting PCF healing.

Impact of stapler versus manual closure techniques on pharyngocutaneous fistula development post-total laryngectomy: A systematic review and meta-analysis.

Pharyngocutaneous fistula (PCF) is a major complication after total laryngectomy, with significant morbidity and mortality. Whether mechanical stapler closure of the pharynx reduces fistula rates compared to hand-sewn techniques remains unclear. We conducted an updated systematic review and meta-analysis to clarify this question. Five databases were systematically searched from inception through November 2023 for studies comparing stapler versus suture closure for fistula outcomes after laryngectomy. Odds ratios (OR) were pooled using random-effects models and fixed-effects models. Subgroup and sensitivity analyses were performed. Risk of bias was appraised using NHLBI tools. Nine studies with 803 patients were included. Mechanical closure significantly reduced fistula incidence versus suture closure (OR = 0.57, 95% CI 0.34-0.95, p = 0.03). Subgroup analysis found that stapling's protective effect varied by patient age, country/region, linear stapler size and female percentage. Stapling reduced fistula odds by 80% in the Turkey subgroup (OR = 0.20, 95% CI 0.09-0.50) but showed no benefit in other regions. Patients <60 years showed an 84% fistula reduction with stapling (OR = 0.17, 95% CI 0.06-0.45), whereas older subgroups did not. Linear stapler size of 60 mm significantly reduced fistula occurrence while 75 mm did not. There was no evidence that low female percentage mitigated stapling benefits. Mechanical stapler closure after total laryngectomy meaningfully reduces the likelihood of postoperative PCF formation compared to hand-sewn closure, especially for patients younger than 60 years old. The absolute risk reduction supports its utility to prevent this complication.

Utero-cutaneous fistula following caesarean section.

A multiparous woman in her 20s, presented to the clinic with bleeding from caesarean scar site. After clinical examination and radiological evaluation with ultrasound and MR fistulogram, the diagnosis was utero-cutaneous fistula. Complete resection of fistulous tract with uterine defect closure and supportive omental patch placement was done after an intraoperative demonstration of the utero-cutaneous fistula by injecting methylene blue dye. Utero-cutaneous fistula is a rare complication after caesarean section. Cyclical bleeding from an abnormal opening in previous caesarean scar site is the classical presentation of this condition.

Prophylactic pectoralis major flap to compensate for increased risk of pharyngocutaneous fistula in laryngectomy patients with low skeletal muscle mass (PECTORALIS): study protocol for a randomized controlled trial.

BACKGROUND: Total laryngectomy (TL) is a surgical procedure commonly performed on patients with advanced laryngeal or hypopharyngeal carcinoma. One of the most common postoperative complications following TL is the development of a pharyngocutaneous fistula (PCF), characterized by a communication between the neopharynx and the skin. PCF can lead to extended hospital stays, delayed oral feeding, and compromised quality of life. The use of a myofascial pectoralis major flap (PMMF) as an onlay technique during pharyngeal closure has shown potential in reducing PCF rates in high risk patients for development of PCF such as patients undergoing TL after chemoradiation and low skeletal muscle mass (SMM). Its impact on various functional outcomes, such as shoulder and neck function, swallowing function, and voice quality, remains less explored. This study aims to investigate the effectiveness of PMMF in reducing PCF rates in patients with low SMM and its potential consequences on patient well-being. METHODS: This multicenter study adopts a randomized clinical trial (RCT) design and is funded by the Dutch Cancer Society. Eligible patients for TL, aged ≥ 18 years, mentally competent, and proficient in Dutch, will be enrolled. One hundred and twenty eight patients with low SMM will be centrally randomized to receive TL with or without PMMF, while those without low SMM will undergo standard TL. Primary outcome measurement involves assessing PCF rates within 30 days post-TL. Secondary objectives include evaluating quality of life, shoulder and neck function, swallowing function, and voice quality using standardized questionnaires and functional tests. Data will be collected through electronic patient records. DISCUSSION: This study's significance lies in its exploration of the potential benefits of using PMMF as an onlay technique during pharyngeal closure to reduce PCF rates in TL patients with low SMM. By assessing various functional outcomes, the study aims to provide a comprehensive understanding of the impact of PMMF deployment. The anticipated results will contribute valuable insights into optimizing surgical techniques to enhance patient outcomes and inform future treatment strategies for TL patients. TRIAL REGISTRATION: NL8605, registered on 11-05-2020; International Clinical Trials Registry Platform (ICTRP).

Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube.

BACKGROUND: There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. METHODS: Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. RESULTS: Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. CONCLUSION: The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.

Videofluoroscopic swallowing study to detect pharyngeal leak after total (pharyngo-) laryngectomy: Retrospective assessment of a single-institution protocol.

BACKGROUND: We aimed to assess the effectiveness of a single-institution protocol of videofluoroscopic swallowing study (VFSS) for the detection of pharyngeal leak (PL) and its usefulness to mitigate evolution into subsequent pharyngocutaneous fistula (PCF) after total (pharyngo-) laryngectomy (TL). METHODS: This retrospective single-center study was conducted between February 2014 and December 2022. We included all patients who underwent TL and performed a VFSS between Day 7 and Day 14 postoperatively to detect a subclinical PL. RESULTS: Two-hundred and forty-eight patients met the inclusion criteria. Among the 186 patients (75%) with a negative VFSS, 11 patients (5.9%) developed a secondary PCF after oral intake resumption (false negative of VFSS). Among the 62 patients (25%) with a positive VFSS, the occurrence of a PCF was avoided in 59.7% of cases. CONCLUSION: This study showed a good effectiveness of VFSS in the detection of PL after TL, alongside a usefulness to mitigate evolution into subsequent PCF.

Cutaneous fistula formation after thyroid nodule rupture: A rare complication after radiofrequency ablation.

BACKGROUND: With innovative treatment options such as radiofrequency ablation (RFA) for thyroid nodules, new complications are being identified. It is important to define and delineate complications in order to counsel patients appropriately about treatment options and their associated risks and benefits. METHODS: A 46-year-old male presented with a left thyroid nodule (6.5 cm). Fine needle aspiration results were benign. He started to develop intermittent dyspnea and underwent one RFA procedure. Approximately 6 days post-RFA, the neck area was raised and red with blister. The skin overlying the blister underwent eventual dehiscence with fluid spillage. Several months later, MRI imaging showed substernal extension with tracheal deviation. RESULTS: A left thyroid lobectomy was performed with cutaneous excision and successful closure of a fistula. CONCLUSIONS: This is the first reported case of a thyroid nodule rupture following RFA which manifested into a thyro-cutaneous fistula and required surgical intervention.

Novel techniques for prevention of post-operative pharyngocutaneous fistula in locally advanced laryngeal and hypopharyngeal cancers.

BACKGROUND: Pharyngocutaneous fistula is one of the most common complications following total laryngectomy. It increases hospital stay and the financial burden on patients, and prolongs nasogastric feeding. This paper presents novel techniques for prevention of pharyngocutaneous fistula. METHOD: A retrospective study was conducted at a tertiary referral centre to assess the effectiveness of continuous extramucosal pharyngeal suturing and the hydrogen peroxide leak test in prevention of pharyngocutaneous fistula in 59 patients who had undergone total laryngectomy with or without partial pharyngectomy for locally advanced cancers of the larynx and hypopharynx. RESULTS: The incidence of pharyngocutaneous fistula in our study was 6.8 per cent, which is considerably lower than the incidence reported in various previous studies. CONCLUSION: The continuous extramucosal suturing technique provides watertight closure of the neopharynx and can be recommended as a reliable method for neopharyngeal closure post total laryngectomy to reduce the occurrence of pharyngocutaneous fistula.

Pharyngo-cervicospinal fistula with destructive osteomyelitis after laryngopharyngectomy and radiotherapy, managed successfully with a vascularized fibula free flap.

Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously.

Development of a nomogram for predicting pharyngocutaneous fistula based on skeletal muscle mass and systemic inflammation indices.

BACKGROUND: Laryngeal and hypopharyngeal cancers often require surgical treatment, which can lead to the development of pharyngocutaneous fistula (PCF). Our research aimed to assess the predictive value of skeletal muscle mass (SMM) and systemic inflammation indices for PCF and construct a clinically effective nomogram. METHODS: A nested case-control study of 244 patients matched from 1171 patients with laryngeal or hypopharyngeal cancer was conducted. SMM was measured at the third cervical level based on CT scans. A PCF nomogram was developed based on the univariate and multivariate analyses. RESULTS: Glucose, white blood cell count, platelet-to-lymphocyte ratio, and skeletal muscle index were independent risk factors for PCF. The area under the curve for the PCF nomogram was 0.841 (95% CI 0.786-0.897). The calibration and decision curves indicated that the nomogram was well-calibrated with good clinical utility. CONCLUSIONS: The nomogram we constructed may help clinicians predict PCF risk early in the postoperative period, pending external validation.

[Spontaneous cholecysto-cutaneous fistula: about two cases]. / Fístula colecisto-cutánea espontánea: a propósito de dos casos.

Cholecysto-cutaneous fistula (CCF) is a rare complication of untreated biliary pathology, with fewer than 100 cases documented in the literature. Most are secondary to bacterial infection, although it has also been described in gallbladder adenocarcinoma and post trauma. Its clinical presentation is variable, being able to present systemic affection, and its most frequent external drainage site is in the right hypochondrium. Due to the low incidence of this pathology, and the variety of forms of presentation, its management does not have, to date, standardized bases. We present two cases of patients who consulted in the emergency room at the Hospital Nacional de Clínicas for presenting cholecysto-cutaneous fistula. The treatment of both was surgical.

La fístula colecisto-cutáneas (FCC) es una rara complicación de la patología biliar no tratada, habiendo menos de 100 casos documentados en la literatura. La mayoría son secundarias a infección bacteriana, aunque también fue descripta en el adenocarcinoma de vesícula y posterior a traumatismo. Su presentación clínica es variable, pudiendo presentar afección sistémica, y su sitio más frecuente de drenaje externo es en hipocondrio derecho. Debido a la baja incidencia de esta afección, y a la variedad de formas de presentación, su manejo no tiene hasta el momento bases estandarizadas. Presentamos dos casos de pacientes que consultaron por guardia de urgencias en el Hospital Nacional de Clínicas por presentar fistula colecisto-cutánea. El tratamiento de ambos fue quirúrgico.

Endoscopic stent placement for the management of gastro-pleural and gastro-cutaneous fistula post laparoscopic sleeve gastrectomy: a case report.

BACKGROUND: Gastro-pleural and gastro-cutaneous fistulae formation are rare yet life-threatening complications post-bariatric surgery. To our knowledge so far only limited cases of gastro-pleural and gastro-cutaneous fistulae post gastric sleeve surgery have been reported in the literature with their corresponding management. Therefore, we are reporting a case of placement of an endoscopic stent in the management of gastro-cutaneous fistula post laparoscopic sleeve gastrectomy. CASE PRESENTATION: A 42 years old Pakistani, female morbidly obese patient, underwent laparoscopic sleeve gastrectomy. Within a week after the procedure, the patient presented with dyspnea. Workup showed a gastric leak for which percutaneous drain placement was done. Later, gastro-pleural and gastro-cutaneous fistulae were formed for which endoscopic fistula closure was done using a metallic stent. CONCLUSION: Endoscopic stent placement is an emerging field and it is considered safe and effective for the management of complications related to bariatric surgery.

Early detection of pharyngocutaneous fistulae after total laryngectomy by cytokine in drainage: A pilot study (DEFILAC).

BACKGROUND: The determination of cytokines in the postoperative drainage (POD) fluid could be a method for early detection of the development of a pharyngocutaneous fistula (PCF). MATERIALS AND METHODS: We conducted a prospective two-center study involving 28 patients. PODs were collected on Day 1 (D1) and Day 2 (D2) postoperatively for determination of a cytokine panel and cytobacteriological examination. RESULTS: Eleven (39%) patients presented with PCF on average 13 ± 5.5 days after surgery. Patients with PCF had higher IL-10 (121 vs. 40.3, p = 0.04, effect size (ES) = 0.98 [0.16, 1.79]) and TNFα level (21.2 vs. 2.2, p = 0.02, ES = 0.83 [0.03, 1.63]) on D2. An IL-10 threshold of 72 pg/mL on D2 was diagnostic of the occurrence of PCF with a sensibility of 70%, specificity of 88%. CONCLUSION: The determination of cytokines in POD fluid on D2 is a reliable tool for predicting the development of a PCF after total laryngectomy.

Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula.

BACKGROUND: Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF. METHODS: We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test. RESULTS: There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test). CONCLUSION: TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

A review of pharyngocutaneous fistula management in head and neck malignancies.

Pharyngocutaneous fistula is a serious complication after head and neck reconstruction and concurrent chemoradiotherapy, yet no consensus or practical protocols regarding the surgical timing and specific procedures could be found in the current literature. The authors aimed to review their clinical experience in surgical management and develop an algorithmic approach accordingly. A retrospective review of all hypopharyngeal cancer patients who developed pharyngocutaneous fistula during 2017 to 2021 at E-Da Hospital was conducted. Seventeen patients developed pharyngocutaneous fistula in all 321 pharyngeal cancer admissions during this period. Three patients received interventions at acute stage (≤2 weeks), with two direct repairs Three patients received interventions at acute stage (≤2 weeks), with two direct repairs and one regional flap coverage then negative pressure wound therapy. Nine received interventions at subacute stages (2 weeks to 3 months), with 4 resolved after debridement and direct repair yet another 4 underwent regional flap reconstruction and 1 free flap reconstruction. Five chronic fistula (>3 months) received secondary reconstructions utilizing a double-layered repair of local turn-over flaps for the internal mucosal opening and another flap harvest (four regional flaps and one free flap) to cover the outer skin defect. All patients after the palliative surgery achieved complete remission of fistula at follow follow-up. Different conservative and surgical approaches should be adopted according to the acute, subacute, and chronic stages of pharyngocutaneous fistula after palliative head and neck reconstructions.

Staged neck dissection prior to transoral robotic surgery for oropharyngeal cancer: does it reduce post-operative complication rates? A multi-centre study of 104 patients.

PURPOSE: Transoral robotic surgery (TORS) has become increasingly recognised as a safe and effective treatment for early oropharyngeal squamous cell carcinoma, often performed in conjunction with neck dissection (ND) and vessel ligation. It has been proposed that performing the neck dissection in a staged fashion prior to TORS results in low rates of transoral haemorrhage and pharyngocutaneous fistula, and may aid in TORS patient selection by eliminating patients who would require multi-modality treatment based on nodal pathology. This study aims to assess the effect of staged neck dissection with TORS in mitigating pharyngocutaneous fistulae and post-operative haemorrhage as well as the impact of staged ND on TORS patient selection. METHODS: A retrospective cohort analysis was performed of patients undergoing staged ND with intent to proceed to TORS at two Australian hospitals between 2014 and 2022. Incidence of post-operative haemorrhage and pharyngocutaneous fistula and length of inpatient stay was identified. The number of patients who did not proceed to TORS was recorded. RESULTS: One hundred and four patients were identified who underwent staged neck dissection with an intention to proceed to TORS. Six patients did not proceed to TORS following pathological assessment of the neck dissection specimen and ninety-eight patients (91 primary, 7 salvage) underwent TORS. There were six cases of secondary haemorrhage (one major, two intermediate and three minor). There were no cases of pharyngocutaneous fistula. CONCLUSION: Staged neck dissection prior to TORS results in low rates of haemorrhage and pharyngocutaneous fistula and can improve TORS patient selection.

Perioperative Factors Aggravating Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Center Retrospective Analysis Using the Clavien-Dindo Classification.

BACKGROUND: Pharyngocutaneous fistula formation represents a major postoperative complication following total laryngectomy. We aimed to investigate the risk factors for pharyngocutaneous fistula development after total laryngectomy and to identify factors that lead to severe cases of pharyngocutaneous fistula. METHODS: Patients who underwent total laryngectomy between January 2013 and February 2021 were included in the study and were divided into 2 groups: Those with and without pharyngocutaneous fistula. The severity of pharyngocutaneous fistula was graded using the Clavien-Dindo classification. RESULTS: Patients with pharyngocutaneous fistula experienced longer operative time, greater intraoperative blood loss, greater decrease in perioperative hemoglobin level, and longer postoperative hospitalization. Unlike in lower-severity cases, patients with grade IIIb pharyngocutaneous fistula underwent preoperative radiotherapy or chemoradiotherapy; preoperative treatment was thus a risk factor for higher severity of pharyngocutaneous fistula (odds ratio, 35; P = 0.004). CONCLUSION: Salvage laryngectomy was found to be a predictor of severe pharyngocutaneous fistula development. Prolonged operative time, increased intraoperative blood loss, and decreased postoperative hemoglobin level were found to be predictors of postlaryngectomy pharyngocutaneous fistula formation.