“ pharyngocutaneous fistulas after salvage laryngectomy : need for vascularized tissue ”
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Wojciech K. Mydlarz , M.D . “ Pharyngocutaneous Fistulas after Salvage Laryngectomy : Need for Vascularized Tissue ”. Disclosures. No Relevant Financial Relationships or Commercial Interests. Educational Objectives. Discuss risk factors for fistula after salvage total laryngectomy - PowerPoint PPT PresentationTRANSCRIPT
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“Pharyngocutaneous Fistulas after Salvage Laryngectomy: Need for Vascularized Tissue”
Wojciech K. Mydlarz, M.D.
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Disclosures
• No Relevant Financial Relationships or Commercial Interests
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Educational Objectives
• Discuss risk factors for fistula after salvage total laryngectomy
• Discuss prevention of fistulas after salvage total laryngectomy
• Discuss outcomes and complications of various surgical management options of fistulas.
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Overview
• Background• Risk factors for pharyngocutaneous
fistulas (PCF) after Salvage Total Laryngectomy (TL)
• Prevention of PCF after Salvage TL: vascularized tissue
• Outcomes
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Clinical Background
• Laryngeal Cancer:• Supraglottis (epiglottis,
arytenoids, aryepiglottic folds, false cords)
• Glottis (true cords, anterior and posterior commissures)
• Subglottis
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Clinical Background2006 ASCO• New cases of laryngeal cancer to be diagnosed
(U.S., 2005): 9,880• Newly diagnosed cases that will lead to death
(U.S., 2005): 3,770• 95% of laryngeal cancers are invasive with
squamous cell carcinoma as the predominant histologic type
• 40% of patients will have stage III or IV laryngeal cancer (upon first evaluation)
• 25% of healthy people are willing to trade a 20% absolute difference in survival for the opportunity to save their voice
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Clinical Background
• Tobacco and/or alcohol use are associated with most cases of laryngeal cancer
• Continued tobacco and/or alcohol use complicates treatment and facilitates medical comorbidity and the development of second primary cancers.
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Clinical Background
• Larynx-preservation options include:– Radiation therapy– Chemoradiation therapy– Function-preserving partial laryngectomy
procedures• TL is surgical procedure most feared by
patients. Common sequelae:– Social isolation– Job loss– Depression
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Clinical Scenario
• 54 year-old man s/p 35 doses of 2 Gray RT over 7 weeks for a T3NOMO squamous cell carcinoma of the right vocal cord
• 6 months later undergoes biopsy because of suspicion of recurrence.
• PMH significant for non–insulin-dependent diabetes mellitus and hypertension.
• Patient continues to smoke 10 cigarettes per day, which has decreased from 25 cigarettes per day before diagnosis of laryngeal cancer. He consumes about 4 beers per day.
• Biopsy histopathology positive for residual tumor. Multidisciplinary oncology board recommends salvage TL surgery.
• Potential complications of TL discussed with patient, including PCF. The patient asks about what are his risks for a fistula?
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PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9
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PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9
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PCF After Total LaryngectomyAarts MCJ et al. “Salvage Laryngectomy After Primary Radiotherapy: What Are Prognostic Factors for the Development of Pharyngocutaneous Fistulae?” Otolaryngology–Head and Neck Surgery 144(1) 5–9
• multivariate logistic regression analysis: only initial T stage & tumor site remained as independent prognostic factors
• Odds ratio (OR) for tumor stage:– 2.08 (95% confidence interval [CI] =
1.26-3.45)– T3-4 in comparison to T1-2 for
developing PCF• OR for tumor site:
– 2.08 (95% CI = 1.25-3.45)– Non-glottic tumors in comparison with
glottic tumors.
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PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.
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PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.
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PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.
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PCF After Total LaryngectomyPaydarfar JA, Birkmeyer NJ. “Complications in Head and Neck Surgery : A Meta-analysis of Postlaryngectomy Pharyngocutaneous Fistula.” Arch Otolaryngol Head Neck Surg. 2006;132:67-72.
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Prevention of PCF: Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery 141, 190-195.
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Prevention of PCF: Vascularized Tissue-PectoralisPatel UA, Keni SP. “Pectoralis myofascial flap during salvage laryngectomy prevents PCF.” Otolaryngology-head and Neck Surgery 141, 190-195.
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Prevention of PCF: Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-1023.
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Prevention of PCF: Vascularized Tissue-PectoralisGil Zm et al. “The role of Pectroalis Major Muscle Flap in Salvage TL.” Arch of Otolaryngology-Head and Neck Surgery 135, 1019-1023.
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Prevention of PCF: Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapFung K, et al. “Prevention of Wound complications following salvage TL using free vascularized tissue.” Head and Neck May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope 117, May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope 117, May 2007.
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Prevention of PCF: Vascularized Tissue-Free FlapWithrow KP, et al. “Free Tissue Transfer to Manage Salvage Laryngectomy Defects After Organ Preservation Failure.” Laryngoscope 117, May 2007.
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Outcomes of VascularizedTissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.
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Outcomes of VascularizedTissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.
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Outcomes of VascularizedTissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.
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Outcomes of VascularizedTissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.
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Outcomes of VascularizedTissue TransferClark JR, et al. “Morbidity After Flap Reconstruction of Hypopharyngeal Defects.” Laryngoscope 116, May 2006.
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Summary
• PCF can occurr after salvage TL• Previous radiotherapy, tumor location
and T stage are important risk factors• Vascularized tissue plays a role in
prevention of PCF after Salvage TL• Pectoralis major and free flaps can both
be used to help prevent PCF with good outcomes
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Questions?