Abstract
Purpose
Pharyngocutaneous fistula (PCF) after laryngectomy continues to be a serious complication, especially after radiation. Recruitment of non-radiated tissue into the surgical defect may decrease the risk of fistula. These techniques however have significant morbidity and increases operative time. We hypothesized that using acellular dermal graft to reinforce the pharyngeal closure could decrease the risk of fistula, without the added morbidity of a vascularized flap.
Methods
We performed a retrospective chart review of all patients that underwent a laryngectomy between 2005 and 2015 at an acedemic tertiary referral center. Patients who underwent primary pharyngeal closure with Alloderm® reinforcement without any other flap reconstruction were identified. Basic demographics, previous treatment, operative technique and fistula were extracted from the medical records. The primary outcome was PCF rate. The time to closure, margin status and disease recurrence was also evaluated.
Results
Among 16 patients with AlloDerm® augmentation, eight had primary laryngectomy and eight had salvage laryngectomy. A total of three in the salvage laryngectomy with prior history of radiation developed PCF. The fistula closed in all three cases with conservative treatment. There was no PCF in the primary laryngectomy group without prior history of radiation.
Conclusion
The rate of PCF among the salvage laryngectomy group with previous radiation did not differ from historical data. AlloDerm® can however, provide a simple alternative for repair in radiation patients where flap cannot be performed for pharyngeal reconstruction. In non-radiated patients, AlloDerm® augmentation may have a protective effect on fistula formation.
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Introduction
Pharyngocutaneous fistula (PCF) is the most common and concerning complication after total laryngectomy. It leads to prolonged hospitalization, delays return to oral diet, and decreases quality of life. After laryngectomy for primary carcinoma, it also delays the start of adjuvant treatment. The risk for PCF is particularly high with previous (chemo)radiation and malnutrition . For salvage laryngectomy, many authors propose introducing non-radiated tissue to the wound bed, most commonly pectoralis major myocutaneous flap (PMMF), even when primary closure of the pharyngeal defect is accomplished. The pectoralis flap causes donor site morbidity and increases operative time . Microvascular flaps, such as radial forearm or anterolateral thigh flaps are in some centers used to introduce vascularized tissue . The limitations of this technique include special microvascular skills and equipment, longer operative times, risk of flap failure and donor site morbidity.
In the current study, we used an acellular dermal graft (AlloDerm®, LifeCell Corporation, Branchburg, NJ) to reinforce the pharyngeal closure. Alloderm® is processed from cadaveric skin obtained from tissue banks. During the processing, the dermis is de-cellularized using a detergent and the epidermis is removed to prevent an immune response by the recipient. AlloDerm® was initially used as replacement for large skin grafts in burn patients . Multiple uses have later been described, including dural repair, carotid coverage, re-surfacing of oral cavity defects, nasal septal perforation repair, temporomandibular joint reconstruction and pharyngeal repair in combination with sternocleidomastoid muscle flap .
To date, pharyngeal reconstruction with an Alloderm® patch as a method of decreasing post-laryngectomy PCF has not been described. We hypothesize that it will provide a similar rate of PCF as flap reconstruction, but will do so at decreased operative risk, less operative time and donor site morbidity.
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