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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 1  |  Page : 32-36

Pectoralis major flap reconstruction in the prevention of wound breakdown and fistula formation after salvage laryngectomy: a controlled study


Eldemerdash Hospital, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Date of Submission06-Jan-2015
Date of Acceptance16-Jan-2014
Date of Web Publication5-Feb-2016

Correspondence Address:
Reda M Sabra
71 Imtedad Walley Elahd Hadayek Elkoppa, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1012-5574.175803

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  Abstract 

Background
Patients undergoing salvage laryngeal surgery after high-dose radiotherapy or concurrent chemotherapy/radiation therapy regimen are more prone to develop pharyngocutaneous fistulas (PCFs). The fistula rates reported are as high as 70%.
Aim of the study
The aim of this study was to assess the effectiveness of pectoralis major muscle flap (PMF) in prevention of fistula formation and in enhancing wound healing in patients undergoing salvage laryngectomy.
Patients and methods
We compared results from patients of salvage laryngectomy repaired with pectoralis major flap with those of a similar group repaired by primary wound closure in 36 consecutive patients. Group A included 16 patients who underwent PMF following salvage total laryngectomy (12 male and four female patients; median age 56 years; interquartile range, 49.8-61.8). The other group included 20 patients who underwent primary closure of the wound without PMF (group B) (15 male and five female patients; median age 43 years; interquartile range, 36-54). Minimum follow-up in both groups was 3 months.
Results
The incidence of PCF in group A was 6.2% and that of wound gap was 6.2%, and there was no carotid blowout. The results in group B were as follows: 60% PCF rate and poor wound healing with gapping in 40% of patients and carotid blowout in 25% of patients (P < 0.001). The mean duration to fistula closure was 20 days in group A compared with 57.5 days in group B.
Conclusion
Pectoralis major flap will give the patients the advantages of less fistula formation, good wound healing, early oral feeding, short hospital stay and protection against catastrophic vascular blowouts.

Keywords: fistula, flaps, laryngectomy, pectoralis major, reconstruction


How to cite this article:
Sabra RM, Taha MS, Hamdy TA, Rabie H, Riad MA. Pectoralis major flap reconstruction in the prevention of wound breakdown and fistula formation after salvage laryngectomy: a controlled study. Egypt J Otolaryngol 2016;32:32-6

How to cite this URL:
Sabra RM, Taha MS, Hamdy TA, Rabie H, Riad MA. Pectoralis major flap reconstruction in the prevention of wound breakdown and fistula formation after salvage laryngectomy: a controlled study. Egypt J Otolaryngol [serial online] 2016 [cited 2019 Sep 17];32:32-6. Available from: http://www.ejo.eg.net/text.asp?2016/32/1/32/175803


  Introduction Top


Laryngectomy is used increasingly as a salvage procedure after radiotherapy or chemoradiotherapy. The development of organ preservation protocols and primary chemoradiotherapy for patients with advanced laryngeal cancer resulted in an organ preservation rate of 64% and survival rates similar to those seen in patients offered laryngectomy followed by radiotherapy [1] .

Patients undergoing salvage surgery are more prone to develop pharyngocutaneous fistulas (PCFs) because of injuries to the tissue microvasculature, resulting in myointimal fibrosis, endarteritis and worsening of atherosclerosis, which lead to a hypovascular, hypocellular and hypoxic environment, reducing healing capacity and increasing the risk for fistula formation to as high as 70% [2] . In an attempt to prevent or reduce the incidence of salivary fistulas, some authors have advocated the routine use of nonirradiated flaps to reduce the morbidities associated with salivary fistulas in salvage laryngectomy patients, even when there is enough mucosa for a primary closure procedure.

Placement of a vascularized tissue that was out of the field of radiation may improve the healing capacity in such settings [3] . In this article, we assess the effectiveness of pectoralis major muscle flap (PMF) in wound healing, protection against catastrophic vascular blowouts and prevention of fistula formation after salvage laryngectomy.


  Patients and methods Top


This is a retrospective study. It was conducted at the Otorhinolaryngology Department, Ain Shams University Hospitals, between January 2011 and October 2014 with Institutional Review Board approval. An informed written consent was obtained from all participants.

Thirty-six patients were enrolled in our study. All of them were diagnosed with T3 or T4 squamous cell carcinoma of the larynx. Eligibility criteria for this study included patients undergoing salvage total laryngectomy following failed attempts in organ preservation protocols with either high-dose radiotherapy or concurrent chemotherapy/radiation therapy regimen. The series consisted of 36 consecutive patients were divided into two groups: group A and group B. Group A included 16 consecutive patients (12 male and four female patients; median age 56 years; interquartile range, 49.8-61.8) who underwent PMF following salvage total laryngectomy. Group B consisted of 20 patients who underwent concomitant chemoradiotherapy and met the same eligibility criteria (15 male and five female patients; median age 43 years, interquartile range, 36-54) [Table 1]. They underwent primary closure of the wound without PMF.

Minimum follow-up in both groups was 3 months. Student's t-test was used in statistical analysis. Skewed numerical data are presented as median and interquartile range. Qualitative data are presented as number and percentage.
Table 1 Patients groups

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Surgical technique [4]

Total laryngectomy with or without neck dissection are performed in the standard way, taking extra care to preserve branches of the superior and inferior thyroid vessels supplying the residual pharyngeal tissues. Care is also taken to clear the field from any devitalized tissues and secure haemostasis. A primary tracheo-oesophageal puncture is created at this stage, because of the difficulties in performing a secondary puncture once the PMF overlies the neopharynx.

A size 14-18-feeding tube is inserted through the tracheo-oesophageal puncture to avoid any pressure on the pharyngoplasty suture line. Pharyngoplasty is then carried out in three layers: first by meticulous suturing and inverting the mucosal edges using 3-0 vicryl extraluminal sutures, followed by enforcing the repair by suturing the overlying buccopharyngeal fascia, and finally by suturing the cut edges of the thyropharyngeus and cricopharyngeus muscles over the repaired pharynx. The neck wound is then covered with swabs soaked in normal saline, and the anterior thoracic wall is prepared for harvesting the PMF.

The surgical technique we used aimed at harvesting two large pedicled flaps: the deltopectoral skin flap and a fasciomuscular pectoralis major flap. The skin flap is resutured to its bed, to be used later only if there is a major wound breakdown, and the PMF is mobilized to cover the pharyngoplasty and major neck vessels [Figure 1] and [Figure 2]. The skin and fascia are then elevated off the muscle by means of a sharp dissection, taking care not to injure the perforating intercostal branches from the internal mammary vessel that supplies the skin flap.
Figure 1: The deltopectoral skin flap

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Figure 2: Deltopectoral flap elevated to expose the pectoralis major muscle

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The exposed pectoralis major muscle is then dissected off the thoracic wall by means of a sharp dissection; branches from the lateral thoracic artery may have to be divided to allow the pedicle length of the PMF to reach the upper neck defect. While harvesting the PMF, the inferior border of the muscle is first incised, and dissection is carried out to lift the muscle off the thoracic wall. Identification of the pectoral branch of the thoracoacromial artery is the crucial step during the procedure. The vessels should be identified on the undersurface of the muscle before any further muscle incisions are carried out. Muscle cuts are then made lateral and medial to the exposed vascular pedicle [Figure 3]. The mobilized muscle flap can now be turned over to cover the neck wound while the vascular pedicle is under clear vision [Figure 4].
Figure 3: Identification of vascular pedicle before muscle cuts

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Figure 4: Pectoralis muscle turned in the neck

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Care must be taken to ensure that the flap is not under any tension in its new position in the neck. Strict haemostasis is secured in the thoracic wound. The deltopectoral skin flap is then returned to its original position and sutured in two layers. The PMF is now used to cover the neopharynx, the carotid sheaths and the supratracheostomy region. Nonabsorbable sutures are used to secure the PMF in the neck; the wound is irrigated and suction drains are inserted.


  Results Top


A total of 36 consecutive patients were included in this study. The results are summarized in [Table 2]. The incidence of PCF was 6.2% for salvage surgery patients with PMF reinforcement, whereas it reached 60% for patients who underwent salvage surgery without PMF reinforcement (P < 0.001). The mean duration to final healing and oral feeding was 22.5 days in group A compared with 51.8 days in group B.
Table 2 Postoperative results

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There was poor wound healing with gapping in 40% of patients and carotid blowout in 25% of patients in group B, compared with group A in which wound gap was seen in 6.2% of patients and there was no incidence of carotid blowout. There was only one case of flap failure in group A [Figure 5].
Figure 5: Postoperative complication. Group A: blue, group B: red, pharyngocutaneous fistula (PCF), wound gap (WG), carotid blowout (CB), flap failure (FF)

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There was early oral feeding and shorter hospital stay (average 3 weeks) in group A compared with late oral feeding and longer hospital stay (more than 9 weeks) in group B (P < 0.001) [Table 2].


  Discussion Top


Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated 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 techniques to minimize postoperative complications in salvage laryngectomy surgery [3] . The effect of radiotherapy translates into injuries to tissue microvasculature, resulting in myointimal fibrosis, endarteritis and worsening of atherosclerosis, leading to a hypovascular, hypocellular and hypoxic environment, thus reducing healing capacity and increasing the risk for fistula formation, its severity and duration [3],[5],[6] .

The use of nonirradiated flaps has been recommended to reduce the incidence rates and the morbidities associated with salivary fistulas in salvage laryngectomy patients, even when there is enough mucosa for a primary closure procedure [7],[8] . The rationale of this strategy revolves around using healthy tissue with abundant vascularization to maximize surgical wound healing, thus preventing local complications. Nowadays, flaps have been used routinely in salvage laryngectomy procedures performed at head and neck surgery centers all over the world [9] . In this study we use the PMF in an effort to improve tissue vascularity, reinforce the pharyngeal suture line and minimize complications in this difficult patient group [6] .

PCF is the most common major complication following laryngectomy. The severity of this fistula increases when it is preceded by chemoradiotherapy [10] . The use of PMF in salvage laryngeal surgery is of great help in high-risk patients to minimize incidence of PCF and to allow primary skin wound healing. This flap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blowouts. The incidence rate of salivary fistulas in group A patients, who underwent augmentation of the pharynx by PMF, was 6.2%, which eventually healed. There were no carotid artery blowouts, and all patients had well-healed wound and resumed oral feeding. In contrast, group B showed 60% PCF rate, poor wound healing with gapping in 40% and carotid blowout in 25%. These results are in accordance with a meta-analysis study conducted by Paydarfar and Birkmeyer [5] , which concluded that preoperative radiotherapy increases the risk of PCFs (P < 0.001).

Our results are in accordance with those of a retrospective study conducted by Patel and Keni [9] , who stated that there were no fistulas in patients for whom PMFs were used, compared with 57% for those in whom primary closure was performed. A study from Memorial University showed that rates of fistula occurrence were reduced from 22.9 to 1% when PMFs were used routinely in salvage laryngectomies [11] . In Weber study (without PMF flap), up to one-third of patients developed a PCF [12] . Oosthuizen et al. [10] recorded a PCF rate of 50% for salvage surgery patients without PMF reinforcement. The incidence rate of salivary fistulas in primary laryngeal closure, in a study by Alexandre et al. [13] , was 32%, as also observed by other authors such as Varghese et al. [14] (41%), Van der Putten et al. [15] (30%) and Ganly et al. [16] (32%). Fistula was more common in patients who underwent initial primary closure (45%) than in patients who had immediate PMF only (10.5%) [17] .

The mean duration to fistula closure was 22.5 days in group A compared with 51.8 days in group B. Oosthuizen et al. [10] showed that the mean time to fistula closure was 20.5 days in salvage patients with PMF compared with 57.16 days in those patients who developed a PCF following primary laryngectomy, indicating that the use of a PMF reduces the severity and duration of PCF in salvage surgery patients. Shorter hospital stay (average 3 weeks) was observed in group A compared with longer hospital stay (more than 9 weeks) in group B (P < 0.001). The same result was seen by Tsou et al. [18] , who showed that the length of hospitalization of patients with PCFs was 37.6 days, compared with 20.7 days for patients without fistulas.

Our rate of total flap loss was 6.2% in this study compared with 2.4% in the study by Kroll et al. [19] ; this is of great importance, as total flap necrosis is the only complication that requires another flap. One drawback of PMF is that follow-up in the neck region is more complicated because the flap can hide neck recurrences. The pectoralis major muscle pedicled flap is reliable and provides safe repair; the flap can be rapidly raised from the anterior chest wall, and no additional expertise in microvascular or abdominal surgery is needed. The main advantages reported are the ease of its technical aspects, the proximity of the head and neck region and the possibility of obtaining a large amount of well-vascularized tissue. As it is a regional flap, it does not require specific materials or teams specialized in microsurgical anastomoses, and it introduces low donor site morbidity [2],[20],[21] . The low morbidity to the donor site and execution in a one-stage procedure has encouraged a wider use of PMF flaps. This flap could also reduce the risk of late complications such as stenosis, dysphagia and use of feeding tubes, as shown by Patel and Keni [9] .


  Conclusion Top


PCF and poor wound healing remain a significant problem following salvage laryngectomy. The use of nonirradiated, vascularized flaps [pectoralis major muscle pedicled flap (PMF)] reduces the incidence, duration and severity of fistula. It improves wound healing and should be considered if salvage laryngectomy is required.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Esteller E, Vega MC, López M, Quer M, León X. Salvage surgery after locoregional failure in head and neck carcinoma patients treated with chemoradiotherapy. Eur Arch Otorhinolaryngol 2011; 268:295-301.  Back to cited text no. 1
    
2.
Gil Z, Gupta A, Kummer B, Cordeiro PG, Kraus DH, Shah JP, Patel SG. The role of pectoralis major muscle flap in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 2009; 135:1019-1023.  Back to cited text no. 2
    
3.
Wakisaka N, Murono S, Kondo S, Furukawa M, Yoshizaki T. Post-operative pharyngocutaneous fistula after laryngectomy. Auris Nasus Larynx 2008; 35:203-208.  Back to cited text no. 3
    
4.
Riad MA, Hamdy TA, Sabra RMI, Adly A. Pectoralis major flap in the reconstruction after salvage laryngectomy: how I do it. Egypt J Otolaryngol 2013; 29:145-148.  Back to cited text no. 4
  Medknow Journal  
5.
Paydarfar JA, Birkmeyer NJ. Complications in head and neck surgery: a metaanalysisof post laryngectomypharyngo-cutaneous fistula. Arch Otolaryngol Head Neck Surg 2006; 132:67-72.  Back to cited text no. 5
    
6.
Fung K, Teknos TN, Vandenberg CD, Lyden TH, Bradford CR, Hogikyan ND, et al. Prevention of wound complications following salvage laryngectomy using free vascularized issue. Head Neck 2007; 29:425-430.  Back to cited text no. 6
    
7.
Hanasono MM, Lin D, Wax MK, Rosenthal EL. Closure of laryngectomy defects in the age of chemoradiation therapy. Head Neck 2012; 34:580-588.  Back to cited text no. 7
    
8.
Furuta Y, Homma A, Oridate N, Suzuki F, Hatakeyama H, Suzuki K, et al. Surgical complications of salvage total laryngectomy following concurrent chemoradiotherapy. Int J Clin Oncol 2008; 13:521-527.  Back to cited text no. 8
    
9.
Patel UA, Keni SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 2009; 141:190-195.  Back to cited text no. 9
    
10.
Oosthuizen JC, Leonard DS, Kinsella JB. The role of pectoralis major myofascial flap in salvage laryngectomy: a single surgeon experience. Acta Otolaryngol 2012; 132:1002-1005.  Back to cited text no. 10
    
11.
Smith TJ, Burrage KJ, Ganguly P, Kirby S, Drover C. Prevention of postlaryngectomy pharyngocutaneous fistula: the Memorial University experience. J Otolaryngol 2003; 32:222-225.  Back to cited text no. 11
    
12.
Weber RS, Berkey BA, Forastiere A, Cooper J, Maor M, Goepfert H, et al. Outcome of salvage total laryngectomy following organ preservation therapy: the Radiation Therapy Oncology Group trial 91-11. Arch Otolaryngol Head Neck Surg 2003; 129:44-49.  Back to cited text no. 12
    
13.
Sousa AA, Castro SM, Porcaro-Salles JM, Soares JM, de Moraes GM, Carvalho JR, Silva GS. The usefulness of a pectoralis major myocutaneous flap in preventing salivary istulae after salvage total laryngectomy. Braz J Otorhinolaryngol. 2012; 78:103-107.  Back to cited text no. 13
    
14.
Varghese BT, Sebastian P, Mathew A. Treatment outcome in patients undergoing surgery for carcinoma larynx and hypopharynx: a follow-up study. Acta Otolaryngol 2009; 129:1480-1485.  Back to cited text no. 14
    
15.
van der Putten L, de Bree R, Kuik DJ, Rietveld DH, Buter J, Eerenstein SE, Leemans CR. Salvage laryngectomy: oncological and functional outcome. Oral Oncol 2011; 47:296-301.  Back to cited text no. 15
    
16.
Ganly I, Patel S, Matsuo J, Singh B, Kraus D, Boyle J, et al. Postoperative complications of salvage total laryngectomy. Cancer 2005; 103:2073-2081.  Back to cited text no. 16
    
17.
Gilbert MR, Sturm JJ, Gooding WE, Johnson JT, Kim S. Pectoralis major myofascial onlay and myocutaneous flaps and pharyngocutaneous fistula in salvage laryngectomy, 2014. The American Laryngological, Rhinological and Otological Society, Inc.  Back to cited text no. 17
    
18.
Tsou YA, Hua CH, Lin MH, Tseng HC, Tsai MH, Shaha A. Comparison of pharyngocutaneous fistula between patients followed by primary laryngopharyngectomy and salvage laryngopharyngectomy for advanced hypopharyngeal cancer. Head Neck 2010; 32:1494-1500.  Back to cited text no. 18
    
19.
Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP, Miller MJ, et al. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps. Plast Reconstr Surg 1997; 99:1282-1286.  Back to cited text no. 19
    
20.
Righini C, Lequeux T, Cuisnier O, Morel N, Reyt E. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005; 262:357-361.  Back to cited text no. 20
    
21.
Sundaram K, Wasserman JM. Prevention of unplanned pharyngocutaneous fistula in salvage laryngectomy. Otolaryngol Head Neck Surg 2009; 141:645-647.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]


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