Re-reconstructions for cases with persistent post-reconstructive orocutaneous or oropharyngocutaneous fistulas after extensive reconstructive operations in head and neck region

doi:10.19438/j.cjoms.2021.04.015

Abstract

Abstract: PURPOSE: Orocutaneous or oropharyngeal fistulas may develop after extensive surgery in the head and neck region. This paper described our experiences in applying salvage secondary or tertiary reconstructions in these situations. METHODS: A retrospective study was performed based on the 10-year experiences of secondary or tertiary reconstructions for correction of persistent post-reconstructive orocutaneous or oropharyngocutaneous fistulas in our institution. Thirty-one cases were considered as eligible. The possible causes for these fistulas were recorded. The salvage reconstructive approaches were summarized, while related complications and follow-up outcomes were reported as well. Multivariate statistical analyses for the survival-related factors were performed using SPSS 25 software package. RESULTS: Among all these cases, 19 cases(61.3%) were with post-reconstructive orocutanenous fistulas, while 12(38.7%) were with oropharyngocutaneous fistulas. Anterolateral thigh flaps(n=15, 48.4%) were the most used flaps in the failed prior operations. Most of the cases(n=19, 61.3%) were with histories of prior irradiation. As for the specific salvage reconstructive approaches, 8 cases (25.8%) were re-reconstructed with anterolateral thigh free flaps, while 18(58.1%) were with pectoralis major myocutaneous flaps and 3(9.7%) with fibular flaps, respectively. All re-reconstructive flaps survived postoperatively. Complication rate reached 38.7%(12/31),with pulmonary infections and minor wound dehiscence representing the most likely ones. The overall survival rate reached 58.1%(18/31) calculated at recent follow-ups. CONCLUSIONS: Secondary or tertiary reconstructions for these cases are challenging. Careful planning and considerable expertise in re-reconstructive surgery are both required for successful management of these serious complications.

Key words: Reconstruction surgery, Orocutaneous, Oropharyngocutaneous

CLC Number:

R782.2

MA Chun-yue, ZHU Yun, GUO Bing, WANG Liang, SHEN Yi. Re-reconstructions for cases with persistent post-reconstructive orocutaneous or oropharyngocutaneous fistulas after extensive reconstructive operations in head and neck region[J]. China Journal of Oral and Maxillofacial Surgery, 2021, 19(4): 362-367.

References

[1] Bresson K, Rasmussen RH, Rasmussen PA.Pharyngo-cutaneous fistulae in totally laryngectomized patients[J]. J Laryngol Otol, 1974, 88(9): 835-842.
[2] Andrews BT, Smith RB, Hoffman HT, et al.Orocutaneous and pharyngocutaneous fistula closure using a vacuum-assisted closure system[J]. Ann Otol Rhinol Laryngol, 2008, 117(4): 298-302.
[3] Redaelli de Zinis L, Ferrari L, Tomenzoli D, et al. Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy[J]. Head Neck, 1999, 21(2): 131-138.
[4] Salgado CJ, Mardini S, Chen HC, et al.Critical oropharyngocutaneous fistulas after microsurgical head and neck reconstruction: indications for management using the “tissue-plug” technique[J]. Plast Reconstr Surg, 2003,112(4): 957-963.
[5] Dawson C, Gadiwalla Y, Martin T, et al.Factors affecting orocutaneous fistula formation following head and neck reconstructive surgery[J]. Br J Oral Maxillofac Surg, 2017, 55(2): 132-135.
[6] Mäkitie AA, Irish J, Gullane PJ.Pharyngocutaneous fistula[J]. Curr Opin Otolaryngol Head Neck Surg, 2003, 11(2): 78-84.
[7] Sayles M, Grant DG.Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis[J]. Laryngoscope, 2014, 124(5): 1150-1163
[8] Paleri V, Drinnan M, van den Brekel MW, et al. Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review[J]. Laryngoscope, 2014, 124(8): 1848-1853.
[9] Sharma S, Chaukar DA, Laskar SG, et al.Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula[J]. J Laryngol Otol, 2016, 130(9): 860-864.
[10] Sharif KF, Baik FM, Yue LE, et al.Osteoradionecrosis of the hyoid bone complicated by pharyngocutaneous fistula: a case report and literature review[J]. Am J Otolaryngol, 2019, 40(2): 314-318.
[11] Hallock GG.Partial failure of a perforator free flap can be salvaged by a second perforator free flap[J]. Microsurgery, 2014, 34(3): 177-182.
[12] Hallock GG.The role of muscle flaps for salvage of failed perforator free flaps[J]. Plast Reconstr Surg Glob Open, 2015, 3(11): e564.
[13] Fearon JA, Cuadros CL, May JW Jr.Flap failure after microvascular free-tissue transfer: the fate of a second attempt[J]. Plast Reconstr Surg, 1990, 86(4): 746-751.
[14] Neubauer P, Cañadas K, Sasaki CT.Delayed platysma myocutaneous turnover flap for repair of pharyngocutaneous fistula[J]. Am J Otolaryngol, 2015, 36(1): 93-96.
[15] Naghibzadeh M, Zojaji R, Mokhtari Amir Majdi N, et al. Using a sternocleidomastoid muscle flap to prevent postoperative pharyngocutaneous fistula after total laryngectomy: a study of 88 cases[J]. Ear Nose Throat J, 2014, 93(8): 362-365.
[16] Iteld L, Yu P.Pharyngocutaneous fistula repair after radiotherapy and salvage total laryngectomy[J]. J Reconstr Microsurg, 2007, 23(6): 339-345.
[17] Khan NA, Medina JE, Sanclement JA, et al.Fistula rates after salvage laryngectomy: comparing pectoralis myofascial and myocutaneous flaps[J]. Laryngoscope, 2014, 124(7): 1615-1617.
[18] Thankappan K.Microvascular free tissue transfer after prior radiotherapy in head and neck reconstruction-a review[J]. Surg Oncol, 2010, 19(4): 227-234.
[19] Andrades P, Pehler SF, Baranano CF, et al.Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects[J]. Laryngoscope, 2008, 118(7): 1157-1163.
[20] Mosahebi A, Chaudhry A, McCarthy CM, et al. Reconstruction of extensive composite posterolateral mandibular defects using nonosseous free tissue transfer[J]. Plast Reconstr Surg, 2009, 124(5): 1571-1577.
[21] Suh JD, Blackwell KE, Sercarz JA, et al.Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis[J]. Otolaryngol Head Neck Surg, 2010, 142(4): 586-591.
[22] Galli J, De Corso E, Volante M, et al.Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors and therapy[J]. Otolaryngol Head Neck Surg, 2005, 133(5): 689-694.
[23] Tian B, Khoo D, Tay AC, et al.Management of orocutaneous fistulas using a vacuum-assisted closure system[J]. Head Neck, 2014, 36(6): 873-881.
[24] McLean JN, Nicholas C, Duggal P, et al. Surgical management of pharyngocutaneous fistula after total laryngectomy[J]. Ann Plast Surg, 2012, 68(5): 442-445.
[25] Anschütz L, Nisa L, Elicin O, et al.Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula[J]. Eur Arch Otorhinolaryngol, 2016, 273(11): 3943-3949.
[26] Patel UA, Keni SP.Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula[J]. Otolaryngol Head Neck Surg, 2009, 141(2): 190-195.
[27] Hsu YC, Wu CI, Cheng HT, et al.Free chimera lateral arm flap for repair of orocutaneous fistulae/osteoradionecrosis in oromandibular cancers[J]. Plast Reconstr Surg, 2010, 126(4): 180e-182e.
[28] Guimarães AV, Aires FT, Dedivitis RA, et al.Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: a systematic review[J]. Head Neck, 2016, 38(Suppl 1): E2317-E2321.
[29] Rees R, Cary A, Shack RB, et al.Pharyngocutaneous fistulas in advanced cancer: closure with musculocutaneous or muscle flaps[J]. Am J Surg, 1987, 154(4): 381-383.
[30] Carlson GW, Thourani VH, Codner MA, et al.Free gastro-omental flap reconstruction of the complex, irradiated pharyngeal wound[J]. Head Neck, 1997, 19(1): 68-71.
[31] Hirano T, Iwasaki T, Fujita K, et al.Repair of a large pharyngocutaneous fistula with a free jejunal patch flap after salvage laryngectomy: a case report[J]. Microsurgery, 2017, 37(1): 61-65.
[32] Markou KD, Vlachtsis KC, Nikolaou AC, et al.Incidence and predisposing factors of pharyngocutaneous fistula formation after total laryngectomy, is there a relationship with tumor recurrence?[J]. Eur Arch Otorhinolaryngol, 2004, 261(2): 61-67.