Salvage total laryngectomy: is a flap necessary?

Introduction: Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy without chemotherapy. Objective: Our purpose is to review the fistula rate in radiated patients undergoing total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors. Methods: We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed. Results: We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p =0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p= 0.03) and large pharyngostomes (64.3% versus 0%, p= 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p=0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p= 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes. Conclusions: Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy. (C) 2018 Associacao Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial. Published by Elsevier Editora Ltda.