Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy

Mauricio A Moreno; Mark K Wax; James Reed Gardner; Steven B Cannady; Evan M Graboyes; Arnaoud F Bewley; Peter T Dziegielewski; Sobia F Khaja; Rodrigo Bayon; Jesse Ryan; Samer Al-Khudari; Mark W El-Deiry; Tamer A Ghanem; Andrew Huang; Rusha Patel; Kevin M Higgins; Ryan S Jackson; Urjeet A Patel

doi:10.1001/jamaoto.2024.0103

Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy

JAMA Otolaryngol Head Neck Surg. 2024 Apr 18. doi: 10.1001/jamaoto.2024.0103. Online ahead of print.

Authors

Mauricio A Moreno¹, Mark K Wax², James Reed Gardner¹, Steven B Cannady³, Evan M Graboyes⁴, Arnaoud F Bewley⁵, Peter T Dziegielewski⁶, Sobia F Khaja⁷, Rodrigo Bayon⁸, Jesse Ryan⁹, Samer Al-Khudari¹⁰, Mark W El-Deiry¹¹, Tamer A Ghanem¹², Andrew Huang¹³, Rusha Patel¹⁴, Kevin M Higgins¹⁵, Ryan S Jackson¹⁶, Urjeet A Patel¹⁷

Affiliations

¹ Division of Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock.
² Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland.
³ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia.
⁴ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston.
⁵ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Davis.
⁶ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Florida, Gainesville.
⁷ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis.
⁸ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City.
⁹ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, State University of New York System, Syracuse.
¹⁰ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois.
¹¹ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Emory Health Care, Atlanta, Georgia.
¹² Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan.
¹³ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas.
¹⁴ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Oklahoma, Norman.
¹⁵ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
¹⁶ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri.
¹⁷ Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, Illinois.

PMID: 38635282
DOI: 10.1001/jamaoto.2024.0103

Abstract

Importance: Closure technique for optimization of postoperative and functional outcomes following salvage laryngectomy remains an area of debate among head and neck surgeons.

Objective: To investigate the association of salvage laryngectomy closure technique with early postoperative and functional outcomes.

Design, setting, and participants: This retrospective cohort study included patients from 17 academic, tertiary care centers who underwent total laryngectomy with no or limited pharyngectomy after completing a course of definitive radiotherapy or chemoradiotherapy with curative intent between January 2011 and December 2016. Patients with defects not amenable to primary closure were excluded. Data were analyzed from February 14, 2021, to January 29, 2024.

Exposures: Total laryngectomy with and without limited pharyngectomy, reconstructed by primary mucosal closure (PC), regional closure (RC), or free tissue transfer (FTT).

Main outcomes and measures: Patients were stratified on the basis of the pharyngeal closure technique. Perioperative and long-term functional outcomes were evaluated with bivariate analyses. A multivariable regression model adjusted for historical risk factors for pharyngocutaneous fistula (PCF) was used to assess risk associated with closure technique. Relative risks (RRs) with 95% CIs were determined.

Results: The study included 309 patients (256 [82.8%] male; mean age, 64.7 [range, 58.0-72.0] years). Defects were reconstructed as follows: FTT (161 patients [52.1%]), RC (64 [20.7%]), and PC (84 [27.2%]). A PCF was noted in 36 of 161 patients in the FTT group (22.4%), 25 of 64 in the RC group (39.1%), and 29 of 84 in the PC group (34.5%). On multivariable analysis, patients undergoing PC or RC had a higher risk of PCF compared with those undergoing FTT (PC: RR, 2.2 [95% CI, 1.1-4.4]; RC: RR, 2.5 [95% CI, 1.3-4.8]). Undergoing FTT was associated with a clinically meaningful reduction in risk of PCF (RR, 0.6; 95% CI, 0.4-0.9; number needed to treat, 7). Subgroup analysis comparing inset techniques for the RC group showed a higher risk of PCF associated with PC (RR, 1.8; 95% CI, 1.1-3.0) and predominately pectoralis myofascial flap with onlay technique (RR, 1.9; 95% CI, 1.2-3.2), but there was no association of pectoralis myocutaneous flap with cutaneous paddle interposition with PCF (RR, 1.2; 95% CI, 0.5-2.8) compared with FTT with cutaneous inset. There were no clinically significant differences in functional outcomes between the groups.

Conclusion and relevance: In this study of patients with limited pharyngeal defects, interpositional fasciocutaneous closure technique was associated with reduced risk of PCF in the salvage setting, which is most commonly achieved by FTT in academic practices. Closure technique was not associated with functional outcomes at 1 and 2 years postoperatively.