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

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.


Introduction
Laryngectomy is used increasingly as a salvage procedure after radiotherapy or chemoradiotherapy. Th e 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 off ered laryngectomy followed by radiotherapy [1].
Patients undergoing salvage surgery are more prone to develop pharyngocutaneous fi stulas (PCFs) because of injuries to the tissue microvasculature, resulting in myointimal fi brosis, endarteritis and worsening of atherosclerosis, which lead to a hypovascular, hypocellular and hypoxic environment, reducing healing capacity and increasing the risk for fi stula formation to as high as 70% [2]. In an attempt to prevent or reduce the incidence of salivary fi stulas, some authors have advocated the routine use of nonirradiated fl aps to reduce the morbidities associated with salivary fi stulas 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 fi eld of radiation may improve the healing capacity in such settings [3]. In this article, we assess the eff ectiveness of pectoralis major muscle fl ap (PMF) in wound healing, protection against catastrophic vascular blowouts and prevention of fi stula formation after salvage laryngectomy.

Patients and methods
Th is is a retrospective study. It was conducted at the Otorhinolaryngology Department, Ain Shams Pectoralis major ap reconstruction in the prevention of wound breakdown and stula formation after salvage laryngectomy: a controlled study Reda M. Sabra, Mohamed S. Taha, Tarek A. Hamdy, Hossam Rabie, Magdy A. Riad

Background
Patients undergoing salvage laryngeal surgery after high-dose radiotherapy or concurrent chemotherapy/radiation therapy regimen are more prone to develop pharyngocutaneous stulas (PCFs). The stula 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 ap ( PMF) in prevention of stula 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 ap with those of a similar group repaired by primary wound closure in 36 consecutive patients.

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 stula closure was 20 days in group A compared with 57.5 days in group B. 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.

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 fi eld from any devitalized tissues and secure haemostasis. A primary tracheooesophageal puncture is created at this stage, because of the diffi culties 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: fi rst 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 fi nally by suturing the cut edges of the thyropharyngeus and cricopharyngeus muscles over the repaired pharynx. Th e neck wound is then covered with swabs soaked in normal saline, and the anterior thoracic wall is prepared for harvesting the PMF.
Th e surgical technique we used aimed at harvesting two large pedicled fl aps: the deltopectoral skin fl ap and a fasciomuscular pectoralis major fl ap. Th e skin fl ap 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 (Figs. 1 and 2). Th e 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 fl ap. Th e 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 fi rst incised, and dissection is carried out to lift the muscle off the thoracic wall. Identifi cation of the pectoral branch of the thoracoacromial artery is the crucial step during the procedure. Th e vessels should be identifi ed 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 (Fig. 3). Th e mobilized muscle fl ap can now be turned over to cover the neck wound while the vascular pedicle is under clear vision (Fig. 4). Data are represented as percentage (number) and median (age); PMF, pectoralis major muscle ap. The deltopectoral skin ap.

Figure 1
Care must be taken to ensure that the fl ap is not under any tension in its new position in the neck. Strict haemostasis is secured in the thoracic wound. Th e deltopectoral skin fl ap is then returned to its original position and sutured in two layers. Th e 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
A total of 36 consecutive patients were included in this study. Th e results are summarized in Table 2. Th e 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). Th e mean duration to fi nal healing and oral feeding was 22.5 days in group A compared with 51.8 days in group B.
Th ere 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. Th ere was only one case of fl ap failure in group A (Fig. 5).
Th ere 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
Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing diffi culties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative Deltopectoral ap elevated to expose the pectoralis major muscle.

Figure 2
Identi cation of vascular pedicle before muscle cuts.

Figure 3
Pectoralis muscle turned in the neck.  complications in salvage laryngectomy surgery [3]. Th e eff ect of radiotherapy translates into injuries to tissue microvasculature, resulting in myointimal fi brosis, endarteritis and worsening of atherosclerosis, leading to a hypovascular, hypocellular and hypoxic environment, thus reducing healing capacity and increasing the risk for fi stula formation, its severity and duration [3,5,6].
Th e use of nonirradiated fl aps has been recommended to reduce the incidence rates and the morbidities associated with salivary fi stulas in salvage laryngectomy patients, even when there is enough mucosa for a primary closure procedure [7,8]. Th e rationale of this strategy revolves around using healthy tissue with abundant vascularization to maximize surgical wound healing, thus preventing local complications. Nowadays, fl aps 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 eff ort to improve tissue vascularity, reinforce the pharyngeal suture line and minimize complications in this diffi cult patient group [6].
PCF is the most common major complication following laryngectomy. Th e severity of this fi stula increases when it is preceded by chemoradiotherapy [10]. Th e 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. Th is fl ap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blowouts. Th e incidence rate of salivary fi stulas in group A patients, who underwent augmentation of the pharynx by PMF, was 6.2%, which eventually healed. Th ere 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%. Th ese 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 fi stulas 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 fi stula occurrence were reduced from 22.9 to 1% when PMFs were used routinely in salvage laryngectomies [11]. In Weber study (without PMF fl ap), 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. Th e incidence rate of salivary fi stulas 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].
Th e mean duration to fi stula 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 fi stula 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). Th e 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 fi stulas.
Our rate of total fl ap 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 fl ap necrosis is the only complication that requires another fl ap. One drawback of PMF is that follow-up in the neck region is more complicated because the fl ap can hide neck recurrences. Th e pectoralis major muscle pedicled fl ap is reliable and provides safe repair; the fl ap can be rapidly raised from the anterior chest wall, and no additional expertise in microvascular or abdominal surgery is needed. Th e 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 fl ap, it does not require specifi c materials or teams specialized in microsurgical anastomoses, and it introduces low donor site morbidity [2,20,21]. Th e low morbidity to the donor site and execution in a one-stage procedure has encouraged a wider use of PMF fl aps. Th is fl ap 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
PCF and poor wound healing remain a signifi cant problem following salvage laryngectomy. Th e use of nonirradiated, vascularized fl aps [pectoralis major muscle pedicled fl ap (PMF)] reduces the incidence, duration and severity of fi stula. It improves wound healing and should be considered if salvage laryngectomy is required.