Postlaryngectomy pharyngocutaneous fistula: Incidence, predisposing factors, and therapy

Background. Pharyngocutaneous fistula is the most common complication follo wing total laryngectomy. The present study was designed to determine the in cidence and predisposing factors and to describe the management of the comp lication. Methods. The records of 246 consecutive patients who underwent total laryng ectomy for squamous cell carcinoma were reviewed. We evaluated 23 factors p otentially predisposing to fistula formation (age, sex, smoking and drinkin g habits, hypertension, diabetes, chronic bronchitis, chronic congestive he art failure, anesthesiologic risk, cholinesterase level, pre- and postopera tive hemoglobin and albumin levels, previous treatment, previous tracheotom y, site of origin of the tumor, surgical procedure, concurrent neck dissect ion, suture material, status of surgical margins, clinical stage, and histo logic grade) using the chi-squared test and logistic regression analysis. Results. A pharyngocutaneous fistula developed in 16% of patients within a mean time of 11 days from surgery. Spontaneous closure with local wound car e was achieved in 70% of cases. Ten patients required surgical closure by d irect suture of the pharyngeal mucosa; a deltopectoral flap and a pectorali s major myocutaneous flap were used in one case each. The mean healing time was 39 +/- 46 days in the group of patients requiring surgical closure, co mpared with 19 +/- 12 days in the group in which spontaneous closure occurr ed. The definitive model of logistic regression analysis showed that pharyn golaryngectomy, chronic congestive heart failure, and postoperative hemoglo bin level lower than 12.5 g/dL carried respectively a two-, five-, and nine fold increase in the risk of fistula development. The model, with a specifi city of 81%, is fairly good in identifying patients with a low risk of fist ula. Conclusions. The results observed in the group of patients under analysis c orroborated the relevance of factors such as the extension of laryngectomy and postoperative hemoglobin level on fistula occurrence. However, chronic congestive heart failure, which is an expression of disturbance of the orga nism, emerged for the first time as an additional statistically significant risk factor for pharyngocutaneous fistula formation. Our experience confir med that most fistulas can be successfully managed with conservative treatm ent. Except for the rare cases in which large defects are present, direct s uture is appropriate when conservative treatment has failed. (C) 1999 John Wiley & Sons, Inc.