Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal functional results. The primary aim of this study is to determine whether complications can be predicted on the basis of reconstruction in patients undergoing
pharyngectomy for
tumors involving the hypopharynx. In addition, we detail a reconstructive algorithm for management of partial and total laryngopharyngectomy defects.
METHOD: A retrospective review was performed of 153 patients undergoing flap reconstruction for 85 partial and 68 circumferential
pharyngectomies at a single institution over a 10-year period. There were 118 males and 35 females, the median age was 62 years, and mean follow up was 3.1 years.
Pharyngectomy was performed for recurrence after
radiotherapy in 80 patients and as primary surgery in 73.
Free flap reconstruction was used in 42%, with 30 jejunal, 15 radial forearm, 11 anterolateral thigh, five rectus abdominis, and three gastro-omental flaps. Gastric transposition and pectoralis major pedicle flap was used in 14% and 44% of patients, respectively. Morbidity was analyzed according to extent of defect, regional versus
free flap, enteric versus fasciocutaneous
free flap reconstruction, and the effect of
laparotomy.
RESULTS: The total operative morbidity and mortality rate was 71% and 3%, respectively. The most common complications were
hypocalcemia in 45%, pharyngocutaneous
fistula in 33%, and
wound complications in 25%. The late complication and
stricture rate was 26% and 15%, respectively. On univariate analysis, circumferential defects were associated with increased total (P=.046) and flap-related morbidity (P=.037),
hypocalcemia (P<.001), late complications (P=.003), and
stricture (P=.009). Gastric transposition had increased total (P=.007), flap-related (P=.035), late complications (P=.034), and
hypocalcemia (P=.001). Pharyngocutaneous
fistula was increased in patients undergoing salvage
pharyngectomy for radiation failure (P=.048) compared with primary surgery. On multivariate analysis, gastric transposition independently predicted for
wound complications (P=.014) and
fistula (P=.012). Circumferential defects predicted for flap-related morbidity (P=.030),
hypocalcemia (P=.017), and late complications (P=.042). Tracheoesophageal speech was the method of voice restoration in 44% of patients. Oral diet was achieved in 93% of patients; however, 16% required
gastrostomy tube feeds for either total or supplemental nutrition.
CONCLUSION: The operative morbidity associated with pharyngeal reconstruction is substantial in terms of early and late complications. We were able to predict morbidity by defect extent and reconstruction type and initial treatment modality. Swallowing function is acceptable; however, less than half of the patients undergoing
pharyngectomy had tracheoesophageal
puncture voice restoration.