Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect

Abstract

Aim of work: This study was carried out to minimize the incidence of pharyngocutaneous fistula (PCF) following salvage laryngeal surgery using vascularized pedicle pectoralis major myocutaneous flap (PMMC) for enhancing wound healing, rapid intake of oral feeding, reconstruction of desqauamated irradiated skin, achieving short hospital stay and protection against catastrophic blow out mortality.

Patients and methods: This case series study of sixteen patients carried out from May 2005 to July 2009, at the National Cancer Institute, Cairo University where we applied PMMC flap in salvage laryngeal surgery for those with high risk to develop complications: Patients of poor general conditions (anemia, hypoproteinemia, diabetics) and/or poor local conditions for healing (irradiated neck, extensive local or nodal recurrence with skin desquamation, infiltration or tumor fungation which need extensive resection). Five cases had been treated with primary cobalt radiotherapy laryngeal field only and 4 cases laryngeal field with draining neck nodes, while photon therapy was given in 4 cases as laryngeal field only and 3 cases laryngeal field with draining neck nodes. All cases were squamous cell carcinoma (13 cases grade 2, 2 cases grade 3 and one case grade 1) proved before radiotherapy. Supraglottic recurrence was detected in 7 cases (43.75%) and glottis in 9 cases (56.25%). Following salvage surgery, 11 cases were staged T3 N0, N1 and N2, 3 cases were T2 N0 or N1 and 2 cases were T4 N2 with skin infiltration. Tracheostomy was there in 4 cases.

Results: The study included fifteen males (93.75%) and one female (6.25%), age was between 38-73 years (mean=55.5 years). Five cases were operated on as total laryngectomy with excision of skin flaps + PMMC flap, 4 cases as total laryngectomy with skin flap excision + functional block neck dissection + PMMC flap and 7 cases as total laryngectomy + block neck dissection with skin excision (modified radical in 4 cases &radical in 3 cases) + PMMC flap reconstruction. Flaps survived in all cases, PCF developed in 2 cases (12.5%) with wound infection but healed conservatively within 2 weeks. Dropped shoulder occurred in 3 cases (18.75%) treated by physiotherapy. Mild postoperative chest infection developed in 7 cases (36.84%) improved by broad spectrum antibiotics and chest physiotherapy.

Conclusion: Routine use of pectoralis major myocutaneous flap in salvage laryngeal surgery is of great help in such high risk patients to minimize incidence of pharyngocutaneous fistula and to allow primary skin wound healing. This flap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blow out mortality.

Key words: Pectoralis major myocutaneous flap - Prevention of pharyngocutaneous fistula - Salvage laryngectomy.