Closure techniques for esophageal reconstruction after total laryngectomy and their impact on fistula formation

Abstract

Background: The rising incidence of laryngeal cancer has led to an increasing number of total laryngectomy procedures. While voice prostheses have significantly improved post-laryngectomy rehabilitation, the risk of salivary fistula remains a major complication. This study aims to compare the stapler and hand-sewn techniques for esophageal closure and evaluate their impact on fistula formation.

Aim: To compare stapler-assisted and hand-sewn esophageal closure techniques after laryngectomy regarding their impact on salivary fistula formation.

Methods: A total of 52 patients (44 men, 8 women), aged 43 to 77 years, underwent total laryngectomy. Esophageal reconstruction was performed using either a stapler (29 patients) or a hand-sewn technique (23 patients). A surgical stapler TA was used for esophageal closure in the stapler group. Patients were clinically monitored for fistula formation during the first 7 days postoperatively and again two weeks after discharge using fiberoptic examination.

Results: A total of 22 salivary fistulas were recorded: 17 (77.3%) occurred following the hand-sewn technique, while 5 (22.7%) developed in the stapler group. Additionally, preoperative radiotherapy was identified as a statistically significant risk factor for fistula formation. No technical complications related to the stapler device were observed.

Conclusion: Although hand-sewn closure is commonly used after total laryngectomy, stapler-assisted closure shows lower fistula rates and is a viable esophageal reconstruction alternative.

Keywords: Laryngeal cancer; Radiotherapy; Salivary fistula; Surgical stapler; Total laryngectomy.

Figure 1

Schematic illustration depicting hand-sewn and stapler-assisted techniques for esophageal closure following total laryngectomy. The upper panel shows the conventional manual suturing method, while the lower panel illustrates the use of a surgical stapler. The figure highlights the procedural differences between the two approaches in pharyngeal reconstruction.

Figure 2

Intraoperative images demonstrating the preparation of the esophagus for surgical stapler application following larynx removal. A and B: Intraoperative images showing the preparation of the esophageal mucosa following larynx removal for stapler application. Frontal view (A) and side view (B) of the esophageal mucosa grasped with forceps.

Figure 3

Intraoperative images demonstrating the application of a surgical stapler following total laryngectomy. Intraoperative images illustrating the application of a surgical stapler. A and B: The stapler is positioned on the esophageal mucosa (A), which is then (B) clamped to ensure precise closure; C: The final result shows two parallel rows of staples securing the sutured pharyngeal mucosa, indicating a well-aligned closure.