Complications of pectoralis major myo‐cutaneous flap, anterolateral thigh flap and radial forearm free flap after total laryngectomy with partial pharyngectomy: A systematic review and network meta‐analysis

Abstract

Background No consensus exists regarding the most effective reconstruction after total laryngectomy with partial pharyngectomy (TLwPP). This study aims to compare different reconstructive techniques (pectoralis major myo‐cutaneous flap, PMMCF; anterolateral thigh flap, ALTF; radial forearm free flap, RFFF) after TLwPP in terms of pharyngocutaneous fistula (PCF), stenosis and feeding tube dependence (FTD) incidence. Methods The Scopus, PubMed/MEDLINE, Cochrane Library, and Google Scholar databases were searched. A single‐arm meta‐analysis was performed for PCF incidence, stenosis incidence, and FTD incidence on the entire cohort. An arm‐based network analysis was conducted to compare three different surgical interventions (PMMCF, ALTF, RFFF). Results A total of 13 studies and 232 patients were included in the network meta‐analysis. The lowest PCF absolute risk was measured for the RFFF (11.7%, 95% CI: 2.8%–33.4%), compared to the ALTF (13.4%, 95% CI: 4.5%–32.1%) and the PMMC (49.0%, 95% CI: 19.2%–79.3%). The RFFF showed a stenosis absolute risk of 0.0% (95% CI: 0.0%–1.1%), while a higher stenosis incidence was measured for the ALTF (5.7%, 95% CI: 0.8%–25.2%) and the PMMCF (11.6%, 95% CI: 0.8%–55.1%). The RFFF showed the lowest absolute risk of FTD incidence (6.8%, 95% CI: 0.5%–28.1%) compared to the other reconstructive techniques (PMMCF: 12.4%, 95% CI: 2.4%–42.1%; ALTF: 17.5%, 95% CI: 6.4%–38.9%). Conclusions The RFFF seems the best choice for reconstruction of partial pharyngeal defects after TLwPP due to the lower incidence of PCF, stenosis and FTD compared to the ALTF and the PMMCF.

Comparison of the outcomes of anterolateral thigh flap and peroneal flap in total laryngectomy reconstruction

“…However, there is currently no gold standard that tells us which flap is the best option. Although the pedicled pectoris major flap can be performed without microsurgery and in less time, some studies have found that it results in a higher rate of leakage and a poorer functional outcome than free flaps 4–10 . Although the jejunum flap has a lower stricture rate and leakage rate when used in circumferential defects, its disadvantages include a short ischemia tolerable time and visceral donor site complications 9–15 .…”

“…Many articles have been written about which flap is a better choice in the reconstruction of total laryngectomy. The conclusion was still debatable 8,9,11 . There was some variation in the outcomes.…”

“…However, in the reconstruction of a noncircumferential defect, a review article with a meta‐analysis published in 2022 discovered that the RF group had the lowest rate of fistula, stricture, and feeding tube dependence compared to the pectoris major and ALT groups. The author assumed that the improved result was due to the benefit of the RF flap's thinness 8 . Thus, the true mass effect of flap in total laryngectomy reconstruction requires further investigation.…”

“…Although the pedicled pectoris major flap can be performed without microsurgery and in less time, some studies have found that it results in a higher rate of leakage and a poorer functional outcome than free flaps. 4 , 5 , 6 , 7 , 8 , 9 , 10 Although the jejunum flap has a lower stricture rate and leakage rate when used in circumferential defects, its disadvantages include a short ischemia tolerable time and visceral donor site complications. 9 , 10 , 11 , 12 , 13 , 14 , 15 The ALT flap is a popular flap that has dependable perforators, a large donor site skin area, a long vascular pedicle, and a low donor site morbidity.…”

“…The author assumed that the improved result was due to the benefit of the RF flap's thinness. 8 Thus, the true mass effect of flap in total laryngectomy reconstruction requires further investigation.…”