Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis

Abstract

Objective: Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction. Data Sources: Scopus 1960—database was searched for terms: “orocutaneous fistula,” “oro cutaneous fistula,” “oral cutaneous fistula,” “orocervical fistula,” “oral cavity salivary fistula.” Review Methods: English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy. Results: Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection. Conclusion: Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

Predictors predisposing to orocutaneous fistula occurrence following free flap reconstruction

“…It could be noted that current OCF formulation rate is a little higher than that (7.7%) reported by Tassone et al. ( 27 ) who also enrolled patients with previous irradiation, there are at least three aspects contributing to the difference, first, all patients in current study received a lip split, second, the two studies have different inclusion criteria, third, previously radiated patients may not have had extensive neck surgery at the time of their salvage resections.…”

“…On one hand, indication for bilateral neck dissection midline across the primary tumor or pathologically proven lymph nodes in the contralateral neck is related to an advanced stage disease, requiring extensive soft or bone tissue resection; increased surgery duration and intraoperative bleeding are expected. On the other hand, tissue fibrosis easily results from previous chemoradiotherapy and conversely causes poor wound healing ( 27 ). These aspects might help to predict the likelihood of OCF development in patients with the two features.…”

Perioperative Outcomes in Patients Who Underwent Fibula, Osteocutaneous Radial Forearm, and Scapula Free Flaps

“…Fistulas or salivary leaks complicate postoperative management and have been reported in up to 30% of oral cavity resections requiring free flap reconstruction . A meta-analysis by Tassone et al reported a pooled prevalence of fistula in 8.6% of oral cavity resections reconstructed with free tissue. Several series have compared rates of complications between OCRFFFs and FFFs, and generally no difference has been seen; however, complication rates may have been somewhat affected by studies that were inadequately powered to detect differences on the magnitude of 5% to 10% .…”

Orocutaneous Fistula Formation in Free Flap Reconstruction for Oral Squamous Cell Carcinoma

“…A difference in the study design might have contributed to this variation. Previous chemoradiotherapy significantly posed an apparent effect on wound healing and tissue fibrosis ( 25 ). This dysfunction could explain the tendency of OCF formation in patients with previous chemoradiotherapy.…”