Outcomes of Anterolateral Thigh Flap Reconstruction for Salvage Laryngopharyngectomy for Hypopharyngeal Cancer after Concurrent Chemoradiotherapy

Abstract

ObjectiveTo evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma.Materials/MethodsA retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated.Results33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease–free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease–free survival (P = 0.027 and 0.038, respectively).ConclusionPharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.

Reconstruction of laryngopharyngectomy defects: Comparison between the supraclavicular artery island flap, the radial forearm flap, and the anterolateral thigh flap

“…Flap failure rates in our cohort were low with only one total flap loss (RFF) and two partial flap losses (one ALT and one SCAIF). This is comparable to other series published on pharyngeal reconstruction (Chan et al, ; Chen, Chang, Chen, Shyu, & Kao, ) and shows that not only RFF and ALT, but also the SCAIF are reliable options for reconstruction in these patients. Fistula formation remains a serious concern after laryngopharyngectomy, reported with 5%‐65% in the literature (Chu & Chang, ).…”

“…Our fistula rate of 12% is relatively low, when compared with other studies of pharyngeal reconstruction (Yu et al, ). This might be due to the fact, that not all of our patients underwent prior radiochemotherapy, whereas other studies only evaluated patients with disease recurrence after radiation (Chen et al, ). Furthermore, all our pharyngeal defects are closed in a two‐layer fashion, as described by Ooi et al In our opinion, this technique is very helpful to reduce fistula rates (Ooi, Butz, Gooi, & Chang, ).…”

“…We absolutely agree with other groups that there is a clear advantage in using vascularized tissue from outside the radiation field in the laryngectomy defect, even if reconstruction is not necessary to close the defect. The kind of flap used seems to be of minor importance, although some authors report superior results regarding postoperative stenosis with the use of a jejunal flap (Chan et al, ; Chen et al, ). This is consistent with our findings as we could not demonstrate any difference between our groups.…”

Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

“…However, it is important to not underestimate the impact of this aspect on outcomes and complications. In this view, the majority of authors do not detail their surgical technique or describe the employment of fasciocutaneous flaps in a tubular fashion when reconstructing CH defects, with highly variable outcomes, going up to 53% for PCF and 36% for PES . In our experience, suturing in a horseshoe shape the lateral edges of the free flap to the prevertebral fascia for CH leads to a large neopharynx, with low PES rates and reduced amount of tissue needed for reconstruction, thus favoring the wound closure at the level of the donor site.…”

Factors associated with gastrostomy tube dependence following salvage total laryngectomy with microvascular free tissue transfer

“…In the STL setting, introduction of vascularized tissue to the irradiated wound bed decreases the rates of pharyngocutaneous fistula (PCF) and stricture . While much has been published regarding the effect of microvascular‐free tissue transfer (MFTT) on the rate of PCF, its impact on long‐term swallowing outcomes and rates of gastrostomy tube (G‐tube) dependence remains largely unknown . After cure from cancer, the ability to swallow consistently ranks as a top priority for head and neck cancer patients .…”