International Journal of Head and Neck Surgery

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VOLUME 13 , ISSUE 4 ( October-December, 2022 ) > List of Articles


Clinical Techniques: Downstate Fistula Formula Update

Rachel Irizarry, Daniel Sukato, Krishnamurthi Sundaram

Keywords : Fistula formula, Pharyngocutaneous fistula, Salvage laryngectomy

Citation Information : Irizarry R, Sukato D, Sundaram K. Clinical Techniques: Downstate Fistula Formula Update. Int J Head Neck Surg 2022; 13 (4):99-101.

DOI: 10.5005/jp-journals-10001-1539

License: CC BY-NC 4.0

Published Online: 21-01-2023

Copyright Statement:  Copyright © 2022; The Author(s).


Aim: Review our case series of salvage total laryngectomies (STL) after 2010 using the downstate fistula formula (DFF) for the incidence of postoperative (post-op) pharyngocutaneous fistulas (PCF). Background: Pharyngocutaneous fistulas (PCF) remains the most common complication after STL, even with the use of vascularized flaps at a rate of 30%. The DFF is a multipronged approach to prophylactically address risk factors contributing to PCF formation. Technique: The DFF incorporates a watertight two-layer closure, pectoralis major myocutaneous flap reconstruction, antibiotic prophylaxis, delayed oral intake using a G-tube, salivary diversion, and an anti-reflux regimen. Conclusion: Initial results of 11 patients treated by the DFF published in 2009 showed a 0% failure rate. A review of patients treated by DFF from 2010 continued to maintain a 0% failure rate. Clinical significance: The use of the DFF in STL patients has reduced the incidence of PCF to zero with a reduced length of stay.

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  1. Weber RS, Berkey BA, Forastiere A, et al. Outcome of salvage total laryngectomy following organ preservation therapy: the radiation therapy oncology group trial 91–11. Arch Otolaryngol Head Neck Surg 2003;129(1):44–49. DOI: 10.1001/archotol.129.1.44
  2. Department of Veterans Affairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324(24):1685–1690. DOI: 10.1056/NEJM199106133242402
  3. Sayles M, Grant DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope 2014;124(5):1150–1163. DOI: 10.1002/lary.24448
  4. Silverman D, Puram S, Rocco J, et al. Salvage laryngectomy following organ-preservation therapy – an evidence-based review. Oral Oncology 2019;88:137–144. DOI: 10.1016/j.oraloncology.2018.11.022
  5. Hasan Z, Dwivedi RC, Gunaratne DA, et al. Systematic review and meta-analysis of the complications of salvage total laryngectomy. Eur J Surg Oncol 2017;43(1):42–51. DOI: 10.1016/j.ejso.2016.05.017
  6. Paydarfar JA, Birkmeyer NJ. Complications in head and neck surgery: a meta-analysis of postlaryngectomy pharyngocutaneous fistula. Arch Otolaryngol Head Neck Surg 2006;132(1):67–72. DOI: 10.1001/archotol.132.1.67
  7. Yeh DH, Sahovaler A, Fung K. Reconstruction after salvage laryngectomy. Oral Oncol 2017;75:22–27. DOI: 10.1016/j.oraloncology.2017.10.009
  8. Miles BA. Moving toward improved outcomes in salvage laryngectomy. Ann Surg Oncol 2018;25(5):1110–1111. DOI: 10.1245/s10434-017-6283-7
  9. Sundaram, K, Wasserman J. Prevention of unplanned pharyngocutaneous fistula in salvage laryngectomy. Otolaryngol Head Neck Surg 2009;141(5):645–647. DOI: 10.1016/j.otohns.2009.08.016
  10. Patel U, Moore B, Wax M, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg 2013;139(11):1156–1162. DOI: 10.1001/jamaoto.2013.2761
  11. Sayles M, Koonce S, Harrison L, et al. Pharyngo-cutaneous fistula complicating laryngectomy in the chemo-radiotherapy organ-preservation epoch. Eur Arch Otorhinolaryngol 2014;271(6):1765–1179. DOI: 10.1007/s00405-013-2727-2
  12. Guimarães AV, Aires FT, Dedivitis RA, et al. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: a systematic review. Head Neck 2016;38(Suppl 1):E2317–E2321. DOI: 10.1002/hed.24248
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