In response to Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review.

We would like to thank Dr. Merdad and colleagues for their interest in our article, "Vascularized Tissue to Reduce Fistula Following Salvage Total Laryngectomy: A Systematic Review," published in the August 2014 issue of The Laryngoscope, and we are grateful for the opportunity to respond to their letter. We would concur with Dr. Merdad and colleagues that their earlier article is a valuable contribution to the debate, and clearly shows support for the use of a vascularized flap in the setting of salvage laryngectomy. In response to their query about their study not being identified in the literature search, we can confirm that the earlier article published in The Laryngoscope by Higgins et al. was present in the search results. However, we excluded the article from the pooled analysis for the following reason. As can be seen from the results of our article (Figure 1 and Table III), the pooled relative risk (RR) was our key outcome measure, because we specifically wanted to show whether the flap conferred any benefit over primary closure. This aim is clearly reflected in our title "Vascularized Tissue to Reduce Fistula Following Salvage Total Laryngectomy: A Systematic Review." We designed our analysis such that each publication had a comparative cohort of patients who underwent salvage laryngectomy and primary closure, so that the RR could be calculated for each center. Unlike the other studies we included (Table II), Higgins et al. did not report a group who had primary closure, and thus the RR could not be calculated for their center. We appreciate that the reason for exclusion is not explicit in the article, and in retrospect we should have made it clear that articles were required to include data on primary closure. In addition, we should have referenced the contribution by Higgins et al. in the list of exclusions or the discussion. We sincerely hope this clarifies the matter. Once again, we would like to congratulate Higgins et al. on their article, which adds support to the management strategy proposed in the article.