What is the role of flap reconstruction in salvage total laryngectomy?

BACKGROUND Given the results of the Department of Veterans Affairs Laryngeal Cancer Study Group investigations in the 1990s and the subsequent publication of the Radiation Therapy Oncology Group 91-11 (RTOG 91-11) study in 2003, treatment for advanced staged laryngeal carcinoma has focused on organ preservation strategies involving chemotherapy and radiation. Analysis of these studies reveals that pharyngocutaneous fistula occurred in at least 30% percent of patients undergoing salvage laryngectomy, and other series have reported even higher fistula rates after organ preservation treatment. Development of a postoperative fistula is a multifactorial process, and the surgeon’s assessment of the patient’s clinical situation could help select those patients who are at a higher risk for fistula development. Fistula development results in increased hospitalization, time before initiation of an oral diet, and use of healthcare resources. Investigators have reported decreased fistula rates following salvage laryngectomy when using flap reconstruction. In addition, patients with primary flap reconstructions that did develop fistulas healed at a faster rate than those without primary flap reconstruction. Reconstructions in these salvage laryngectomy surgeries have involved free flaps or pedicled myocutaneous flaps. This review will seek to answer the question of best practice with regard to flap reconstruction of laryngectomy defects for salvage laryngectomy following failed organ preservation treatment.