Back to 2014 Annual Meeting Abstracts

BACKGROUND:
Reconstruction of hypopharyngeal defects after tumor ablation is associated with a high rate of post-operative complications. Multiple donor sites are frequently available for use, but limited data exists to guide flap selection. Thus, a better understanding of risk factors and outcomes is imperative for proper patient selection and operative planning.
METHODS:
Patients who underwent free flap reconstruction of hypopharyngeal defects after tumor ablation at the University of Pittsburgh Medical Center between 2002 and 2012 were identified via CPT code. Data was collected retrospectively with regard to demographics, co-morbidity, radiation history, flap type, surgical defect, and post-operative complication. Multivariate analysis was conducted with covariate selection based on applicable trends revealed in bivariate analysis.
RESULTS:
56 patients (44 male and 12 female, median age 60) met inclusion criteria for the study. Mean length of follow up was 509 days post-operative. 23 (41%) received a radial forearm free flap (RFF), 17 (30%) received a jejunal free flap (JF), and 16 (29%) received an anterolateral thigh free flap (ALT). When compared to ALT, patients receiving JF experienced longer average post-operative hospital stays (30 days vs. 12 days, p=0.01) and increased rates of flap necrosis (41% vs. 0%, p=0.007). Flap necrosis was also more prevalent for JF as compared to RFF (23.5% vs. 4.3%). Multivariate analysis using generalized linear models predicted post-operative length of stay at 2.06 (p=0.002) and 1.74 (p=0.01) times longer in JF and RFF respectively as compared to ALT. Total flap loss, re-admissions, minor post-operative complications, fistulas, and complications requiring return to the OR were not significantly different between flap types.
34 patients (61% of RFF, 59% of JF, and 62% of ALT) had previously received neck radiation, completed at a median of 11.2 months pre-operative. When compared to patients who were radiation naive, patients with prior radiation exhibited increased risk of post-operative complication (56% vs. 27%, p=0.05) and longer average post-operative hospital stay (36 days vs. 15 days, p=0.046). Comparisons of rate of total flap loss (15% vs. 0%), re-admission (21% vs. 4.5%), and fistula development (29% vs. 14%) trended higher in the radiation group but did not reach statistical significance. Radiation history was not associated with stricture formation at one year or with complications requiring return to OR.
CONCLUSIONS:
Complication rates in hypopharyngeal reconstruction remain significant. ALT flaps may provide some advantages as compared to RFF or JF via shorter hospital stay and reduced risk of flap necrosis. Moreover, patients with a history of radiation are likely to experience more post-operative complications and longer hospital stays following reconstruction than the radiation naive. Finally, given our somewhat limited sample size, the trends borne out in our data merit further investigation with an expanded cohort.