1. Risk Factors and Incidence of Fistula formation in salvage laryngectomy Miss Lisa Pitkin Consultant ENT Head and Neck Surgeon

2. Summary of Presentation Current Laryngeal Cancer Management Salvage Laryngectomy Fistula incidence and causation Fistula prevention

3. Laryngeal cancer staging Supraglottis Glottis

4. Laryngeal cancer Management UK: Before 2002 – Primary total laryngectomy if bulky T2, T3, T4 After 2002: – Veterans and RTOG trials - organ preservation – ChemoRT as initial treatment for all including early T4.

5. Salvage Laryngectomy For residual or recurrent disease at any time post RT +/- chemotherapy – Usually concurrent neck dissection. “Functionless” larynx

6. Fistula definition “An abnormal passageway between an organ and skin or between 2 organs” In a laryngectomy: results from breakdown of the neopharynx. – Pharyngocutaneus – (Tracheo-oesophageal.)

7. Fistula Examples

8. Fistula incidence Literature review. – Primary total laryngectomy 10-35% – Salvage total laryngectomy 10-60% LP and MDT salvage figures 2009-14 11.5% (3/26)

9. Risk Factors for fistula formation *Radiotherapy – Dose: 57Gy- 25%. 72Gy-92% – Larger RT field Adjuvant chemotherapy – 2x increased risk. Salvage surgery within 4 months of RT Hypoalbuminaemia Anaemia Smoking Liver disease Hypothyroidism ? Primary TEP.

10. Consequences of a fistula Infection Increased length of hospital stay and time to achieve rehabilitation Potential for carotid blow out

11. Fistula prevention MDT Optimisation prior to surgery Surgical extent and technique ? Primary puncture

12. Pectoralis Major Flap

13. Salivary Fistula Tube

14. Additional....... iv Augmentin 7 days iv PPI and metoclopramide Nutrition – PEG/NG/TEP Chest physiotherapy and Mobilisation Nursing and Stoma Care SALT

15. THANK YOU........