Radial forearm free flap and a freka-trelumina tube for management of a refractory pharyngocutaneous fistula: A case report

Abstract

The management of pharyngocutaneous fistulas (PCFs) is challenging. A multidisciplinary treatment approach according to the clinical needs of a patient is essential for PCF management. Here, we describe the use of a double-layer closure technique involving a radial forearm free flap (RFFF) and a Freka-Trelumina nasojejunal tube in the reconstruction of a refractory PCF.

Introduction

Pharyngocutaneous fistulas (PCFs) represent a major complication of head and neck surgeries. ¹ The radial forearm free flap (RFFF) has been considered the flap of choice in head and neck reconstruction. ² However, salivary leak, reflux esophagitis, and malnutrition have been reported as risk factors for flap failure in PCF reconstruction. ³ The Freka-Trelumina nasojejunal tube is often placed in pancreatic disease patients for enteral feeding and gastrointestinal decompression, ⁴ but has gained little attention in head and neck reconstruction patients. Here, we present a case double-layer closure with RFFF and endoscopy–guided Freka-Trelumina tube placement for the salvage reconstruction of a refractory PCF in an advanced hypopharyngeal carcinoma patient.

Case report

A 42-year-old woman with a history of hoarseness and neck swelling was presented. Physical examination revealed two enlarged lymph nodes in the right neck (3.5×2.5 cm, 2.0×2.0 cm, respectively). Subsequent fiberoptic laryngoscopy, gastroscopy, and cervical computed tomography (CT) demonstrated a lesion extending from the right pyriform sinus to the lower pharynx and laryngeal cavity (3.2×2.6×3.0 cm). Biopsy of the lesion confirmed a diagnosis of advanced hypopharyngeal squamous cell carcinoma (T4N2M0), with muscular and lymphovascular invasion, and negative surgical margins. Evidence of a history of reflux esophagitis was shown on esophagoscopy. No distant metastasis was seen on positron emission tomography (PET)-CT.

Due to the extent of the lesion, primary tumor resection and neck dissection were indicated, alongside pectoralis major myocutaneous flap (PMMF) reconstruction and a tracheostomy. On postoperative day 9, the incision site appeared erythematous and swollen, with evidence of salivary leak. Culture of the saliva grew Klebsiella pneumoniae. In addition to conservative interventions such as wound care, nutrition optimization, and antibiotic therapy, and scratching of the wound to promote healing, up to three rounds of local flap closure surgery were performed. However, the PCF recurred and increased to a length of 5 cm (Figure 1).

Figure 1.

(A) Local tissue repair. (B) The internal opening of the fistula sealed by bundled iodoform strip (arrow). (C) The gross appearance of the fistula.

At 21 months post-primary surgery, the patient appeared undernourished and emaciated, with a body mass index of 15.6. Due to the proximal location and size of the fistula, closure using titanium clips and stent, as well as gastroesoghageal anastomosis, were not feasible. The PCF was therefore repaired using a double-layer approach, which involved the overlapping of a RFFF on a local adjacent flap. A circular adjacent skin flap (7.0×9.0 cm) was created according to the area of the defect, while the RFFF was harvested from the left arm. Microvascular anastomosis was performed between the radial artery and the superior thyroid artery, and between the radial venae comitantes and the internal jugular vein branch. The RFFF was then sutured onto the adjacent flap, and the donor site was closed with a split thickness skin graft from the abdomen. A nasogastric tube was placed for enteral feeding. Both the recipient and donor sites appeared to recover well.

However, secretions were reported from the lower margin of the flap on postoperative day 18, which showed Pseudomonas aeruginosa growth on culture. Gastroscopy was thus performed to identify the internal opening of the fistula. The nasogastric tube was replaced with a triple-lumen Freka-Trelumina nasojejunal tube under endoscopy guidance. This involved expansion of the upper segment of the esophagus, and placement of the negative pressure suction tube 15 cm from the incisors (Figure 2). Antibiotic irrigation, nutrition optimization, and saliva suction were conducted when necessary through the Freka-Trelumina tube. Good healing of the flap was shown on gross observation and gastroscopy. The Freka-Trelumina tube was removed two months later. At 14 months follow-up, no local recurrence or distant metastasis were observed, with no reports of impaired wrist motion or abdominal discomfort (Figure 3).

Figure 2.

(A) Scarring at the pharyngeal–esophageal junction and the recurred fistula (arrow). (B) Expansion of the upper esophageal segment and Freka-Trelumina tube placement. (C) The triple-lumen Freka-Trelumina nasojejunal tube.

Figure 3.

(A) Flap viability during long-term follow-up. (B) Good fistula closure observed on gastroscopy. (C) The abdominal scar. (D) The left arm scar.

Discussion

PCFs are a major complication of total laryngectomy. ¹ Most fistulas can be managed conservatively, with surgical management often reserved for PCFs that are large, chronic, or refractory to conservative interventions, which may be challenging. ⁵ In PCF reconstruction, classical regional and free flaps have been increasingly replaced by the supraclavicular artery island flap, due to limitations such as bulking, long operative time, and donor site morbidity.^2,6 However, donor site selection depends on multiple factors such as body habitus, neck status, defect size, vascular status of the neck, technical skills of the surgeon, and available resources. ⁷

Considering that the PMMF is a reliable and suitable option for debilitated patients due to ease of harvest and low donor site morbidity, ⁶ it was employed for primary PCF reconstruction following radical excision of the hypopharyngeal carcinoma in our patient. Local flap closure has limited role in the management of PCFs. Supraclavicular artery island flap is not practicable according to the patient's neck condition. ⁷ Previous literature reported RFFFs, as a versatile tool for head and neck reconstructive surgeries ² ; however, due to its association with relatively high fistula rates, it is rarely used for PCF closure is rarely used for PCF closure. Thus, a double-layer closure technique involving a RFFF and a local adjacent flap was opted for in our case to avoid PCF recurrence. Secondary flap surgeries often associate with the risk of infection, venous thrombosis, as well as fistula development and recurrence. ⁶ However, complications or subjective complaints related to the donor site, which may represent potential risk factors for PCFs, were not reported in our patient. The locoregionally advanced hypopharyngeal carcinoma not only associated with high mortality, but also represented a significant risk for PCF. Local infection, reduced nutrition, low BMI, and bile reflux were additional PCF risk factors in our patient.

Salivary bypass tubes and low-pressure drainage suctions have recently been reported to reduce the risk of PCF after laryngectomy.^8,9 However, the placement of both of these, in addition to a single-cavity nasogastric tube, was not a viable option for our patient. The triple-lumen Freka-Trelumina nasojejunal tube has normally been used in pancreatic disease patients. ⁴ Moura et al. reported its use for enteral feeding and drainage in the treatment of early post-bariatric surgery leak. ¹⁰ However, to our knowledge, it has not been employed in PCF management, and our study is the first to describe its use in this field. The purpose of placing the Freka-Trelumina tube in our patient was to: (1) prevent direct contact of saliva with the healing tissue, (2) allow for drainage to promote wound healing, and (3) allow for enteral nutrition optimization and gastrointestinal decompression. The Freka-Trelumina tube thereby mitigated the known risk factors of PCF in our patient, while reducing the risk of infection to promote closure of the refractory PCF. The patient resumed oral diet and returned to work during follow-up, with no reports of impaired wrist function or abdominal discomfort. Unfortunately, cutaneous scarring was poor. It may be related to the patient's scar constitution, surgical suture, and no use of descarring drugs or materials after surgery, which we need to pay attention to reduce scar formation in future surgery.

Conclusion

Our study describes the successful management of a refractory PCF using double-layer closure with RFFF and Freka-Trelumina tube placement in a patient with advanced hypopharyngeal carcinoma. Further studies are warranted to assess the early use of this approach following total laryngectomy and validate its effects in reducing the incidence of PCF.