Prevention of Pharyngocutaneous Fistula After Total Laryngectomy: Evidence-based Strategies for Head and Neck Surgeons

Pharyngocutaneous fistula (PCF) remains the most common and challenging complication following total laryngectomy (TL), occurring in 17%–34% of patients despite advances in surgical technique and perioperative care. PCF significantly increases morbidity, prolongs hospitalization by an average of 2–3 weeks, delays adjuvant therapy, and substantially increases healthcare costs. The pathogenesis of PCF is multifactorial, involving patient-related factors (comorbidities including hypothyroidism, nutritional status, and smoking), disease-related factors (tumor extent, previous radiotherapy, disease-free interval, and extralaryngeal spread), and surgical factors (closure technique and use of vascularized tissue). Recent systematic reviews and meta-analyses have identified several modifiable risk factors, including preoperative anemia (hemoglobin < 12.5 g/dL), hypoalbuminemia, hypothyroidism, and active smoking. Prevention strategies encompass three critical phases: preoperative optimization of nutritional status, correction of anemia and thyroid dysfunction, and pulmonary prehabilitation through incentive spirometry; intraoperative meticulous surgical technique with appropriate pharyngeal closure methods and selective use of vascularized tissue reconstruction; and postoperative monitoring with early fistula detection protocols, anti-reflux measures, structured respiratory physiotherapy, and antiemetic and laxative regimens. Salvage TL following chemoradiotherapy carries particularly high PCF rates (20%–35%), necessitating prophylactic reconstruction with pedicled or free flaps. Evidence demonstrates that pectoralis major myofascial flaps reduce PCF rates by approximately 22% in salvage cases, while horizontal pharyngeal closure decreases fistula incidence compared to T-shaped closure. Evidence for routine salivary bypass tube use is insufficient, and selective placement based on individualized risk assessment is recommended. This narrative review synthesizes current evidence on PCF prevention with Oxford Centre for Evidence-Based Medicine level of evidence grading, examining risk stratification systems, preoperative patient optimization protocols, surgical techniques, reconstructive strategies, and postoperative management approaches to reduce PCF incidence and improve outcomes for patients undergoing TL.