To simplify our analysis, we limited it to a review of studies about pharyngocutaneous fistula PCF after total laryngectomy. The literature addressing postlaryngectomy PCF is extensive. Through a meta-analysis of observational studies about PCF, this article summarizes the available evidence about risk factors contributing to PCF. The search period was from January 1, , to March 31, The following search terms were used to identify relevant articles: fistula , pharyngocutaneous fistula , cutaneous fistula , laryngectomy , postoperative complications , radiation therapy , and wound healing Boolean operators were used to narrow searches.
Additional studies were identified through article references. Only those studies meeting strict inclusion criteria were selected. The inclusion criteria were as follows: 1 Site only primary cancers of the larynx, excluding primary cancers of the hypopharynx or other sites in the aerodigestive tract. Risk factors, or variables, examined in each article meeting the inclusion criteria were recorded in a spreadsheet. To be included in the meta-analysis, a variable had to be present in more than 1 article. Variables that were significant but were examined in a single article were also tabulated Table 1.
For each variable, a relative risk RR was calculated for each study in which data were reported for that variable. Combined summary estimates of effect for each risk factor were then calculated from a random-effects model using the method of DerSimonian and Laird. Figure 1 is a flowchart outlining the systematic review process. Sixty-five studies presenting data on risk factors contributing to PCF formation were identified a complete list of all studies reviewed is available from the authors.
Of these studies, 26 met the inclusion criteria. Table 2 lists the 26 studies, the overall fistula rate reported in each study, and the variables analyzed in each study. Table 3 gives the pooled analysis of the effect of each variable on the formation of PCF. The heterogeneity of effects among studies is also summarized. The results given in Table 3 are graphically shown in Figure 2.
Four of 10 potential risk factors evaluated in the pooled analysis were significant, including the following: postoperative hemoglobin level less than Pooled estimates of the effects of radiotherapy dose RR, 0. The degree of heterogeneity of effects among studies was significant for postoperative hemoglobin level and for preoperative radiotherapy. Concurrent neck dissection and comorbid illness did not demonstrate an overall increase in RR; however, the degree of heterogeneity of effects was also significant for these variables.
Table 1 lists the variables in single articles that were found to be significant in those studies 3 - 8 but were excluded from the pooled analysis because only the single article discussed the variable in question. Six studies, 2 , 6 , 8 , 13 , 21 , 23 summarized in Table 4 , included data on the severity of fistula, comparing patients with and without preoperative radiotherapy.
A pooled analysis could not be performed because of the lack of standardized presentation of these data among studies; however, the overall severity of fistula was greater among patients who underwent preoperative radiotherapy. Wound complications ie, infection, flap necrosis, and fistula after head and neck surgery are associated with increased hospitalization, resource utilization, and patient anxiety and morbidity.
Multiple factors contributing to increased risk of wound complications have been implicated, including prior radiotherapy, chemoradiotherapy, malnutrition, duration of surgery, anemia, tobacco use, medical comorbidity, and others.
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However, studies about complication rates are often limited by small sample sizes, as well as by variability in the type of surgery performed, the tumor site and stage, and the method of reconstruction. In addition, the definition of complication varies among studies.
This article presents a meta-analysis of the current literature about postlaryngectomy wound complications. Meta-analysis is a statistical method in which separate studies that are considered to be combinable are statistically integrated. This statistical tool was originally described as a means of studying the pooled effects of multiple randomized controlled trials.
When a highly structured and systematic method of data collection and analysis is used and when the studies analyzed include binary outcomes eg, disease vs no disease, dead vs alive, or fistula or no fistula , it is considered a reliable means of performing a systematic review of observational studies. We chose studies about postlaryngectomy PCF because of the standard surgical approach to laryngectomy and the binary nature of PCF a patient has or does not have a fistula. This allows for combining similar observational studies in which a binary outcome measure is reported.
Search for books, journals or webpages All Pages Books Journals. Authors: David Eisele Richard Smith. Hardcover ISBN: Imprint: Mosby. Published Date: 25th September Nonwound infections following head and neck oncologic surgery.go here
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Laryngoscope ; 1 Pt 1 Less collagen production in smokers. Surgery ; Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from the National VA Surgical Risk Study. Nutritional status in head and neck cancer patients. J Otolaryngol ; Cancer of the upper aerodigestive tract. Global study of cases. Bull Cancer ; Antibiotic prophylaxis in clean-contaminated head and neck oncologic surgery. Ann Otol Rhinol Laryngol Suppl ; Becker GD. Identification and management of the patient at high risk for wound infection.
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Head Neck Surg ; American Society of Anesthesiologists classification of physical status as a predictor of wound infection. ANZ J Surg ; Ahospitalwide intervention program to optimize the quality of antibiotic use: Impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance.
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Clin Infect Dis ; Risk index for prediction of surgical site infection after oncology operations. Am J Infect Control ; Advanced Search Users Online: Changing trends in antibiotic prophylaxis in head and neck surgery: Is short-term prophylaxis feasible?. J Head Neck Physicians Surg ; Table 1: The distribution of surgical site infection among the subjects of different additional treatment, discharge, erythema, purulent discharge, separation of deep tissue, isolation of bacteria and stay scores Click here to view.
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Table 2: The distribution of surgical site infection among the subjects who had different National Nosocomial Infections Surveillance score and its statistical significance Click here to view. Table 3: The distribution of surgical site infection among the subjects who had different American Society of Anesthesiologist scores and their statistical significance Click here to view. Figure 1: a Surgical site infection on the 5 th postoperative day following excision of a benign neck lesion b well-granulating wound on the 10 th postoperative day same patient Click here to view.
Table 4: The distribution of infected cases of surgical site infection with different diagnosis among clean-contaminated patients Click here to view. Figure 2: a Patient with surgical site infection on the 10th postoperative day following total laryngectomy. Table 5: The distribution and statistical significance of different patient variables among non-infected and surgical site infection cases Click here to view. Figure 3: a The only one subject 1.
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