MMed (Otorhinolargngology). Faculty of Health Sciences, University of the Witwatersrand / Introduction The bulk of the surgical literature about laryngeal cancer is concerned with cure rates or five-year survival rates. While this is important, the five year survival rate is only one measure of success of laryngeal cancer surgery. Whereas, postoperative morbidity and mortality are also very important. Pharyngocutaneous fistula (PCF) is the most frequent complication in the early post operative period after total laryngectomy. It creates a communication between the pharynx and the cervical skin or less frequently with the stoma of the tracheostomy. The pharyngeal contents, usually saliva, flow through the fistula emerging from the cutaneous orifice. This study aims to determine the incidence and the predisposing factors for the development of pharyngocutaneous fistula (PCF); and to review the management and outcome of such cases following total laryngectomy at Ear, Nose and Throat (ENT) department, Chris Hani Baragwanath Hospital. Patients and methods This is a retrospective study. The medical records of 30 patients who underwent total laryngectomy surgery for squamous cell carcinoma of the larynx with no local neck metastases between June 2000 and May 2008 were assessed. iii All patients had similar (standard) preoperative and post operative care. I studied a number of factors that could influence pharyngocutaneous fistula formation such as age, smoking habit, alcohol consumption, tumour stage, preoperative tracheostomy, preoperative hemoglobin and associated systemic diseases (gastroesophageal reflux, chronic obstructive pulmonary disease, systemic high blood pressure and diabetes mellitus) Results Pharyngocutaneous fistula appeared in 20% (6/30 patients). Spontaneous closure with local wound care was noted in 5 patients (83.3%), whereas a surgical closure was necessary in one patient . Conclusion The results of our study concluded that pharyngocutaneous fistula remains a troublesome complication of the early post-operative period after total laryngectomy. There are many conflicting reports in the literature concerning the pharyngoctaneuos fistula predisposing factors, but our study data (table 1 page 22) of age, smoking habit, alcohol consumption, tumor stage, preoperative tracheostomy, preoperative hemoglobin and associated systemic diseases( gastroesophageal reflux, chronic pulmonary obstructive disease, systemic high blood pressure and diabetes mellitus) did not show any significant value. Our experience confirmed that most pharyngocutaneous fistulas can be successfully treated conservatively.

Esta pesquisa utilizou a revisão sistemática com o objetivo de identificar os principais tratamentos da fístula faringocutânea após a laringectomia total e elaborar recomendações para as intervenções de enfermagem na assistência ao paciente submetido a laringectomia total, com a complicação fístula faringocutânea. Foram previamente localizados 1007 estudos, dos quais foram selecionados 37 estudos publicados em periódicos científicos indexados no Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE e LILACS, desses 17 (46%) abordavam o tratamento da fístula faringocutânea, após laringectomia total, 10 (27%) discutiam os fatores de risco e os outros 10 (27%) as complicações após a laringectomia total. A análise desses artigos revelou que o delineamento da pesquisa predominante nos estudos foi o retrospectivo com 88,5%, e 11,5% prospectivos. A média de tempo de acompanhamento foi de 8,8 anos e a incidência de fístula faringocutânea, após a laringectomia total variou entre 8,7% e 27,0%, envolvendo um total de 635 pacientes. Os fatores de risco estudados pelos pesquisadores foram: radioterapia pré-operatória, técnica cirúrgica, traqueostomia pré-operatória, estadiamento do tumor, febre, doenças crônicas, vômito, nível de hemoglobina e reinício da alimentação oral, formando subgrupos com um número menor de pacientes e, conseqüentemente obtiveram percentuais individuais maiores de incidência da fístula faringocutânea, quando comparados com o índice geral de fístula proveniente da amostra inicial do estudo. O tratamento conservador e cirúrgico da fístula tem por finalidade preservar e restaurar a região lesada e envolve um processo complexo, dinâmico e sistêmico. Esta complicação aumentou o período de internação e de cicatrização, com médias de 28 e de 36 dias respectivamente. O tratamento predominante é ainda o conservador que implica cuidados higiênicos intensivos e o tratamento da ferida. O planejamento da assistência de enfermagem alicerçado em conhecimentos e habilidades técnico-científicas acerca do tratamento de feridas aliadas à dimensão psicossocial resultarão em intervenções de maior qualidade.A incorporação de conhecimentos oriundos da prática baseada em evidências na prática clínica, trará maior consistência à atuação do enfermeiro no cuidado do laringectomizado total e portador de fístula faringocutânea. / This research carried out a systematic review aimed at identifying the main treatments of pharyngocutaneous fistula after total laryngectomy and at elaborating recommendations for nursing interventions in care delivered to patients submitted to total laryngectomy, including the pharyngocutaneous fistula complication. In advance, 1007 studies were found, out of which we selected 37 studies published in scientific journals indexed in Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE and LILACS. Among these, 17 (46%) dealt with the treatment of pharyngocutaneous fistula after total laryngectomy, 10 (27%) discussed the risk factors and the other 10 (27%) were about complications after total laryngectomy. The analysis of these articles revealed that the predominant research orientation was retrospective (88.5%) and 11.5% corresponded to prospective studies. Average follow-up time was 8.8 years and the occurrence of pharyngocutaneous fistula after total laryngectomy varied from 8.7% to 27.0%, involving 635 patients in total. Analyzed risk factors were: pre-operative radiotherapy, surgical technique, pre-operative tracheostomy, tumor stage, fever, chronic disease, vomiting, hemoglobin level and restarting oral feeding. These constitute subgroups with a lower number of patients which, consequently, obtained higher individual percentage values for the occurrence of pharyngocutaneous fistula in comparison with the general fistula rate from the initial study sample. The conservative and surgical treatment of fistula aims to preserve and restore the injured region and involves a complex, dynamic and systemic process. This complication increased the internment and healing periods, with an average duration of 28 and 36 days respectively. The conservative treatment still predominates and implies intensive hygienic care and wound treatment. The planning of nursing care, based on technical-scientific knowledge and abilities related to wound treatment, in association with the psychosocial dimension, will result in higher-quality interventions. Incorporating evidence-based knowledge into clinical practice will offer greater consistency to nursing actions in caring for patients after total laryngectomy who suffer from pharyngocutaneous fistula.

Esta pesquisa utilizou a revisão sistemática com o objetivo de identificar os principais tratamentos da fístula faringocutânea após a laringectomia total e elaborar recomendações para as intervenções de enfermagem na assistência ao paciente submetido a laringectomia total, com a complicação fístula faringocutânea. Foram previamente localizados 1007 estudos, dos quais foram selecionados 37 estudos publicados em periódicos científicos indexados no Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE e LILACS, desses 17 (46%) abordavam o tratamento da fístula faringocutânea, após laringectomia total, 10 (27%) discutiam os fatores de risco e os outros 10 (27%) as complicações após a laringectomia total. A análise desses artigos revelou que o delineamento da pesquisa predominante nos estudos foi o retrospectivo com 88,5%, e 11,5% prospectivos. A média de tempo de acompanhamento foi de 8,8 anos e a incidência de fístula faringocutânea, após a laringectomia total variou entre 8,7% e 27,0%, envolvendo um total de 635 pacientes. Os fatores de risco estudados pelos pesquisadores foram: radioterapia pré-operatória, técnica cirúrgica, traqueostomia pré-operatória, estadiamento do tumor, febre, doenças crônicas, vômito, nível de hemoglobina e reinício da alimentação oral, formando subgrupos com um número menor de pacientes e, conseqüentemente obtiveram percentuais individuais maiores de incidência da fístula faringocutânea, quando comparados com o índice geral de fístula proveniente da amostra inicial do estudo. O tratamento conservador e cirúrgico da fístula tem por finalidade preservar e restaurar a região lesada e envolve um processo complexo, dinâmico e sistêmico. Esta complicação aumentou o período de internação e de cicatrização, com médias de 28 e de 36 dias respectivamente. O tratamento predominante é ainda o conservador que implica cuidados higiênicos intensivos e o tratamento da ferida. O planejamento da assistência de enfermagem alicerçado em conhecimentos e habilidades técnico-científicas acerca do tratamento de feridas aliadas à dimensão psicossocial resultarão em intervenções de maior qualidade.A incorporação de conhecimentos oriundos da prática baseada em evidências na prática clínica, trará maior consistência à atuação do enfermeiro no cuidado do laringectomizado total e portador de fístula faringocutânea. / This research carried out a systematic review aimed at identifying the main treatments of pharyngocutaneous fistula after total laryngectomy and at elaborating recommendations for nursing interventions in care delivered to patients submitted to total laryngectomy, including the pharyngocutaneous fistula complication. In advance, 1007 studies were found, out of which we selected 37 studies published in scientific journals indexed in Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE and LILACS. Among these, 17 (46%) dealt with the treatment of pharyngocutaneous fistula after total laryngectomy, 10 (27%) discussed the risk factors and the other 10 (27%) were about complications after total laryngectomy. The analysis of these articles revealed that the predominant research orientation was retrospective (88.5%) and 11.5% corresponded to prospective studies. Average follow-up time was 8.8 years and the occurrence of pharyngocutaneous fistula after total laryngectomy varied from 8.7% to 27.0%, involving 635 patients in total. Analyzed risk factors were: pre-operative radiotherapy, surgical technique, pre-operative tracheostomy, tumor stage, fever, chronic disease, vomiting, hemoglobin level and restarting oral feeding. These constitute subgroups with a lower number of patients which, consequently, obtained higher individual percentage values for the occurrence of pharyngocutaneous fistula in comparison with the general fistula rate from the initial study sample. The conservative and surgical treatment of fistula aims to preserve and restore the injured region and involves a complex, dynamic and systemic process. This complication increased the internment and healing periods, with an average duration of 28 and 36 days respectively. The conservative treatment still predominates and implies intensive hygienic care and wound treatment. The planning of nursing care, based on technical-scientific knowledge and abilities related to wound treatment, in association with the psychosocial dimension, will result in higher-quality interventions. Incorporating evidence-based knowledge into clinical practice will offer greater consistency to nursing actions in caring for patients after total laryngectomy who suffer from pharyngocutaneous fistula.