Contralateral Pectoralis Flap for Repair of Spinal Hardware-Associated Fistula

We report a case of a recurrent hypopharyngeal fistula following spinal hardware placement that required multiple procedures. The course was complicated by a medication error and ultimately the fistula resolved after contralateral pectoralis muscle flap.

Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis

Objective To determine the most cost-effective reconstruction method after salvage total laryngectomy. Study Design Cost-effectiveness analysis Setting Tertiary care hospitals with head and neck oncologic and reconstructive surgeons. Subjects and Methods We constructed a Markov-based decision model to compare reconstruction by primary closure to pectoralis flap and free flap after salvage total laryngectomy. The model simulated disease with transition probabilities and health utilities found in primary literature and estimated the average overall cost of each reconstructive method using Medicare billing codes. Effectiveness was compared using quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were performed to scrutinize the conclusions of our model. Reconstruction methods were compared using incremental cost-effectiveness ratios (ICERs). In the United States, less than $150,000 per QALY gained is considered cost-effective (2019 US dollars). Results Our base case analysis revealed that primary closure was less expensive ($44,370) and yielded more QALYs (0.91) than both pectoralis ($45,163, 0.81 QALYs) and free flap ($46,244, 0.85 QALYs), making it the most cost-effective option. Between flaps, free flap was cost-effective over pectoralis flap (ICER = $27,025/QALY gained). Sensitivity analyses showed primary closure as cost-effective 69% of the time over either flap. These conclusions were sensitive to the health utilities (quality of life) of each method of reconstruction. Conclusion Tissue flaps to augment closure after salvage total laryngectomy are not always the most cost-effective reconstructive option. The long-term morbidity of flap surgery oftentimes outweighs the benefit of lowering fistula rates after surgery. Careful consideration must be taken when advising patients of their reconstructive options.

Use of advanced flap and microsurgery techniques in the resolution of mediastinitis as a complication of cardiac surgery

In the majority of cases, mediastinitis is a potential complication in any cardiac surgical procedure. The objective of this case report is to accurately describe how the combination of microsurgery and soft tissue flaps can be an effective therapeutic alternative in the treatment of mediastinitis as a complication of cardiac valve replacement. Female 63-year-old patient with a background of obesity, hypertension and extense cardiac interventions, she was programmed for necrosectomy with left pectoralis flap technique. Mediastinitis, although a rare complication of the sternotomy performed in cardiac surgery, occurring in 1-2%, carries a high mortality rate. Early diagnosis of mediastinitis after cardiac surgery requires high clinical suspicion, initially making the diagnosis may be difficult, risk factors should be considered. An early surgical approach can reduce the morbidity and mortality of this condition. The pectoralis flap should be considered as a safe therapeutic option.

Pectoralis Myofascial Flap during Salvage Laryngectomy Prevents Pharyngocutaneous Fistula

OBJECTIVE: To determine the rate of pharyngocutaneous fistula after salvage laryngectomy and assess if pectoralis myofascial flap reinforcement over primary pharyngeal closure prevents pharyngocutaneous fistula. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care public hospital. SUBJECTS AND METHODS: This study included 43 patients undergoing total laryngectomy between 2003 and 2008. Pectoralis myofascial flap reinforcement of the pharyngeal closure during salvage laryngectomy was performed on patients after June 2006. The main outcome measure was pharyngocutaneous fistula after primary laryngectomy, salvage laryngectomy, and salvage laryngectomy with pectoralis flap reinforcement. RESULTS: Of the 43 patients, 26 were treated with primary total laryngectomy while 17 received salvage laryngectomy. Seven of 26 patients (27%) undergoing primary total laryngectomy developed pharyngocutaneous fistula. All patients in this group were closed primarily with no flap reinforcement. For salvage laryngectomy, four of seven patients (57%) with primary pharyngeal closure developed pharyngocutaneous fistula; however, none of 10 patients (0%) undergoing salvage laryngectomy with pectoralis myofascial flap reinforcement developed fistula ( P < 0.02; 0%-23%; 95% CI). CONCLUSIONS: With pectoralis myofascial flap reinforcement, pharyngocutaneous fistula rate after salvage laryngectomy dropped to 0 percent in this study (0%-23%; 95% CI). This is a simple, reliable technique that prevents postoperative pharyngocutaneous fistula and its associated morbidity after salvage laryngectomy.