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��ࡱ�>��	Y[����X�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[����Lbjbj����4Rΐΐ�$5���������������������8 d�$�0&0�(�������s%u%u%u%u%u%u%$`'�*B�%Q�������%������%"""������s%"�s%"""�����0��&����`"_%&00&"D*!�D*""&D*�7"(��"������%�%�!^���0&������������������������������������������������������������������������D*�����������:A DIFFERENT APPROACH IN THE TREATMENT OF PHARYNGOCUTANEOUS FISTULA: Closure through the desepithelised skin overlying pectoralis major flap. 

(Short running head: A different approach in the treatment of pharyngocutaneous fistula)

Ismail Yilmaz MD,* Harun Cologlu MD,� Furkan Sokmen MD, � Fatih Aslan MD�
* Professor, Baskent University School of Medicine, Department of Otolaryngology, Ankara, Turkey 
� Assistant Professor, Baskent University School of Medicine, Department of Plastic and Reconstructive Surgery, Ankara, Turkey
� Resident, Baskent University School of Medicine, Department of Otolaryngology, Ankara, Turkey

Corresponding Author:  Ismail Yilmaz, MD
Baskent University, Adana Seyhan Hospital, Otolaryngology Department 
Baraj Yolu 1.durak No:37, 01110 Seyhan, Adana, Turkey
Tel: +90 322 4586868          Fax: +90 322 4599197    e-mail:  HYPERLINK "mailto:iy38@yahoo.com" iy38@yahoo.com

Note: This material has never been published and is not currently under evaluation in any other peer-reviewed publication.
INTRODUCTION
Pharyngocutaneous fistula (PCF) is the formation of a passage between the pharynx and the skin. Pharyngocutaneous fistula (PCF) is a common complication emerging following the total laryngectomy and its incidence rate was reported to be between 7.6% and 50% [1,2,3]. It was also reported that in the development of PCF there are such factors playing roles as the growth of the tumor, diabetes, liver disease, congestive heart failure, anemia, malnutrition, preoperative radiotherapy (RT), excessive homeostasis as a result of improper surgical technique, postoperative hypovolemia and bad wound care [1,2,4]. These factors cause deterioration in the tissue perfusion, the decrease in the partial pressure of the oxygen in the wound, impairment in the mechanisms which are against the resistance of the infection and the delays in wound healing [5]. There is a need to repair pharynx and neck through vascularised flap in the patients with mucosal and skin necrosis as a result of the deep neck infection depending on large fistulas. The most commonly used flaps are deltopectoral, latissimus dorsi (LD) and pectoralis major (PM) myocutaneous flaps [4,6,7]. In the story of the reported case, he is a PCF case with only one of the factors listed above RT and as a result of the salvage surgery he has a depleted neck vessel, in the closure of the fistula, pectoralis major myocutaneous flap (PMMCF) and another different technique was applied.

CASE REPORT 
The 65-year old patient was diagnosed as having T2N0M0 poor differentiated squamous cell carcinoma (SCC) of the supraglottic larynx in March, 2010. The patient received 67 Gray definitive RT. In the control neck magnetic resonance imaging following 80 days; it was found that there was a recurrence both at epiglottic and glottic levels. Direct laryngoscopy and biopsy was performed again; thus, it was reported as the recurrence of SCC. Initially, the patient was indecisive in terms of being operated on, yet he sought health-care as he had respiratory problems after 5 months. Total laryngectomy and selective neck dissection (II-V levels on the right, II-IV levels on the left) was performed on the patient having no distant metastasis on positron emission tomography. He did not receive any additional RT during postoperative period. After 15 months, he applied at the hospital as he had a 3 cm. mass with skin invasion under right jaw. Fine needle aspiration biopsy was performed on the mass; the malign epithelial tumor was reported. Right radical neck dissection was performed and it was repaired through right PMMCF. After 5 months, local recurrence was detected. The right carotid was blocked by the tumor in the carotid-cerebral angiography; however, the left carotid compensated the circulatory system in the brain. Accordingly, enlarged neck dissection and resection of the contents of right carotid sheet were performed. As the tumor was close to lateral pharyngeal mucosa, during the dissection a 2 cm opening on the lateral pharyngeal wall emerged; it was repaired primarily through inverting suture immediately. On postoperative day 2, PCF was detected. In the following 20 days, fistula continued despite inverting suture, local flap rotation, debridement of necrotic tissues. This time fistula was repaired through left PMMCF to treat persistent fistula (Figure 1). In this operation, the skin part PMMCF (6x8 cm) was desepithelised except for the central elliptical island (2x4cm) which was to close the opening of fistula (Figure 2 a-b-c). The central skin island was sutured on the debrided edge of the fistula through mattress technique. Desepithelised part of the skin was sutured on lateral wall of pharynx and vertebrobasilar fascia, and thus the stress on the fistula line decreased. Finally, PM muscle was fixed on the surrounding tissue and neck skin flaps were closed. The patient�s endoscopic (Figure 3 a-b-c-d) and external (Figure 4) views were presented after postoperative month 4.

DISCUSSION
In the surgical repair of the persistent fistula, PMMCF and LDMCF are among the most common choices. In the massive tissue defects, the closure of pharyngotomy through pectoralis flap and the closure of the surface of the pectoralis muscle through split thickness skin graft are presented as workhorse method due to both in terms of its cosmetic features and reliability in the reconstruction [4]. In the closure of the fistula, there are various techniques that have been identified. Their common characteristics are to make two epithelial surfaces get close without any tension and the tissue used is well-vascularised [8]. In addition, in order to lower the tension on the mucosal closure line, it was recommended that the dermal part should be suture onto the prevertebral fascia [9]. In our case we applied a technique which we did not encounter in the literature, we were able to not only close the epithelial surface through PMMCF without any tension, but also lower the tension on mucosal closure line by suturing the desepithelised part of skin of the flap onto surrounding tissue and the fascia. As was the case in our patient, the persistent fistula, which is hardly manageable and resulted from the preoperative RT [3,8] as well as vessel depletion [10], which are known to increase the risk of fistula, was successfully treated. Through this technique, it was possible to close the fistula line by the use of central skin island as well as enhancing the stabilization by the use of desepithelised skin part; furthermore, it was also guaranteed that the area would be vascularized through vascularized PM.
Thus far, there have been some unsuccessful attempts in which there are some different types of techniques are used in managing the persistent PCF cases, which are hard to close; however, the reported technique in our case could be different one which may be recommended to prefer in further cases. 

REFERENCES
[1] Conley JJ. Oropharyngocutaneous fistula. In: Conley JJ (Ed): Complications of Head and Neck Surgery. WB Saunders Company. Philadelphia 1979. p: 92-98.
[2] Soylu L, Kiroglu M, Aydogan B, Cetik  F, Kiroglu F, Akcali C, Ozsahinoglu C. Pharyngocutaneous f1stula following laryngectomy. Head Neck. 1998:20(1):22-25.
[3] Patel UA, Keni SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg. 2009;141: 190-195
[4] M�kitie AA, Irish J, Gullane PJ. Pharyngocutaneous fistula. Otolaryngol Head Neck Surg. 2003;11:78�84.
[5] Hunt TK. Critical care of wounded patients. In: Shoemarker WC, Ayres S, Grenvik A, Holbrook PR, Thompson WL (Eds): Textbook of Critical Care. WB Saunders Company. Philadelphia. 1989: p. 1285-1294.
[6] Mathes JS, Nahai F. Pectoralis major flap. In: Mathes JS, Nahai F (Eds): Reconstructive Surgery: Principles, Anatomy and Technique. Churchill Livingstone. New York, 1997; Vol 1:  pp. 441-465.
[7] Ozluoglu LN, Akcayoz N, Saydam L, Gokler A, Velidedeoglu HV. Ba_ boyun kanser cerrahisinde fasiokutan servikohumeral omuz flebi kullan1m1. KBB Bulteni. 1994;3:76-80.
[8] McLean JN, Nicholas C, Duggal P, Chen A, Grist WG, Losken A, Carlson GW. Surgical 
management of pharyngocutaneous fistula after total laryngectomy. Ann Plast Surg. 2012;68(5):442-5.
[9] Ariyan S, Cuono CB. Myocutaneous flaps for head and neck reconstruction. Head Neck Surg. 1980;2:321-45.
[10] Pirgousis�P, Fernandes R. Use of the internal mammary artery perforator flap for repair
 of  pharyngocutaneous fistulas in the vessel-depleted neck.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/20739115" \o "Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons." J Oral Maxillofac Surg. 2011;69(4):1225-8.


FIGURE LEGEND
Figure 1. The intraoperative view of the fistula, the aspirator indicates the opening of the fistula.
Figure 2. a) PMMCF was prepared, central skin island was drawn.
 b) The surrounding of the central skin island was desepithelised. 
 c) The illustration of the desepithelisation process.
Figure 3. The view of the central skin island from the mouth which is completely closed fistula; postoperative a))CDLSTYghlmvw�����������ͳ����������������vgTA%h;�h;�B*CJOJQJaJph%hS{�h;�B*CJOJQJaJphhS{�h;�CJOJQJaJhm�CJOJQJaJ,h]%5�CJOJQJ\�aJmH	nHsH	tH2h{�h]%5�CJOJQJ\�aJmH	nHsH	tH2h{�h \5�CJOJQJ\�aJmH	nHsH	tH2h{�h�O5�CJOJQJ\�aJmH	nHsH	tH/h{�h�O5�CJOJQJaJmH	nHsH	tH����3	�	
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