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| Year : 1985 | Volume
: 31
| Issue : 2 | Page : 95-7 |
Some thoughts on prevention of post-operative salivary fistula.
Shah AK, Ingle MV, Shah KL
How to cite this article:
Shah A K, Ingle M V, Shah K L. Some thoughts on prevention of post-operative salivary fistula. J Postgrad Med 1985;31:95 |
Pharyngo-cutaneous fistulae are a major problem in radical surgery for the larynx and pharynx. fistula may set the stage for a fatal complication such as carotid artery rupture. It prolongs the convalescence of the patient, depressing and demoralizing him. Fistulae are common after neck surgery, occurring in upto 64% of non-irradiated and in as many as 76% of irradiated necks.[2] In our department, the incidence was about 60% of all operated cases. The present study was undertaken to evaluate the possible advantages of a new operative cum post-operative procedure.
Twenty-five patients with carcinoma of the larynx underwent total laryngectomy either with or without neck dissection. None of the patients received preoperative irradiation. These patients were divided into two groups. Group I was treated by the conventional procedure (Plan A) which was (a) T-shaped closure of the pharyngeal defect reinforced with layers of soft tissue and muscles when available and (b) commencement of nasogastric feeding from the first post-operative day. Group II was treated by the modified procedure (Plan B) which comprised (a) suturing the pharyngeal defect in a vertical straight line (B in [Fig. 1]) with a continuous inverting Connel's stitch, reinforced with interruped stitches through the submucosa and by a third layer of soft tissues and muscles as available, (b) continuous nasogastric drainage for 24 hours to keep the stomach empty and (c) no nasogastric feeds for the first 3 days, hydration being maintained parenterally.
Both groups of patients were treated with (a) continuous suction drainage of the operative wound and (b) fixing a soft polyvinyl chloride nasogastric tube in place to prevent its accidental removal for 10 days.
[Table - 1] shows the distribution of the patients into different groups. [Table - 2] shows the results in the two groups. The difference in the incidence of a fistula between the two groups is obvious.
Inspite of the high incidence of fistula formation, very few papers have appeared on the preventive aspect of this problem. Stell and Cooney[2] reported the lowest incidence of fistulae (13%) and stressed the importance of meticulous suturing, suction drainage and well planned incisions. Further, Stell and Maran[8] are advocates of vertical pharyngeal closure. On the other hand, Lavelle and Maws do not think that the method of pharyngeal repair and the type of wound drainage determine the outcome of the surgery.
We used 3-0 chromic catgut for the pharyngeal suturing but polyglycolic sutures could be used, especially in irradiated necks. Piercing the mucosa in Connel's stitch, in our opinion, is desirable since there is no serosa available and submucosa alone may not be strong enough to hold the stitch. Contrary to the opinion of Wallace et al,[9] piercing the mucosa does not seem to promote outgrowth of mucosa along the suture and increase the rate of infection.
The use of the nasogastric tube as in the modified procedure has the following advantages. The gastric contents are prevented from regurgitating into the throat and putting the suture line under tension. The avoidance of gastric feed also takes away the gastric phase of salivary secretion which occurs especially if the stomach gets distended.[3] This reduction in salivary secretion avoids repeated swallowing, thus giving rest to the suture line and reduces the irritant effect of the saliva.[4] The bilateral ligation of parotid duct as suggested by Bernard and Gignoux[1] and giving propantheline bromide as suggested by Maurice and Sharma[6] are thus no longer necessary. In our opinion, the soft, polyvinyl chloride nasogastric tubes do not cause any damage to the suture line inspite of being kept for 10 days. Elective gastrostomy or oesophagostomy[4] are certainly not warranted.
This study has demonstrated the superiority of plan B over plan A which has since been abandoned in our department.
The authors wish to thank the Dean, Seth G.S. Medical College and K.E.M. Hospital, Bombay, for his permission to publish the hospital data.
| 1. | Bernard. P. and Gignaux, B.: L'inhibiteur de Frey dans le traitement et la prevention des fistulas pharyngces post-operatoires (anti-enzyme polypeptidique). Ann. Otolaryngol. (Paris), 87: 219-222, 1970. Quoted by Fredrickson and Haight.[4]  |
| 2. | Bresson, K., Rasmussen, H. and Rasmussen, P.A.: Pharyngo-cutaneous fistula in totally laryngectomised patients, J. Laryngol. & Otol., 88: 835-842, 1984. |
| 3. | Chatterjee, C. C.: "Human Physiology," Vol. 1, Medical Allied Agency, Calcutta, 1981, pp. 453-458. |
| 4. | Fredrickson, J. M. and Haight, J. S. J.. Prevention of pharyngeal fistulae. In "Controversy in Otolaryngology." Editor: J. B. Snow Jr., W. B. Saunders Company, Philadelphia, London and Toronto. 1980, pp. 371-381. |
| 5. | Lavelle, R. J. and Maw, A. R.: The aetiology of past-laryngectomy pharyngo-cutaneous fistulae. J. Laryngol. & Otol., 86: 785-793, 1972. |
| 6. | Maurice, D. G. and Sharma, D. P.: Repair of a pharyngo-cutaneous fistula. Brit. J. Plast. Surg., 28: 268-271, 1975. |
| 7. | Stell, P. M. and Cooney, T. C.: Management of fistulae of the head and neck after radical surgery. J. Laryngol. & Otol., 88: 819-834, 1974. |
| 8. | Stell, P. M. and Maran, A. G. D.: "Head and Neck Surgery." 2nd Edition, William Heinemann Medical Books Ltd., London, 1978, pp. 153-193. |
| 9. | Wallace, W. R., Maxwell, G. R. and Calvaris, C. J.: Comparison of polyglycolic acid suture to black sillk, chromic and plain catgut in human oral tissues. J. Oral. Surg., 28: 739-746, 1970. |
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