Videofluoroscopic Swallow Study-Guided Management and Assessment of Neopharyngeal Integrity after Total Laryngectomy With or Without Partial Pharyngectomy: Diagnostic Accuracy and Risk Factor Analysis for Pharyngocutaneous Fistula.

Abstract

Pharyngocutaneous fistula (PCF) is the most frequent complication after total laryngectomy. Videofluoroscopic swallow study (VFSS) is often used to guide postoperative feeding, but its diagnostic reliability and the relative contribution of nutritional versus surgical risk factors remain uncertain. A prospective observational study was conducted on 30 patients undergoing total laryngectomy with or without partial pharyngectomy between August 2021 and July 2023 at a tertiary referral center. VFSS with Gastrografin was performed on postoperative day (POD) 7 and repeated on POD 14 or 21 if indicated. Diagnostic accuracy of VFSS was calculated against clinically evident PCF. Potential risk factors were analysed using logistic regression. Six patients (20%) developed PCF. VFSS demonstrated a sensitivity of 83.3% (95% CI: 44-97), specificity of 100% (95% CI: 86-100), positive predictive value of 100% (95% CI: 57-100), and negative predictive value of 96% (95% CI: 80-99). Five fistulas were identified on POD 7, while one clinically evident fistula was diagnosed on POD 12 despite a negative VFSS. On multivariable analysis, BMI < 18.5 (OR 12.5, p = 0.042) and serum albumin < 3.0 g/dL (OR 8.7, p = 0.049) independently predicted PCF. Flap reconstruction, margin status, prior treatment, extent of surgical resection and closure technique, though exhibited trend towards formation of PCF, however statistically were not significant predictors. VFSS is highly specific for PCF but insufficiently sensitive to exclude fistula on the basis of a single early study. Staged assessment improves detection of delayed leaks. Nutritional factors, particularly low BMI and hypoalbuminemia, are stronger predictors of PCF than surgical variables. Perioperative care should integrate nutritional optimization and structured VFSS protocols to reduce fistula risk and enable safer initiation of oral feeding.