Authors (including presenting author) :
PANG YK(1)
Affiliation :
(1) Stoma and Wound Care Nurse Clinic, Department of Surgery, Queen Elizabeth Hospital
Introduction :
The incidence of pharyngocutaneous fistula (PCF) is as high as 65% after laryngectomy1. PCF is intractable to manage, especially in a background history of radiotherapy, can significantly reduce patient’s quality of life and prolong the fasting period and hospitalization2. There was no definite consensus recommendation nor large scale studies while the management of PCF was individual based1. Systemic reviewed of descriptive case series demonstrated >90% overall success rate by using non-surgical intervention such as scopolamine ointment patch, negative pressure wound therapy (NPWT)1 in a higher vacuum force2 and conventional wound dressing3.
Objectives :
To report a refractory PCF successfully resolved by scopolamine ointment patch, NPWT, and advanced wound care.
Methodology :
An aged 61 gentleman had a history of nasopharyngeal cancer treated by chemoradiotherapy, was diagnosed of cancer of larynx undergone total laryngectomy, partial pharyngectomy, pectoralis major (PM) flap, and tracheoesophageal fistulisation by local otorhinolaryngology team in Mar 2024. Post-operative day 15, he developed PCF confirmed by imaging investigation with contrast leakage to the left submandibular dehisced surgical wound. Despite the amount of salivation was decreased after receiving scopolamine ointment patch, pooling of saliva was persistent from the wound. The stoma and wound care nurse (SWCN) performed advanced wound bed preparation at first then started NPWT twice per week, gradually increasing the vacuum force from -120 to -150 mmHg2 continuous mode. Ward nurses provided closed observation and care, while allied healthcare professionals optimized his nutritional status and strengthened his mobility.
Result & Outcome :
The primary outcome measures were wound healing status and duration of NPWT while the secondary was complications because of NPWT3. After 43 days NPWT, the opening of PCF was closed and remained of a shallow wound. There was no active wound bleeding nor infection. The PM flap was healthy. Initially the patient was put on tube feeding. After 2 weeks NPWT, his PCF internal opening was not obvious in laryngoscopic view and he was allowed to resume oral feeding and enjoyed the meal-delivery by his wife. Patient showed satisfaction to have walking and exercise with the NPWT device. He was discharged from hospital 1 week after stopped NPWT. Follow-up imaging study showed no more PCF. Continued regular outpatient wound care by SWCN till his shallow neck wound completely healed in total four months after the ultra-major surgery. This case report demonstrated a refractory PCF with a background history of radiotherapy, can be treated with scopolamine ointment patch and NPWT in a higher vacuum force consistent with the systemic evidence findings through dedicated advanced wound care and patient-centered multidisciplinary teamwork.
