The role of reconstruction for transoral robotic pharyngectomy and concomitant neck dissection

Objective: To evaluate the impact of primary reconstruction of postablative defects following transoral robotic surgery on function and the risk of orocutaneous fistula. Design: Prospective nonrandomized clinical trial. Setting: Tertiary academic medical center. Patients: Thirty-one patients treated with transoral robotic pharyngectomy for malignant disease. Each case was analyzed for patient age, sex, primary site of the tumor, pathologic characteristics, stage of disease, complications, fistula rate, and functional outcomes. Functional outcomes were assessed using the Performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale. Interventions: In 25 patients, the primary treatment was with transoral robotic pharyngectomy, and 6 cases were salvage procedures performed for recurrent disease following radiation (3 patients) or chemoradiation (3 patients). Twenty-six patients underwent a concomitant unilateral selective neck dissection, and 3 patients underwent concomitant bilateral selective neck dissections; 2 patients did not require a neck dissection for treatment of the primary malignant tumor. Main Outcome Measures: Complication rate, fistula rate, and oral function. Results: Primary intraoral reconstruction was performed in all 31 patients. Musculomucosal advancement flap pharyngoplasty was performed in 25 patients with a concomitant velopharyngopasty (6 patients), and radial forearm free flap reconstruction was performed in 6 patients. There were no intraoperative complications; however, postoperatively, 1 patient developed a neck hematoma that was treated with bedside drainage and 4 patients sustained minor musculomucosal flap necrosis of the superior aspect of the flap. None of the patients developed a neck infection of salivary fistula. Endoscopic evaluation of swallowing demonstrated that none of the patients experienced aspiration or velopharyngeal reflux, and the performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale at 2 weeks, 2 months, 6 months, 9 months, and 1 year demonstrated a progressive improvement in diet, swallowing, and oral function. Conclusions: Primary transoral robotic reconstruction may provide a benefit by decreasing the fistula rate in patients undergoing concomitant neck dissection. Patients regain excellent function following surgery and adjuvant therapy.