Resident Surgeon Vanderbilt University Medical Center Nashville, Tennessee
Introduction: Fistula following oral cavity composite resection (OCCR) and free flap (FF) reconstruction is a common yet understudied problem. The goal of this study is to leverage a large cohort of patients who underwent an OCCR for oral cavity squamous cell carcinoma (OCSCC) with FF reconstruction in order to better understand fistulas and factors that may lead to their development.
Methods: Retrospective case series of all OCCRs performed between 2000 and 2020 at a single quaternary care center. OCCRs were identified from a combination of billing and pathology databases. Manual and automated data extraction were used to obtain demographic, clinical, surgical, and pathologic data from the medical record. Fistulas, as defined by surgeons, were identified by a natural language search. Uni- and multi- variable analyses were performed to identify factors identified with fistula formation.
Results: 504 patients underwent an OCCR for OCSCC with FF reconstruction between 2005 and 2020. Ninety-two (18.3%) developed a fistula post-operatively. Fistulas were significantly associated with morbidity (e.g. increased readmission and FF failure rates) and mortality (e.g. decreased progression free and overall survival). On univariable analysis, no single patient-related (e.g. pre-operative albumin, history of diabetes), treatment related (e.g. previous treatment, extent of neck dissection), or tumor related (e.g. size, invasion) factors were associated with the development of a fistula. Multivariable analysis of previously described risk factors (e.g. smoking history, prior radiation, length of surgery) likewise demonstrated a trend (with regards to pack years of tobacco) but no significant association.
Conclusion: Despite refinements in surgical technique, fistula following OCCR for OCSCC with FF reconstruction remains a common problem, which often requires readmission to the hospital and frequently leads to worse oncologic outcomes. In this large retrospective case series, we could not identify any modifiable factors that could be used to address this problem. Further study is required to help reduce the rate of this complication and improve patient morbidity and mortality.