Reconstruction Versus Primary Closure in Salvage Total Laryngectomy: Impact on Complications and Functional Outcomes - a Clinical Case Series.

Background: Salvage total laryngectomy (STL) remains a difficult procedure in patients with recurrent or persistent laryngeal neoplasms after radiotherapy and chemoradiotherapy. The choice of the most appropriate method for pharyngeal closure continues to be debated, especially in relation to the possible associated postoperative complications and functional recovery. Objective: To compare postoperative complications and functional outcomes between primary pharyngeal closure and pectoralis major flap reconstruction in patients undergoing salvage total laryngectomy. Materials and methods: A retrospective study was conducted on 62 patients treated between January 2022 and December 2025 at Coltea Clinical Hospital. All patients underwent salvage total laryngectomy following failure of organ preservation therapy. Pharyngeal closure was performed by primary suture in 27 patients and reconstruction with a pectoralis major flap in 35 patients. Postoperative complications, such as pharyngocutaneous fistula (PCF), wound infection, bleeding and wound dehiscence, were analyzed. We analyzed functional outcomes by determining the time required to resume eating and the length of hospital stay. The need for surgical reintervention was additionally analyzed according to closure technique and complication type. Fisher's exact test was used for statistical analysis because of the small sample size and we considered the results to be statistically significant if p < 0.05. Results: There were more patients with pharyngocutaneous fistulas in the primary pharyngeal closure group than in the pectoralis major flap reconstruction group (63.0% vs. 28.6%, p = 0.0099). Wound infection was also more frequent in the primary closure group although this difference did not reach statistical significance. Postoperative haemorrhage and skin flap dehiscence occurred significantly more frequently in the primary closure group compared to the pectoralis major flap reconstruction group. The presence of complications, especially pharyngocutaneous fistulas, was associated with a delayed return to oral feeding and a longer recovery. Although patients undergoing pectoralis major flap reconstruction had fewer complications and lower surgical reintervention rates, they also had a prolonged hospital stay in patients without postoperative complications. Conclusions: Pharyngeal reconstruction with pectoralis major flap was associated with lower rates of postoperative complications and reduced need for surgical reintervention compared with primary closure in salvage total laryngectomy patients. Pharyngocutaneous fistula, postoperative hemorrhage and skin flap dehiscence occurred more frequently in the primary closure group and were associated with higher rates of surgical reintervention. Functional recovery was strongly influenced by postoperative complications, particularly PCF, which was associated with delayed oral feeding initiation and prolonged hospitalization. These findings support an individualized surgical approach based on patient risk factors and anticipated postoperative morbidity.