The debate amongst head and neck surgeons, as to whether a skin flap or enteric flap offers superior outcomes in pharyngeal reconstruction, still rumbles on. The evidence pool is very shallow, even accounting for the so-called ‘landmark’ papers that swung favour toward thigh skin flap reconstructions in the ‘noughties’. This paper used hospital episode statistical data (HES) to group types of pharyngeal reconstruction into direct repair, skin / muscle flap repairs, and enteric flaps; primarily jejunal flaps. It is a commendable effort to analyse such a large data-set for episodes between 2002-2012. Ultimately some notable findings may be useful to head and neck oncology teams. Gastric pull-up carries significantly more morbidity and mortality than any other form of reconstruction. The rarity of this modality is probably demonstrated by the low number of cases compared to jejunal and skin flaps. Similarly, in-hospital survival is superior in the skin flap group versus jejunal flaps. However, when skin flaps are combined with muscle flaps (free or pedicled) this survival advantage is neutralised. This is a curious finding but is in-keeping with some other longitudinal series of jejunal flaps. There are a variety of explanations for this, and other series suggest that the traditional dogma of breaching the abdominal cavity guarantees worse morbidity, is inaccurate. Nonetheless, skin flaps seem safe for the purposes of perioperative survival but in terms of post-operative morbidity, hospital stay and medical complications, there does not seem to be a significant difference.
This study has captured a large cohort but the data-set is missing some vital information I believe is crucial when comparing reconstructive outcomes in this group of difficult oncology patients. There is no data on which cases were salvage pharyngolaryngectomy (i.e., was primary treatment chemoradiation?), what were functional outcomes such as return to full enteric diet without need for latent dilation, rate of adjuvant radiotherapy in primary cases and what proportion of skin flaps were circumferential reconstructions. It is entirely plausible the sub-group comparison of skin flaps versus jejunal flaps includes a majority of skin flaps used for pharyngeal augmentations rather than total circumferential repair. These are clearly different clinical entities with different outcomes and functional needs postoperatively. There is no doubt this paper provides a large cross section of information, but it is lacking crucial data points and thus, does not rationalise the ongoing debate.