Does Omitting Distal Anastomosis in Hypopharyngeal Defect Reconstruction Improve Dietary Outcomes?

Abstract

Circumferential reconstruction is required for total hypopharyngeal defects to restore swallowing. Reconstructive options differ in conduit biology and anastomotic configuration, particularly the presence of a distal alimentary anastomosis. This study compared postoperative complications, dietary recovery, and survival among three reconstructive strategies. This retrospective cohort study included 102 patients who underwent total hypopharyngeal reconstruction between 2015 and 2025 using a free anterolateral thigh (ALT) fasciocutaneous flap (n = 57), gastric pull-up (n = 24), or free ileocolonic flap (n = 21). Postoperative complications, long-term dietary outcomes, and 5-year survival were evaluated. Time to regular diet was analyzed using multivariable Cox proportional hazards models adjusting for age, body mass index, length of hospitalization, and endocrine comorbidities. Baseline characteristics were similar across groups. Early pharyngocutaneous fistulas were most common in the ileocolonic flap group (23.8%), whereas late fistulas occurred mainly after gastric pull-up reconstruction (12.5%). At 3 years, regular diet was achieved by 63.2% of ALT flap patients, compared with 100% of gastric pull-up and 90.5% of ileocolonic flap patients. After adjustment, gastric pull-up (adjusted HR 1.79; 95% CI, 1.05-3.07) and ileocolonic flap reconstruction (adjusted HR 2.00; 95% CI, 1.06-3.79) were independently associated with faster dietary recovery compared with ALT flaps. Five-year survival did not differ significantly among groups. Visceral reconstructions yield superior dietary recovery compared with fasciocutaneous flaps for total hypopharyngeal defects. The absence of a distal anastomosis alone did not confer a clear functional benefit, underscoring the importance of conduit biology over anastomotic number.