Pharyngeal and Cervical Reconstruction and Fistula Management Following Total Laryngectomy: Contemporary Strategies and Evidence

Total laryngectomy (TL) is still the standard treatment for advanced laryngeal and hypopharyngeal cancer, with pharyngeal reconstruction being a challenging determinant of outcomes. We searched PubMed/MEDLINE, Scopus, and Web of Science from inception to July 2026 for studies reporting pharyngeal reconstruction techniques or fistula outcomes after TL. This narrative review synthesizes current evidence on reconstruction following TL across three domains: prevention, reconstruction, and management of pharyngocutaneous fistula (PCF). Defect classification into minimal, partial, and circumferential categories guides reconstructive decision-making, each supported by a distinct evidence stream. Risk stratification identifies prior radiotherapy, poor nutritional status, sarcopenia, and salvage setting as the strongest PCF predictors. For minimal defects, stapler-assisted closure reduces PCF risk in primary TL, and double-layer manual closure outperforms single-layer repair. Partial defects in the salvage setting benefit from vascularized tissue augmentation, with pedicled onlay flaps associated with lower fistula rates than primary closure or free flap patching. For circumferential defects, network meta-analytic data suggest that the free jejunal flap ranks highest for fistula prevention. Comparative cohort data indicate that anterolateral thigh flaps may offer better long-term speech outcomes. The optimal choice depends on the outcome prioritized. Salivary bypass tubes represent the most consistently supported adjunct for fistula and stenosis prevention. PCF management follows a stage-based approach: conservative care for early fistulas, negative pressure wound therapy as a bridge in subacute cases, and vascularized flap reconstruction for chronic or refractory fistulas.