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Program Number: B158
Session Name: Poster Session

Implementation of Postoperative Intravenous Levothyroxine Following Salvage Total Laryngectomy

Ryan Judd, MD; Stephen Sansoterra; Singyi Yen; Amy Lin; Lauren Miller, MD; Enver Ozer, MD; Amit Agrawal, MD; James Rocco, MD, PhD; Stephen Y Kang, MD; Nolan B Seim, MD; Matthew O Old, MD; Catherine Haring, MD; The Ohio State University

Introduction: Prior history of radiation predisposes patients to hypothyroidism and wound healing issues, including pharyngocutaneous fistula following total laryngectomy (TL). A recent Phase II single-institution trial demonstrated that postoperative intravenous (IV) levothyroxine after salvage TL may reduce rates of fistula and the need for re-operation. The objective of this study was to investigate implementation outcomes of utilizing IV levothyroxine after salvage TL at a distinct institution.

Methods: Patients who underwent salvage TL from January 2008 to July 2024 were included. Starting June 2021, our institution adopted an optional protocol for IV levothyroxine after salvage TL, developed in conjunction with endocrinology colleagues. On protocol, patients were started on weight-based IV levothyroxine with dose titrated based on free T4 on postoperative days two, four, and seven then twice weekly. Patients with severe heart disease, atrial fibrillation, or preoperative hyperthyroidism were not treated on protocol. Patients off protocol were treated with standard of care enteral levothyroxine with doses adjusted based on preoperative and postoperative twice weekly TSH/T4.  Binary logistic regression determined factors associated with postoperative fistula. Differences in length of stay (LOS, summation of index and readmission) were compared using Mann Whitney- U test.

Results: A total of 203 patients who underwent salvage TL were included. At time of TL, 62.1% (126/203) underwent flap reconstruction (free or locoregional). The post-operative fistula rate was 21.2% (N= 43/203). On univariate analysis, undergoing simultaneous total (OR 3.3 (95% CI 1.1-9.6), p<0.05) or hemithyroidectomy (OR 2.6 (95% CI 1.1-6.4), p<0.05) versus no thyroidectomy was associated with postoperative fistula. Flap reconstruction, smoking status, protein-calorie malnutrition, and Charlson Comorbidity Index were not associated with postoperative fistula (p>0.05).

Since implementation of post-operative IV levothyroxine protocol, N=81 patients underwent salvage TL of which 82.7% (67/81) had flap reconstruction. Eighteen patients (22.2%) were treated on the IV levothyroxine protocol. There was no difference in rate of fistula based on use of IV levothyroxine (22.2% (4/18) vs 20.6% (13/63), p=0.9). Of the four patients treated with IV levothyroxine who developed fistula, all were managed with local wound care and none required re-operation; of those off trial, 38.5% (5/13) required re-operation for fistula repair. Of the four patients treated with IV levothyroxine who developed fistula, none required readmission due to fistula, compared to 23.1% (3/13) of patients who developed fistula off trial. LOS was longer for those who developed postoperative fistula versus those who did not (median 21 vs 8 days, p<0.001). Median LOS for patients treated with IV levothyroxine who developed fistula was 19 days vs 24 days for those who developed fistula off trial (p=0.4).

Conclusion: There has been relatively low adoption of using IV levothyroxine following salvage TL at our institution. While fistula rates did not differ for patients treated with IV levothyroxine, rates of re-operation, re-admission and length of stay due to fistula seem to be lower. These data suggest that IV levothyroxine following salvage TL may decrease the severity of pharyngocutaneous fistula, highlighting potential opportunities for quality improvement initiatives and cost savings. A larger cohort is needed.

 

 

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