Safety of Primary Tracheoesophageal Puncture in Patients Submitted to Enlarged Total Laryngectomy with Pectoralis Major Reconstruction

Background/Objectives: Total laryngectomy (TL) remains a key treatment option for advanced laryngeal cancer. Primary tracheoesophageal puncture (TEP) with voice prosthesis (VP) enables early speech restoration and is increasingly adopted, even in patients with conditions traditionally considered contraindications, such as prior/adjuvant radiotherapy, extended resections, and immediate reconstructive procedures. This study evaluates complication rates and long-term outcomes associated with primary TEP in these settings. Methods: A retrospective cohort of 101 patients undergoing TL for laryngeal or hypopharyngeal squamous cell carcinoma at the University Hospital of Sassari (August 2017–December 2024) was analyzed. Demographic, clinical, surgical, and oncological data were collected, with a particular focus on postoperative early complications and late sequelae and oncological outcomes. Results: Primary TEP was performed in 78 patients (77.2%). Overall, pharyngocutaneous fistula occurred in 6/101 patients (5.9%), postoperative bleeding in 5/101 (5.0%), and dysphagia in 11/101 (10.9%), with only 2/11 (2.0%) requiring intervention. Mean follow-up was 44.6 ± 3.2 months (median 41, range 4–93). No significant association was found between primary TEP and complication rates, including in patients undergoing enlarged TL with pectoralis major reconstruction. Conclusions: Primary TEP appears safe and effective, even in cases requiring extended resections and reconstructive procedures. It should be considered to enhance functional recovery and postoperative quality of life for all motivated patients undergoing total laryngectomy without patient-related contraindications. Our findings may constitute a step towards personalized medicine in laryngeal oncology as they support priortizing patient-specific factors, such as pneumological and neurological clinical conditions and level of cooperation, over purely surgical considerations.