Current status of pharyngolaryngo-esophagectomy and pharyngogastric anastomosis

A Nationwide Survey on Digestive Reconstruction Following Pharyngolaryngectomy With Total Esophagectomy: A Multicenter Retrospective Study in Japan

AIM

Digestive reconstruction after pharyngolaryngectomy with total esophagectomy (PLTE) remains challenging, with the optimal method remaining unclear. The current study aimed to clarify the short-term outcomes after PLTE and determine the optimal digestive reconstruction method.

METHODS

Based on a nationwide survey of 151 patients who underwent PLTE, outcomes of digestive reconstruction methods are described.

RESULTS

Among digestive reconstruction methods, a simple gastric tube was most frequently used (37.1%), followed by gastric tube combined with free graft transfer (FGT) (35.1%), gastric tube with microvascular anastomosis (22.5%), and other procedures (5.3%). Intraoperative evaluation of microcirculation (IOEM) was utilized in 29 patients (19.2%). Among the included patients, 66.9% developed any-grade complications, 41.0% developed severe complications, and 23.8% developed digestive reconstruction-related complications (DRRCs; leakage or necrosis). Reoperation within 30 days for any complications and DRRCs was required in 13.9% and 8.6% of the patients, respectively. Mortality within 90 days was observed in 4.6%. Among the three major methods, gastric tube combined with FGT promoted the least DRRCs in the gastric tube (P = .005), although the overall incidence of DRRCs was comparable. The use of IOEM was significantly associated with a reduction of severe DRRCs (P = .005).

CONCLUSIONS

Pharyngolaryngectomy with total esophagectomy is a high-risk surgery significantly associated with the occurrence of postoperative morbidity and mortality. Nonetheless, the addition of FGT can help prevent gastric tip complications, while IOEM can be an effective method for improving outcomes.

Pathological Level VI Lymph Node Metastasis in Clinical N3b Pyriform Sinus Squamous Cell Carcinoma

OBJECTIVE

The frequency of metastasis to level VI lymph nodes in advanced pyriform sinus squamous cell carcinoma (PSSCC) is unknown. We intended to analyze the clinical features and pathological presence or absence of level VI lymph node metastasis in patients with PSSCC.

METHODS

The data of 270 patients with previously untreated hypopharyngeal squamous cell carcinoma from 2006 to 2016 were obtained. Patients who underwent pharyngolaryngectomy for the pyriform sinus subsite with a curative intent with level VI dissection were included. We retrospectively analyzed the clinical Tumor-Node (TN) status (TNM classification of malignant tumors, eighth edition) and the presence or absence of pathological level VI lymph node metastasis.

RESULTS

A total of 34 patients were included. Eight patients (24%) had pathological level VI lymph node metastasis. The rate of pathological level VI lymph node metastasis was directly proportional to the clinical N status (P = .0002, Chi-square test for trend). In all, 5 patients with cN2b- 3 were classified as cN3b. Ipsilateral pathological level VI lymph node metastasis was observed in 1 patient, and bilateral metastasis was observed in 3 patients. There was no association between clinical T status or pyriform sinus apex invasion and pathological level VI metastasis (both P > .99, Fisher's exact test).

CONCLUSIONS

PSSCC with cN3b is prone to bilateral level VI metastasis. We recommend that patients with PSSCC with cN3b should undergo bilateral level VI lymph node dissection.

Digestive Reconstruction After Pharyngolaryngectomy with Total Esophagectomy

BACKGROUND

Pharyngolaryngectomy with total esophagectomy (PLTE) is often indicated for patients with synchronous head and neck cancer and thoracic esophageal cancer or those with head and neck cancer extending to the upper mediastinum. A long conduit is required for the reconstruction, and the blood flow at the tip of the conduit is not always sufficient. Thus, reconstructive surgery after PLTE remains challenging, and optimal reconstruction methods have not been elucidated to date.

METHODS

This analysis investigated 65 patients who underwent PLTE. The short-term outcomes among the procedures were compared to explore the optimal digestive reconstruction methods.

RESULTS

We used a simple gastric conduit for 7 patients, a gastric conduit with microvascular anastomosis (MVA) for 10 patients, an elongated gastric conduit with an MVA for 20 patients, a gastric conduit combined with a free jejunum transfer (FJT) for 25 patients, and other procedures for 3 patients. Postoperatively, 17 (26.2%) of the patients experienced severe complications, classified as Clavien-Dindo grade 3b or higher, including graft failure for 3 patients (6.2%). Anastomotic leakage was found in six patients (9.2%), and all leakages occurred at the pharyngogastric anastomosis. The reoperation rate was 15.4% (n = 10), and three patients (4.6%) died of massive bleeding from major vessels. The patients who underwent simple gastric conduit more frequently had graft failure (P = 0.04), anastomotic leakage (P < 0.01), and reoperation (P = 0.04) than the patients treated with the other reconstructive methods.

CONCLUSION

Additional procedures such as MVA, gastric tube elongation, and FJT contribute to improving the outcomes of reconstruction after PLTE.

Mapping of Regional Failures After Definitive Radiotherapy in Patients with Locally Advanced Cervical Esophageal Carcinoma

Purpose

This study aimed to retrospectively analyze the failure patterns and clinical outcomes in patients with locally advanced cervical esophageal carcinoma (CEC) after definitive radiotherapy (RT), and illustrate the mapping of regional failures.

Patients and Methods

We reviewed 82 patients with CEC confirmed as squamous cell carcinoma who had completed definitive RT from August 2008 to December 2017. Data on clinical characteristics were collected from the medical records system. Patterns of treatment failures and the survival follow-up were analyzed.

Results

The median age was 58 (38–78) years. In 37 patients, the lesions were limited to the cervical esophagus, while in the remaining 45 patients, the disease got beyond the cervical esophagus (pharynx or thoracic esophagus involved). While 10 patients had stage Ⅱ disease, 72 had stage III disease. The completed median dose for 95% PGTV and 95% PTV was 66 Gy and 58 Gy. While the median follow-up was 27.6 months, the median progression-free survival (PFS) and overall survival (OS) was 16.1 and 28.3 months, respectively. The 3-year PFS and OS was 30.3% and 45.3%, respectively. Treatment failures were reported in 55 patients, of which 22, 8, 7, 9, 2, 3, and 4 patients had developed local, regional, distant, local-regional, regional-distant, local-distant and local-regional-distant failure, respectively. Of the 41 relapsed nodal sites, 28 were located “in-field” whereas 1 was “marginal” and 12 were “out-field”. The most frequent regional relapses were at level VIb, IV and the upper-middle mediastinum.

Conclusion

Regional recurrences focused on lower neck and upper-middle mediastinum, and mainly “in-field”, after definitive RT in patients with CEC.

"End to Side Technique": More organ preservation with less morbidity in patients with pyriform sinus apex SCC

INTRODUCTION

Hypopharyngeal squamous cell carcinoma (SCC) is rare, but highly aggressive. Due to the advanced stage of this cancer at the time of diagnosis, radical surgery with reconstruction of pharynx is the standard care with high morbidity and mortality rate. A safer partial pharyngectomy could also be used for invasive hypopharyngeal cancer. In this study, we investigated the short and long-term outcomes in patients with SCC of the pyriform sinus apex undergoing standard partial pharyngectomy using a new suturing technique, called end to side technique.

METHODS

This case series was performed on 8 patients with SCC of the pyriform sinus apex at the otorhinolaryngology clinic. All participants underwent standard partial pharyngectomy using "end to side technique". Post-operative evaluations included 6 and 12 months CT scan and 1-year barium swallow.

RESULTS

Of 8 patients, 7 were male (87.5%) and 1 was female (12.5%) with a mean age of 60 years old. All patients were diagnosed at stage III of hypopharyngeal cancer and cervical lymph node involvement was reported in 3 patients (37.5%). Tumor margins were negative in all patients. Fistula was reported in 2 patients (25%) which was managed using conservative treatments.

CONCLUSIONS

According to our study, the standard partial pharyngectomy with end to side technique is a safe and feasible method for the surgical resection of the squamous cell carcinoma of the pyriform sinus apex with good short-term and long-term outcomes.

Oncologic and Functional Outcomes After Primary and Salvage Laryngopharyngoesophagectomy With Gastric Pull-Up Reconstruction for Locally Advanced Hypopharyngeal Squamous Cell Carcinoma

Background/Purpose: Hypopharyngeal squamous cell carcinomas (SCC) are generally diagnosed in an advanced disease stage. A total laryngopharyngoesophagectomy with gastric pull-up reconstruction is a time tested surgical treatment in our centre for resectable failures or recurrences after primary treatment with organ preservation protocols (radiotherapy or chemoradiation), or as a primary surgical treatment for very advanced hypopharyngeal tumors. We present the results of our approach in terms of success rate, postoperative complications and functional and oncologic outcomes.

Methods: We retrospectively reviewed the charts of all patients with hypopharyngeal SCC, who underwent laryngopharyngoesophagectomy with gastric pull-up reconstruction during the period 1989–2015.

Results: The cohort included 60 patients. Mean follow-up was 32 months. Stage III and stage IV disease was present in 35 and 60% of patients, respectively. Successful reconstruction by intended gastric transposition was possible in 98.3% of cases. The in-hospital mortality rate was 8.3%. Two-year and five-year actuarial overall survival were 39.5 and 21.1%, respectively. Two-year and five-year actuarial disease specific survival were 58.5 and 46.6%, respectively. Two-year and five-year actuarial locoregional recurrence free survival were both 49.5%. A significantly lower locoregional recurrence free survival was observed in patients with pN+ disease compared to pN0 (Log rank, p <0.05). Complete oral intake was achieved in 82.7% of patients. Speech rehabilitation by means of Provox® puncture or electrolarynx was achieved in 66% of patients.

Discussion/Conclusion: Total laryngopharyngoesophagectomy with gastric pull-up reconstruction for advanced stage hypopharyngeal SCC combines relatively good oncologic and functional outcomes in a prognostically unfavorable patient group.

TYPE II HYPOPHARYNGEAL DEFECT RECONSTRUCTION - A SINGLE INSTITUTION EXPERIENCE

SUMMARY – There are several options for hypopharyngeal reconstruction depending on defect size. Reconstructive options include primary closure, local flaps, regional axial flaps or regional intestinal flaps, and free flap transfer with skin or intestinal free flaps. The preferred method of reconstruction should minimize early postoperative complications that prolong hospital stay and/or become life threatening, ensure early restoration of function and decrease donor site morbidity. The purpose of this study was to evaluate functional outcomes of different flap reconstruction methods in type II hypopharyngeal defects. In this non-randomized retrospective cohort study, data on 31 (27 male and four female) patients were collected over a 10-year period of single institution type II hypopharyngeal defect reconstructions. The following measures of functional outcome were extracted from patient medical histories: postoperative complications (flap failure, fistula formation, donor site related complications), hospital stay in days and swallowing function after 14 days, 1 month and 6 months. There were nine patients in the radial forearm free flap (RFFF) reconstruction group, seven in the jejunum reconstruction group, and 15 in the gastric tube reconstruction group. In the RFFF group, three patients experienced flap failure; in the jejunal transfer group, no donor site morbidity was observed; whereas three patients from the gastric tube reconstruction group had minor abdominal skin wound dehiscence. Out of the 3 different reconstructive methods, RFFF was most likely to fail. The mean duration of hospital stay was 22.6 days, being shortest in the RFFF group. There were no significant differences in early postoperative swallowing function among the groups. The choice of flap used for hypopharynx reconstruction should be driven by donor site factors and functional outcomes. When assessing type II hypopharyngeal defect reconstruction results, the findings of this study suggest that free jejunal flaps and gastric tubes offer superior functional results in comparison with RFFFs.

The management of mid & proximal oesophageal squamous cell carcinoma

Despite the rise in incidence of adenocarcinoma, squamous cell cancer of the oesophagus remains the commonest cell type worldwide and is predominant in the East. Except for very early tumours where endoscopic therapy can be performed with curative intent, in more advanced but potentially curative cancers, treatment for mid and upper third tumours is primarily surgery with extended lymphadenectomy, together with multimodal therapies such as preoperative chemotherapy or chemoradiotherapy. Definitive chemoradiotherapy is utilized in those who decline surgery or in those who are unfit for major procedures. For cervical oesophageal cancer, the anatomical proximity to the larynx influences the choice of treatment and surgical options. Definitive chemoradiation with the aim of laryngeal preservation has become the treatment of choice; long-term prognosis is believed to be comparable to radical pharyngo-laryngo-oesophagectomy. Selected patients with residual disease or disease recurrence can consider salvage surgery. The decision to operate is a major undertaking as salvage surgery carries high morbidity and even mortality risks. Careful patient selection, choice of treatment, meticulous operative technique and postoperative care are the cornerstones of success.

Cervical Esophageal Cancer Treatment Strategies: A Cohort Study Appraising the Debated Role of Surgery

BACKGROUND

Few studies have examined optimal treatment specifically for cervical esophageal carcinoma. This study evaluated the outcome of three common treatment strategies with a focus on the debated role of surgery.

METHODS

All patients with cervical esophageal cancer treated at a single center were identified and their outcomes analyzed in terms of morbidity, mortality, and recurrence according to the treatment they received, i.e. surgery alone, definitive platinum-based chemoradiation (CRT), or CRT followed by surgery.

RESULTS

The study population included 148 patients with cervical esophageal cancer from a prospective database of 3445 patients. Primary surgery was the treatment of choice for 56 (37.83%) patients, definitive CRT was the treatment of choice for 52 (35.13%) patients, and CRT followed by surgery was the treatment of choice for 40 (27.02%) patients. CRT-treated patients obtained 36.96% complete clinical response, with overall morbidity and mortality rates of 36.95 and 2.17%, respectively. Surgical complete resection was achieved in 71.88% of surgically treated cases, with morbidity and mortality rates of 52.17 and 6.25%, respectively. No significant survival difference existed among the three treatments, but patients who underwent surgery alone had a significantly lower stage of disease (p = 0.031). Compared with patients with complete response after CRT, surgery did not confer any significant survival benefit, and overall 5-year survival was lower than definitive CRT alone. In contrast, surgery improved survival significantly in patients with non-complete response after definitive CRT (p = 0.023).

CONCLUSIONS

Definitive platinum-based CRT should be the treatment of choice for cervical esophageal cancer. Surgery has a role for patients with non-complete response as it adds significant survival benefit, with acceptable morbidity and mortality.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

Management algorithm for failed gastric pull up reconstruction of laryngopharyngectomy defects: case report and review of the literature

BACKGROUND

Gastric pull up remains a popular reconstructive option for pharyngoesophagectomy defects extending to thoracic inlet. Gastric necrosis is a dreaded complication of gastric pull up reconstruction and few studies report on management of this complication. MEDLINE, EMBASE, and Web of Science™ databases were searched for publications in the last 25 years on gastric pull up reconstruction following pharyngoesophagectomy. The rates of complications related to gastropharyngeal anastomosis were extracted, and methods of managing gastric necrosis were noted. Forty seven case series were identified reporting on the use of gastric pull up for reconstruction of pharyngoesophageal defects. Mortality rate varied from 0 to 33 % with a weighted average of 8.6 %. In 39 % of patients, mortality was either caused or directly related to failure of the gastropharyngeal anastomosis. The reported rate of gastric necrosis ranged from 0 to 24 % resulting in a 28 % mortality. Options for managing gastric necrosis included: temporary cervical diversion, free jejunum flap, colonic interposition, tubed radial forearm flap, deltopectoralis and pectoralis myocutaneous flaps.

CASE PRESENTATION

We present the first case of an anterolateral thigh flap rescue of gastric necrosis after gastric pull up reconstruction. The case report is followed by a review of literature on management of gastric pull up failures.

CONCLUSION

Based on the extracted information, we propose an algorithm for managing gastric pull up failure following pharyngoesophageal reconstruction.

A Clinical Study of Pharyngolaryngectomy with Total Esophagectomy: Postoperative Complications, Countermeasures, and Prognoses

OBJECTIVE

Patients with advanced hypopharyngeal or cervical esophageal cancer have a comparatively high risk of also developing thoracic esophageal cancer. Pharyngolaryngectomy with total esophagectomy is highly invasive, and few reports about it exist. We examined the postoperative complications and respective countermeasures and prognoses of patients who underwent pharyngolaryngectomy with total esophagectomy.

STUDY DESIGN

Case series with chart review.

SETTING

Department of Head and Neck Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan.

SUBJECTS AND METHODS

We examined the postoperative complications and respective countermeasures and prognoses of 40 patients who underwent pharyngolaryngectomy with total esophagectomy in our hospital.

RESULTS

Postoperative complications were observed in 23 patients (57.5%) and consisted of 8 groups: tracheal region necrosis in 5 patients; neck abscess formation/wound infection in 5; fistula in 4; tracheostomy suture leakage in 2; ileus in 2; lymphorrhea in 2; pulmonary complications in 2; and other complications, including hemothorax, tracheoinnominate artery fistula, temporary cardiac arrest due to intraoperative mediastinum operation, methicillin-resistant Staphylococcus aureus enteritis, and sepsis, in 1 patient each. A lethal complication-brachiocephalic vein hemorrhage due to tracheostomy suture leakage and hemorrhagic shock due to tracheoinnominate artery fistula-occurred in 2 (5%) patients. The crude 5-year survival rate was 48.6%.

CONCLUSIONS

Serious postoperative complications were related to tracheostomaplasty. Although pharyngolaryngectomy with total esophagectomy is highly invasive, we believe that our outlined treatment method is the most appropriate for cases of advanced hypopharyngeal or cervical esophageal cancer that also requires concurrent surgery for esophageal cancer.

Barrett's esophagus: cancer and molecular biology

The following paper on the molecular biology of Barrett's esophagus (BE) includes commentaries on signaling pathways central to the development of BE including Hh, NF-κB, and IL-6/STAT3; surgical approaches for esophagectomy and classification of lesions by appropriate therapy; the debate over the merits of minimally invasive esophagectomy versus open surgery; outcomes for patients with pharyngolaryngoesophagectomy; the applications of neoadjuvant chemotherapy and chemoradiotherapy; animal models examining the surgical models of BE and esophageal adenocarcinoma; the roles of various morphogens and Cdx2 in BE; and the use of in vitro BE models for chemoprevention studies.

Current management strategy of hypopharyngeal carcinoma

OBJECTIVES

Squamous cell carcinoma (SCC) of the hypopharynx represents a distinct clinical entity among other cancers of the head and neck region. Despite recent advances in chemoradiotherapy, surgery remains the preferred therapeutic option for locally advanced disease and salvage for failure after chemo-radiotherapy. In this article, several aspects of surgical and non-surgical approaches in the management of hypopharyngeal cancer are discussed.

METHODS

A search in pubmed was made for publications with regard to the management of hypopharyngeal carcinoma.

RESULTS

In early-staged hypopharyngeal cancer, the overall and disease-specific survival rates after organ-preserving radiotherapy is comparable to that after surgery. However, for advanced staged disease, the results initial surgery with post-operative adjuvant radiotherapy was superior to chemoradiotherapy alone. The incidence of occult nodal metastasis is found to be more than 20%. Selective neck dissection removing cervical lymph node level II-IV is the procedure of choice for patients with clinically N0 neck. Contralateral nodal clearance may also be considered in tumors involving the medial wall of the pyriform recess, post-crioid region or the posterior wall, and those with ipsilateral palpable nodal metastasis and clinical stage IV disease. Transoral robotic surgery (TORS) has the potential value as the minimally invasive procedure for the management of carcinoma of the hypopharynx.

CONCLUSIONS

The treatment strategy for carcinoma of the hypopharynx has been evolving with time. Organ preserving chemoradiotherapy has been the treatment of choice for early stage disease, with surgical resection and reconstruction reserved for advanced and recurrent tumors.

Gastric pull up reconstruction after pharyngo laryngo esophagectomy for advanced hypopharyngeal cancer

Hypopharyngeal cancers are uncommon. The management of advanced hypopharyngeal carcinomas has been a difficult problem. Surgical resection has been more successful. While many surgical methods have been used and reported pharyngolaryngo esophagectomy with gastric pull up remains the best option. This study documents our experience with patients who underwent total pharyngolaryngoesophagectomy with immediate gastric pull-up for advanced carcinoma hypopharynx. The clinical data of 17 patients treated with pharyngo-laryngo-esophagectomy for advanced carcinoma of the hypopharynx between 2001 and 2004 was analyzed. All patients had advanced disease and required a gastric pull-up for reconstruction. Data obtained included age, sex, site, stage, post op complication, duration of follow up, recurrence & survival. Average age was 37.7 years and ranged from 27 to 56 years. There were 13 female patients and 4 male patients .13 patients presented with postcricoid tumours and 4 with posterior pharyngeal wall tumors, 13 patients presented with stage 3 tumors and 4 patients presented with stage 4 tumors. Wound infection was present in 2 patients (11.7%), anastomotic leak in 1(5.8%), hypocalcemia in 1(5.8%) and malignant pleural effusion in 1 patient (5.8%). Local recurrence occurred in 1(5.8%) while nodal recurrence occurred in 5(29.4%) patient. The average over all survival in our study was 19.5 months and ranged from 2 to 101 months. The gastric pull-up operation is a useful and effective method for the immediate reconstruction of the advanced hypopharyngeal malignancy.

Complication following gastric pull-up reconstruction for advanced hypopharyngeal or cervical esophageal carcinoma: a 20-year review in a Chinese institute

OBJECTIVES

Carcinoma of the hypopharynx and cervical esophagus is a very aggressive cancer with a high incidence of multifocal mucosal involvement and a high incidence of submucosal lymphatic spread. Total pharyngolaryngoesophagectomy and gastric pull-up reconstruction are often the procedures of choice. The aim of this study is to review the complication after gastric pull-up reconstruction in patients with advanced hypopharyngeal or cervical esophageal cancer.

MATERIALS AND METHODS

A total of 208 patients undergoing gastric pull-up reconstruction for squamous cell carcinoma of the hypopharynx invading the cervical esophagus and cervical esophagus at the Affiliated Provincial Hospital of Anhui Medical University in China from 1988 to 2007 were reviewed. Of 208 patients, 124 patients had hypopharyngeal carcinoma invading cervical esophagus; and 84 patients had cervical esophageal carcinoma. The analysis focused on the most common complications and the survival following gastric pull-up reconstruction. This study and its methods have been approved by the institutional review board.

RESULTS

Of the 208 patients, 87 (41.8%) developed some complications, including anastomotic leak (19, 9.1%), pneumonitis (23, 11.1%), pleural effusion (15, 7.2%), wound infection (8, 3.9%), heart failure (4, 1.9%), anastomosis stricture (7, 3.4%), chylous fistula (4, 1.9%), hemothorax (3, 1.4%), hemoperitoneum (2, 1.0%), and burst abdomen (2, 1.0%); there was no gastric necrosis. In our cases, there was no immediate operative mortality; but there were 4 hospital deaths. The average hospital stay was 15 days.

CONCLUSIONS

Gastric pull-up reconstruction is a relatively safe and effective method and can be performed with low mortality and acceptable morbidity and result in good quality of lives.

Circumferential pharyngeal reconstruction: history, critical analysis of techniques, and current therapeutic recommendations

Reconstruction of circumferential pharyngeal defects following total pharyngolaryngectomy presents major challenges with respect to surgical morbidity and restoration of functional deficits, which are often made more demanding by the increasing trend to utilize primary chemoradiation protocols with surgery reserved for salvage cases. The present review evaluates the reconstructive techniques described in the literature, including historical techniques as well as more recent innovative methods. Each technique is critically appraised with particular reference to postoperative morbidity and functional rehabilitation. Treatment recommendations are made based on the available evidence.

Pharyngolaryngoesophagectomy using the thoracoscopic approach

BACKGROUND

Thoracoscopic mobilization of the esophagus for pharyngolaryngoesophagectomy allows dissection under direct vision, and therefore it potentially results in fewer complications than conventional transhiatal mobilization. In this article we report our experience with this approach. It was also hypothesized that a learning curve existed and that results have improved over time.

PATIENTS AND METHODS

From July 1994 until January 2004, 57 patients underwent pharyngolaryngoesophagectomy in our institution. Intraoperative events and postoperative outcome were prospectively documented, and long-term follow-up data were also studied. Results were compared between the first 30 patients and the last 27 patients.

RESULTS

There were no significant differences between the two groups with respect to the various clinicopathological characteristics. There was no difference in the median thoracoscopic time between the first 30 and last 27 patients at 90 and 75 min, respectively, p = 0.18. For the complete procedure there was significantly less blood loss in the later group; median (range) blood loss 700 (164-3000) ml versus 400 (100-1200) ml, p = 0.002. Overall pulmonary complications occurred in 12 patients (40%) in the first group versus 13 (48%) in the second group, p = 0.6. The incidence of atrial arrhythmia was also similar, affecting 6 (20%) patients and 3 (11%), respectively, p = 0.47. Hospital mortality rates were 13.3% and 7.4%, p = 0.67. Two-year survival rates were no different (46% versus 45% p = 0.85).

CONCLUSIONS

Although, subjectively, operating skills have improved over time, better results in the second half of this series could not be demonstrated clearly, likely because the operating surgeons had prior extensive experience in esophageal and thoracoscopic procedures.

Morbidity after flap reconstruction of hypopharyngeal defects

OBJECTIVES

Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal functional results. The primary aim of this study is to determine whether complications can be predicted on the basis of reconstruction in patients undergoing pharyngectomy for tumors involving the hypopharynx. In addition, we detail a reconstructive algorithm for management of partial and total laryngopharyngectomy defects.

METHOD

A retrospective review was performed of 153 patients undergoing flap reconstruction for 85 partial and 68 circumferential pharyngectomies at a single institution over a 10-year period. There were 118 males and 35 females, the median age was 62 years, and mean follow up was 3.1 years. Pharyngectomy was performed for recurrence after radiotherapy in 80 patients and as primary surgery in 73. Free flap reconstruction was used in 42%, with 30 jejunal, 15 radial forearm, 11 anterolateral thigh, five rectus abdominis, and three gastro-omental flaps. Gastric transposition and pectoralis major pedicle flap was used in 14% and 44% of patients, respectively. Morbidity was analyzed according to extent of defect, regional versus free flap, enteric versus fasciocutaneous free flap reconstruction, and the effect of laparotomy.

RESULTS

The total operative morbidity and mortality rate was 71% and 3%, respectively. The most common complications were hypocalcemia in 45%, pharyngocutaneous fistula in 33%, and wound complications in 25%. The late complication and stricture rate was 26% and 15%, respectively. On univariate analysis, circumferential defects were associated with increased total (P=.046) and flap-related morbidity (P=.037), hypocalcemia (P<.001), late complications (P=.003), and stricture (P=.009). Gastric transposition had increased total (P=.007), flap-related (P=.035), late complications (P=.034), and hypocalcemia (P=.001). Pharyngocutaneous fistula was increased in patients undergoing salvage pharyngectomy for radiation failure (P=.048) compared with primary surgery. On multivariate analysis, gastric transposition independently predicted for wound complications (P=.014) and fistula (P=.012). Circumferential defects predicted for flap-related morbidity (P=.030), hypocalcemia (P=.017), and late complications (P=.042). Tracheoesophageal speech was the method of voice restoration in 44% of patients. Oral diet was achieved in 93% of patients; however, 16% required gastrostomy tube feeds for either total or supplemental nutrition.

CONCLUSION

The operative morbidity associated with pharyngeal reconstruction is substantial in terms of early and late complications. We were able to predict morbidity by defect extent and reconstruction type and initial treatment modality. Swallowing function is acceptable; however, less than half of the patients undergoing pharyngectomy had tracheoesophageal puncture voice restoration.

A reappraisal of surgical management for squamous cell carcinoma in the pharyngoesophageal junction

BACKGROUND

Squamous cell carcinoma (SCC) in the pharyngoesophageal junction (PEJ) with concomitant involvement of both the hypopharynx and cervical esophagus occurs rarely and poses a challenge in treatment. Data regarding the long-term result of aggressive surgical management was lacking.

METHODS

Forty-one consecutive patients were treated with total pharyngolaryngo-esophagectomy (PLE) and reconstruction between 1984 and 2002. The clinicopathological parameters and prognostic data were analyzed.

RESULTS

The surgery carried a postoperative mortality rate of 9.8%. The overall median survival was 18.5 months, with a 31.5% 5-year survival rate. By multivariate analysis, patients with major tumor localization in the hypopharynx had significantly favorable prognosis (median survivals for hypopharyngeal versus esophageal localization, 37.2 versus 7.1 months, P = 0.043). The administration of adjuvant radiotherapy and tumor size less than 5 cm also contributed to a better outcome (P = 0.001 and P = 0.037, respectively).

CONCLUSIONS

An aggressive surgical approach with total PLE in conjunction with adjuvant radiotherapy represents a feasible option for treatment of advanced SCC simultaneously involving the hypopharynx and cervical esophagus, given the major tumor localization in the hypopharynx. On the other hand, radical surgery for those with major esophageal localization or with tumor size larger than 5 cm yielded ominous results and warrants further justification.

Thyroidectomy and hypoparathyroidism in patients with pharyngoesophageal tumors

BACKGROUND

Total pharyngolaryngoesophagectomy and gastric transposition (TPLEGT) for pharyngoesophageal (PE) tumors may require thyroidectomy (with or without removal of the parathyroid glands) to obtain adequate margins around the tumor. As a result, a considerable number of patients may have hypoparathyroidism (HP) develop. The objective of this article is to report our experience with different types of thyroidectomy and to describe the relationship of thyroidectomy to HP in TPLETG. These results are compared with data in the literature.

METHODS

From 1985 to 2001, 40 patients underwent TPLEGT, with main index tumors in the esophagus (n = 17), hypopharynx (n = 17), and larynx (n = 6). All patients had advanced cTNM or pTNM stages (III or IV). Postoperative HP was diagnosed based primarily on the symptoms and calcium and phosphorus analysis but not on parathyroid hormone (PTH) levels.

RESULTS

Total thyroidectomy (TT) was done in 12 (30%) patients and 11 (91.6%) had permanent HP develop. In none of these patients was the parathyroid separated and implanted (fear of a tumor implant). Partial thyroidectomy (PT) (lobectomy and isthmus) was done in 25 (62.5%) patients, and permanent HP occurred in 11 (44%) patients. The thyroid was preserved in three patients, and none had HP develop. Of the 40 patients, 13 (32.5%) had no HP, five (12.5%) had temporary HP, and 22 (55%) had permanent HP. There was a correlation between the type of thyroidectomy, location of primary tumors, and development of HP. Only seven reports in the past 30 years have dealt with TPLEGT, thyroidectomy, and HP. HP occurred in 32.5% of the cases of TT and in 19.5% of the cases of PT.

CONCLUSIONS

Permanent HP was very frequent (55%) in our series. In patients who underwent TPLEGT, HP was almost certain when TT was done (91.6%). PT was no guarantee that HP would not occur (44% permanent HP). The frequency of permanent HP based on primary index tumors was 47%, 59%, and 66.6% for esophageal, hypopharyngeal, and laryngeal cancer, respectively.

Minimally invasive pharyngo-laryngo-esophagectomy: a salvage procedure for recurrent postcricoid esophageal cancer

Hypopharyngeal and cervical esophageal tumors represent 5-10% of all esophageal neoplasms and are challenging for both surgeons and oncologists, because the choice of the adequate therapeutic strategy is not clearly defined and therefore difficult. In fact, although surgical treatment represents the gold standard of therapy, chemo-radiotherapy, previously used as adjuvant treatment, has been more recently adopted with curative intent, leaving to surgery a salvage role only. When surgery is required it is advisable to reduce patients' trauma. The present study reports on a personal technique for minimally invasive pharyngo-laryngo-esophagectomy and reconstruction with the whole stomach. We use a laparoscopic approach for mobilization of the stomach, transhiatal esophageal dissection and to follow transhiatal gastric transposition to the neck combined to a cervicotomy to perform pharyngo-laryngectomy, proximal esophageal mobilization, and pharyngo-gastric anastomosis. We performed this technique on four patients with recurrent disease after initially curative primary chemo-radiotherapy. Mean operative time was 345 min (range: 300-384). There were no intraoperative complications. All patients were extubated immediately after the operation and were managed in postoperative care unit for a mean time of 10 days (range: 7-12). Enteral nutrition was begun on post-operative day (POD) 1. The nasogastric tube and drainages were removed on POD 11, and patients immediately started oral nutrition. One patient had a TIA (transient ischemic attack) on POD 2. All patients were discharged within 20 days (18-20). Initial experience with this minimally invasive technique in selected patients is encouraging because it seems to minimize postoperative complications and allows early rehabilitation.

Results of Gastric Pull-up Reconstruction for Pharyngolaryngo-oesophagectomy in Advanced Head and Neck Cancer and Cervical Oesophageal Squamous Cell Carcinoma

OBJECTIVE

To study long-term clinical swallowing function and survival outcome in head and neck and cervical oesophageal cancer patients who underwent pharyngolaryngo-oesophagectomy (PLE).

METHODS

The clinical data of 48 patients who were treated with PLE were analysed. All patients had advanced disease, so the construction required a transposed stomach. Body weight and clinical swallowing function were evaluated postoperatively. The swallowing function was assessed at an interview concerning food ingestion and regurgitation. The survival group was studied using a Kaplan-Meier survival curve.

RESULTS

Forty-one cases of hypopharyngeal cancer and four cases of cervical oesophageal cancer were studied. In three cases (6%), hypopharyngeal and thoracic oesophageal squamous cell carcinoma occurred together. Most cases had good-to-fair results. The average body weight gain was increased after surgery. There was one hospital death. The most common complications were pulmonary (4%). Median survival was 27 months.

CONCLUSION

A pharyngogastric anastomosis after PLE can be performed with low morbidity and good swallowing function.

[Reconstruction after total circular pharyngolaryngectomy: comparison between gastric interposition and free jejunal flap]

AIM OF THE STUDY

To elucidate hospital mortality, morbidity and actuarial survival rates of patients with carcinoma of the hypopharynx and cervical oesophagus and to identify the technique of choice for reconstruction after pharyngolaryngectomy.

PATIENTS AND METHODS

We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and January 2000. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical oesophageal in 78 cases. Follow-up was complete for all patients. Chi 2 and log rank tests were used, with a limit of significance of 5%.

RESULTS

The postoperative mortality and morbidity rates were 4.8% and 38.3%, respectively. Alimentary continuity was achieved using the stomach (127 patients), colon (5 patients), or free jejunal autograft (77 patients). The 1-year and 5-year survival rates were 62% and 24%, respectively. There was no significant difference with regard to the survival between gastric transposition and free jejunal autograft, but there were fewer complications in the gastric pull-up group with regard to the respiratory complications (33% vs 47.0%, p < 0.05), local recurrences (15.8% vs 33.8%, p = 0.004) and survival without dysphagia (76% vs 89%, p < 10(-5)).

CONCLUSION

Surgical ablation is a viable option for advanced hypopharyngeal and cervical oesophageal neoplasms, and stomach interposition is the preferred method of reconstruction.

Current status of surgery for carcinoma of the hypopharynx and cervical esophagus

Hypopharynx and cervical esophagus represent a critical location for a squamous cell carcinoma, a neoplasm that usually requires extensive surgery. Although morbidity and mortality of resection have markedly decreased over the past decade, the major issue in these patients remains quality of life owing to the need for combination with a laryngectomy to provide radical treatment. Chemoradiation therapy has the potential to downstage and even cure the disease without altering quality of life dramatically. Today, in the absence of randomized trials, the choice between surgery and definitive chemoradiotherapy should be based on clear information and the patient's preference. Salvage surgery is feasible and effective in selected patients.

Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy

BACKGROUND

Pharyngolaryngoesophagectomy (PLE) for hypopharyngeal cancers and tumors of the cervical esophagus is a procedure of significant morbidity and mortality. Conventional esophageal mobilization is performed with the transhiatal dissection technique. Thoracoscopic esophageal mobilization is tested as an alternative to determine whether surgical outcome can be improved.

METHODS

From 1994 to 1998, thoracoscopic mobilization was carried out in 30 consecutive patients who underwent PLE (PLE-TS). This was compared to a historical cohort of 30 patients who had PLE with transhiatal mobilization (PLE-TH).

RESULTS

In PLE-TS, thoracoscopic esophageal mobilization was successful in 28 patients (93%). Median blood loss was 700 mL (range, 164 to 3,000 mL) compared to 1,000 mL (range, 400 to 2,200 mL) in group PLE-TH, p = 0.21. Thoracoscopy time was 90 minutes (range, 60 to 180 minutes). Total operating time were 392 minutes (range, 180 to 570 minutes) and 300 minutes (range, 150 to 550 minutes) in PLE-TS and PLE-TH, respectively (p = 0.03). Major pulmonary complications occurred in 7 (23%) and 8 (27%) patients in PLE-TS and PLE-TH, respectively (p = 0.77). Cardiac complications occurred in 7 (23%) and 5 (17%) patients in PLE-TS and PLE-TH, respectively (p = 0.52). Thirty-day mortality rates were 3.3% and 10% (p = 0.6) and hospital mortality rates were 13% and 17%, (p = 1.0).

CONCLUSIONS

Thoracoscopy was safe and feasible. Morbidity and mortality after PLE was not significantly reduced. The theoretical advantage offered by thoracoscopy may be offset by the lengthened time of one-lung anesthesia.

Multicentricity in pharyngoesophageal tumors: argument for total pharyngolaryngoesophagectomy and gastric transposition

BACKGROUND

Pharyngoesophageal tumors pose a challenge to surgical management, and there is controversy in the literature as to the best procedure to be used. Advantages and disadvantages are mentioned for total pharyngolaryngoesophagectomy and gastric transposition (PLE&GT), free jejunal transplants, and free forearm flaps. One of the arguments for PLE&GT is the persistence or subsequent occurrence of multiple primaries in a field cancerization region. Multiple tumors in the head and neck/esophagus/lung axis have been reported. However, despite extensive investigation, there is little information on specific multicentricity in patients treated with PLE&GT for pharyngolaryngoesophageal carcinomas.

METHODS

A clinicopathological study was undertaken in 35 consecutive patients who underwent PLE&GT for pharyngoesophageal cancer to evaluate synchronicity, multicentricity, and metachronicity. Only in situ and invasive carcinomas were considered. The findings were compared with the reports in the literature.

RESULTS

Thirty-eight tumors were diagnosed preoperatively, with the main indications for PLE&GT being tumors located in the esophagus or hypopharynx (32 patients) and larynx (three patients). After the surgical treatment, 21 patients had single primaries (60%) and 14 (40%) had 25 multiple primaries in addition to their main primaries (total of 60 tumors in the whole group). Synchronous, previous metachronous and subsequent metachronous carcinomas occurred in 26%, 17%, and 8.5% of the instances, respectively. Twenty of the 25 multicentric carcinomas were invasive (80%). Either the main primaries or the multicentric carcinomas were located in the esophagus or hypopharynx (91.5% and 60%, respectively). Other sites included the larynx, oropharynx, oral cavity, and lung.

CONCLUSION

The incidence of multicentric tumors in patients with pharyngoesophageal carcinomas may favor total PLE&GT as the procedure of choice, because it includes all the condemned upper pharyngolaryngoesophageal mucosa.