Present status of pharyngogastric anastomosis following pharyngolaryngo-oesophagectomy

Surgical Outcomes of Cervical Esophageal Cancer: A Single-Center Experience

Background

Cervical esophageal cancer is a rare malignancy that requires specialized care. While definitive chemoradiation is the standard treatment approach, surgery remains a valuable option for certain patients. This study examined the surgical outcomes of patients with cervical esophageal cancer.

Methods

The study involved a retrospective review and analysis of 24 patients with cervical esophageal cancer. These patients underwent surgical resection between September 1994 and December 2018.

Results

The mean age of the patients was 61.0±10.2 years, and 22 (91.7%) of them were male. Furthermore, 21 patients (87.5%) had T3 or T4 tumors, and 11 (45.8%) exhibited lymph node metastasis. Gastric pull-up with esophagectomy was performed for 19 patients (79.2%), while 5 (20.8%) underwent free jejunal graft with cervical esophagectomy. The 30-day operative mortality rate was 8.3%. During the follow-up period, complications included leakage at the anastomotic site in 9 cases (37.5%) and graft necrosis of the gastric conduit in 1 case. Progression to oral feeding was achieved in 20 patients (83.3%). Fifteen patients (62.5%) displayed tumor recurrence. The median time from surgery to recurrence was 10.5 months, and the 1-year recurrence rate was 73.3%. The 1-year and 3-year survival rates were 75% and 33.3%, respectively, with a median survival period of 17 months.

Conclusion

Patients with cervical esophageal cancer who underwent surgical resection faced unfavorable outcomes and relatively poor survival. The selection of cases and decision to proceed with surgery should be made cautiously, considering the risk of severe complications.

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.

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.

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.

Surgical treatment of recalcitrant radiation-induced gastric erosions

BACKGROUND

Uncontrolled bleeding as a result of radiation gastritis in patients who have pharyngo-laryngo-esophagectomy and gastric pull-up is seldom reported. Surgical resection in the management of this condition has rarely been described.

METHOD

A 66-year-old man with hypopharyngeal cancer was treated by pharyngo-laryngo-esophagectomy and gastric transposition. He received postoperative radiotherapy and had recurrent hemorrhagic gastritis, necessitating surgical resection. The manubrium was resected to access the mediastinal part of the gastric conduit. The diseased part of the gastric conduit was removed and a free jejunal graft was interposed to replace the resected stomach.

RESULTS

Manubrial resection offered adequate access to the stomach transposed in the mediastinum, and the life-threatening bleeding gastritis was successfully controlled by surgical resection.

CONCLUSION

Surgical resection of the radiation-damaged transposed stomach through a manubrial resection approach can safely be performed. Free jejunal graft is the choice of reconstruction of the circumferential defect.

Reconstruction with free jejunal autograft after circumferential pharyngolaryngectomy: eighty-three cases

The free jejunal autograft (FJA) has become a common procedure for pharyngeal reconstruction after circumferential pharyngolaryngectomy. In order to evaluate the postoperative outcome and the functional and carcinologic results, we retrospectively reviewed 83 cases of reconstruction with FJA. Fifty-one patients had received no prior radiotherapy, and 25 had received prior radiotherapy for their hypopharyngeal tumor or for another previous primary. Seven patients underwent a secondary reconstruction. In the postoperative course, there were 2 postoperative deaths, 4 graft failures (5%), and 11 salivary fistulas. The median time to removal of the nasogastric tube was 16 days, and to discharge, 23 days. Forty-eight patients received postoperative radiotherapy, with good tolerance. At 1 year postoperatively, 98% of the patients were able to eat a solid or soft diet. The postoperative radiotherapy did not impair the quality of the functional results in a long-term assessment. The vocal results were disappointing. The 3-year survival rate was 40%. The main carcinologic failures (45 patients) were locoregional recurrences (20 patients) and metastasis, which was the cause of death in 34% of the cases. It seems clear that FJA allows one-stage reconstruction and good swallowing rehabilitation, tolerates postoperative radiotherapy, and increases the quality of life in these patients with a poor prognosis.

Current status of pharyngolaryngo-esophagectomy and pharyngogastric anastomosis

BACKGROUND

Pharyngolaryngo-esophagectomy and pharyngogastric anastomosis (PLO & PGA) is one of the surgical options in the management of tumors arising from the hypopharynx and cervical esophagus. Indications of the operation and the outcome are changing over the years. To examine these, the experience of this operation in one Institute (the Head and Neck Division of the Department of Surgery, The University of Hong Kong at Queen Mary Hospital, Hong Kong) over the last 30 years was reviewed.

METHODS

From 1966 to 1995, a total of 317 patients underwent PLO & PGA. The clinical results of 69 patients operated on between 1986 and 1995 were analyzed and compared with those of the two groups of patients reported previously from the same Institute to establish the current status of PLO & PGA.

RESULTS

The demographic data of three groups of patients were similar. In previous years, 53% of the primary tumors were advanced laryngeal carcinomas extending to the hypopharynx, whereas the other 47% originated from hypopharyngeal and cervical esophageal regions. In recent years, all patients belonged to the latter group.

CONCLUSIONS

The hospital mortality has decreased from 31% to 9%, and the incidence of morbidity such as anastomotic leakage and bleeding has also been reduced, from 20% to 10%. This may be related to the introduction of transthoracic endoscopic mobilization of the esophagus and patient selection. The overall minor morbidity has, however, remained at about 49%, and the 5-year actuarial survival rate has improved, from 18% in the 1970s to 24.5% at present.

Comprehensive analysis of pharyngeal recurrence of laryngeal carcinoma after total laryngectomy

PURPOSE

This study analyzes the incidence, risk factors, treatment results, and prognosis of local recurrence at the pharynx after total laryngectomy for laryngeal carcinoma.

PATIENTS AND METHODS

The records of 292 patients who underwent total laryngectomy for the treatment of laryngeal carcinoma between January 1978 and December 1990 were reviewed.

RESULTS

Of these 292 patients, there were 24 patients who developed local recurrence at the pharynx. The 5-year actuarial cumulative local recurrence rate was 10%. There were 17 cases of pharyngeal recurrence alone, five cases of pharyngeal and nodal recurrence, one case of pharyngeal and tracheostomal recurrence, and one case of pharyngeal and distant metastasis. Ten (42%) patients were salvaged surgically; the 5-year actuarial survival rate after surgical salvage was 53%. The other 14 patients were treated with palliative treatment, and all died of tumor, with the longest period of survival being 28 months.

CONCLUSION

Surgical salvage of pharyngeal recurrence has acceptable results. Close monitoring of patients is important to have an early diagnosis of salvageable recurrence.

Prognosis of recurrent laryngeal carcinoma after laryngectomy

BACKGROUND

Recurrence is common after total laryngectomy for advanced laryngeal carcinoma. The aim of the present study was to review the prognosis of recurrent laryngeal carcinoma after total laryngectomy.

METHODS

The records of 165 patients who developed recurrences after total laryngectomy for laryngeal squamous cell carcinoma between January 1971 and December 1990 were reviewed.

RESULTS

Of the 165 patients who developed recurrences, 34 (21%) patients had surgical salvage. The sites of recurrence of these 34 operable patients included 11 pharyngeal, 3 tracheostomal, 15 nodal, 2 pharyngeal with nodal, and 3 pulmonary metastasis. Pharyngeal recurrence had the highest salvage rate, followed by nodal and pulmonary recurrence. All patients with tracheostomal had recurrence after salvage surgery. After the surgical salvage, the tumor recurrence rate was 44% and the 5-year actuarial survival rate was 42%. Of the other 131 patients who had palliative treatment without surgical salvage, the 5-year actuarial survival rate was 2%.

CONCLUSIONS

The present study showed that patients who had surgical salvage for recurrent tumor after total laryngectomy had satisfactory prognosis. Close follow-up of patients after initial operation is essential to detect recurrence early, while surgical salvage is still feasible.

Results of Surgical Salvage for Radiation Failures of Laryngeal Carcinoma

The results of surgical salvage of radiation failures of laryngeal carcinoma were reviewed. There were 167 stage T3 and T4 patients. The operative mortality was 7%. The complication rates were 8% wound infection, 13% chest complication, and 25% anastomotic leakage. After the first salvage operation, pharyngeal recurrence developed in 28 (48%) patients. Seven (25%| patients were feasible for second salvage operation, and none of them had further local recurrence. There were 9 (5%) tracheostomal recurrences. Of the 126 NO patients, 23(18%) had nodal recurrence, and only 5 of the nodal recurrences were feasible for salvage by radical neck dissection. All 41 node-positive patients underwent radical neck dissection, and 9 (23%) had nodal recurrence. Of the 126 node-negative patients, 19 (15%) had distant metastasis. Of the 41 node-positive patients, 18 (44%) had distant metastasis. The node-positive patients had a significantly high distant failure rate despite locoregional control of tumor. The adjusted 5-year survival rate of T3–4NOMO was 45%, and that of T3–4N + MO was 22%.

Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases

BACKGROUND

Reconstruction of tubular defects following pharyngolaryngectomy has required complicated surgery with high perioperative morbidity and mortality. Free jejunal interposition provides an excellent reconstruction with potential for lower immediate complications and better long-term results than other procedures.

METHODS

A total of 201 consecutive free jejunal interpositions were performed following pharyngolaryngectomy between 1977 and 1993. Operative details, complications, and outcome were prospectively documented.

RESULTS

Perioperative mortality was low (4.5%) and microvascular success rate high (97%), although a small number of late failures were recorded. Average time until swallowing postoperatively was 11 days, and 92% of patients could maintain full nutrition. Voice rehabilitation was mentioned, and increasingly good results are being obtained. Complication rates for the neck (17%) and the abdomen (2.5%) were also low. There were no problems with excess mucus production or reflux. Radiation effect on the jejunal conduit was not detrimental to long-term patency of the vascular anastomoses or to function as a conduit.

CONCLUSIONS

Comparison with other published techniques permits the contention that a free jejunal interposition is the reconstruction of choice after pharyngolaryngectomy.

Squamous cell carcinoma of the hypopharynx--analysis of treatment results

The results of surgical treatment and causes of failure in 109 patients with squamous cell carcinoma of the hypopharynx were analyzed. The 5-year survival was significantly related to the stage of the disease (stage I, 74%; stage II, 63%; stage III, 32%; and stage IV, 14%) and the preoperative nodal staging (N0, 57%; N1, 28%; N2, 6%; and N3, 0%), but not related to the extent of tumor resection. The local control rate was 86% and the majority of the local recurrences occurred at the upper resection margin. There was no significant difference in the local recurrence rate between those patients who had pharyngolaryngoesophagectomy and those who had pharyngolaryngectomy. However, the resection-associated complications (bleeding, cardiac arrhythmia, pulmonary complications) were more frequent when total esophagectomy was performed. Reconstruction-associated complications such as wound infection and anastomotic leakage occurred less often after gastric pull-up reconstruction as compared with the use of myocutaneous flap, but was associated with more serious outcome after pharyngo-gastric anastomosis. Thirty-seven patients (34%) had neck node recurrences and these were significantly related to the preoperative nodal staging (N0, 20%; N1, 37%; N2, 48%; and N3, 83%). Additional primary cancers occurred in 17% of the patients and was a significant cause of death in those patients who survived more than 2 years.

[Resection of esophageal cancer without thoracotomy by manual dissection and eversion stripping]

At the department of surgery of the university of Cologne-Lindenthal, 184 patients (142 with squamous cell carcinoma of the esophagus, 42 with adenocarcinoma of the gastroesophageal junction) underwent blunt dissection of esophageal cancer between 1983 and 1991. Tumor expansion classified by the pathologist was stage I in 13.6%, stage II in 31.0%, stage III in 41.8%, and stage IV in 13.6% of all cases. Histological tumor differentiation was graded well in 4.3%, moderate in 71.7%, and poor in 19.6%. Principally a gastric tube was used for esophageal replacement (96.3%), while interposition of the large bowel was performed in 5 cases. All the patients were prospectively monitored for perioperative complications. 64.7% fared without any complications intraoperatively. The most frequent intraoperative complications were damage of the pleura parietalis (16.3%), rupture of the tumor during dissection (13.0%), and lesion of the spleen (11.4%). 29.9% of the patients had a postoperative course without any complications. Pleural effusion (38.6%) and insufficiency of the cervical anastomosis (22.8%) were the most frequent complications seen postoperatively. Hospital mortality amounted to 6.0%. Six months after the operation most patients deemed their quality of life satisfying or excellent, respectively. The cumulative survival rate (without hospital mortality) was 78.3% after the first year, 24.7% after the third year and 20.6% after the fifth year.

Management of Hypopharyngeal Carcinoma: A 6-Year Review

A retrospective review of 16 consecutive cases of squamous carcinoma of the hypopharynx treated by pharyngo-laryngo-oesophagectomy (PLO) and gastric transposition with a thoracotomy as part of the surgical technique is presented. An operative mortality of 6% and a hospital mortality of 12% occurred. Other complications are discussed. No significant morbidity or mortality occurred as a result of the thoracotomy. A comparison is made with the extra-thoracic technique of gastric transposition.

Surgical voice restoration with the Blom-Singer prosthesis following laryngopharyngoesophagectomy and pharyngogastric anastomosis

Surgical voice restoration using the Blom-Singer technique is a well-established procedure in patients who have undergone simple laryngectomy. Operations for hypopharyngeal carcinoma are more extensive and require reconstruction using regional skin or myocutaneous flaps, or reanastomosis with colon, jejunum, or stomach. We report the use of the Blom-Singer prosthesis in four patients who had undergone pharyngogastric repair following laryngopharyngoesophagectomy and who had failed to achieve a satisfactory voice. All patients initially developed good speech using the prosthesis. Two patients subsequently had their prostheses removed: one because of recurrent malignant disease and one because the procedure had not significantly altered the quality of the voice. The remaining two patients have continued to use the device at 2 and 5 years after insertion with good voice production.

Mortality and morbidity of primary pharyngogastric anastomosis following circumferential excision for hypopharyngeal malignancies

Seventy-five patients underwent gastric transposition for replacement of the pharyngoesophagus. These patients had primary or recurrent malignant tumors of the hypopharynx, postcricoid region, and cervical esophagus. The operative procedure consisted of a transhiatal esophagectomy and gastric pull-up to establish gastrointestinal continuity, with a unilateral or bilateral neck dissection where indicated. Seven patients died, a mortality rate of 9.33%. The average hospital stay of uncomplicated cases was 18 days and for complicated cases was 40 days. Immediate restoration of oral intake was achieved in 70.6% of patients. We conclude that gastric transposition after circumferential laryngopharyngeal excision is a procedure with low mortality and acceptable morbidity leading to early relief of dysphagia.

A new technique for delivering the stomach or colon to the neck following total esophagectomy

After total esophagectomy, swallowing is usually restored by stomach or colon interposed to the neck. The use of a new technique to facilitate the passage of these conduits to the neck for anastomosis to the cervical esophagus is described.