Salvage surgery for recurrent or residual hypopharyngeal squamous cell carcinoma: A systematic review

BACKGROUND

This systematic review aggregates the data of studies that include site-specific analyses of patients undergoing salvage surgery for residual or recurrent hypopharyngeal squamous cell carcinoma.

METHODS

The primary outcomes are disease-free, disease-specific, and overall survival (DFS, DSS, and OS, respectively). Secondary outcomes include complications and postoperative feeding requirements.

RESULTS

Fifteen studies met the inclusion criteria with a total of 442 patients. Two-year DFS is reported from 30.0 to 50.0% and 5-year DFS ranges from 15.0 to 57.1%. Five-year DSS ranges from 28.0 to 57.1%. Two-year OS ranges from 38.8 to 52.0% and 5-year OS ranges from 15.5 to 57.1%. Complications include pharyngocutaneous fistula (0.0-71.4%), carotid artery rupture (2.9-13.3%), and stomal stenosis (4.2-20.0%). Complete oral feeding achieved following surgery ranges from 61.9 to 100.0%, while complete gastrostomy tube dependence ranges from 0.0 to 28.6%.

CONCLUSIONS

Salvage surgery for residual or recurrent hypopharyngeal squamous cell carcinoma has a relatively high complication rate and should be offered to patients with the understanding of a guarded prognosis.

Functional and quality-of-life outcomes following salvage surgery for recurrent squamous cell carcinoma of the head and neck: a systematic review and meta-analysis

BACKGROUND

Recurrent head and neck squamous cell carcinomas (HNSCC) are frequently managed with salvage surgery, but the impact these operations have on function and quality-of-life (QoL) is understudied. This review aimed to provide a quantitative and qualitative assessment of the functional and QoL effects of salvage surgical procedures.

METHODS

Systematic review and meta-analysis were conducted of studies reporting QoL and function following salvage HNSCC resections.

RESULTS

The search identified 415 articles and 34 were selected for inclusion. Pooled random effects analysis revealed long-term feeding and tracheostomy tube rates of 18% and 7%. Pooled long-term feeding tube rates in open oral and oropharyngeal, transoral robotic, total and partial laryngectomy surgeries were 41%, 25%, 11% and 4%. Eight studies used validated QoL questionnaires.

CONCLUSIONS

Functional and QoL outcomes from salvage surgery are acceptable, but appear to be worse following open procedures. Prospective studies measuring changes over time are needed to assess these procedures impact on patient well-being.

Oncological results of salvage treatment in patients with hypopharyngeal carcinoma

INTRODUCTION AND OBJECTIVE

The aim of this study is to analyse the variables related to the feasibility of salvage surgery with radical intention in patients with a local recurrence of hypopharyngeal carcinoma, and to evaluate the oncological performance of this type of surgery.

METHODS

Retrospective study of 96 patients with hypopharyngeal carcinoma with local tumour recurrence RESULT: Only 27 patients (28.1%) were considered for surgical salvage treatment. The variables related to feasibility of salvage surgery were non-surgical initial treatment of the tumour and a disease-free interval greater than 6 months. All 69 patients non-candidates for salvage surgery died as a result of tumour progression in a period of less than 2.5 years. The 5-year disease-specific survival rate for the patients treated with salvage surgery was 39.5%. The only variable significantly related to disease-specific survival was the status of the resection margins. Patients with extensive tumour recurrence (rT3-T4) or with simultaneous nodal involvement had a lower survival rate, but the differences did not reach statistical significance.

CONCLUSION

Only 28% of the patients with hypopharyngeal carcinoma with local recurrence of the tumour were eligible for salvage surgery with radical intention. The patients treated with salvage surgery had a 5 -year disease-specific survival of 39.5%.

Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer

Background

Patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma are at high risk of postoperative complications due to the adverse effects of radiotherapy on wound healing. Malnutrition is an additional risk factor and we tested the hypothesis that preoperative administration of immunonutrition would decrease complications in this high risk population.

Methods

This single armed study with historical control included consecutive patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma. We compared outcomes before and after implementation of preoperative immunonutrition and adjusted the regression analysis for gender, age, body mass index, Nutritional Risk Screening (NRS 2002), tobacco and alcohol consumption, tumor localization, tumor stage, and type of surgery. The primary endpoint was overall complications from surgery within a follow-up of 30 days.

Results

Ninety-six patients were included (intervention group: 51, control group: 45). Use of preoperative immunonutrition was associated with a significant reduction in overall complications (35% vs. 58%, fully-adjusted odds ratio 0.30 (95%CI 0.10–0.91, p = 0.034). Length of hospital stay was also significantly reduced (17 days vs. 6 days, p = < 0.001). No differences in mortality and hospital readmission were found. These results remained robust in multivariate analysis.

Conclusions

In patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma, preoperative immunonutrition exhibited favorable effects on the complication rate and consequently reduced the length of hospital stay. By improving both tissue regeneration and immune response, immunonutrition may help to improve surgical outcomes in this high-risk population.

Upregulation of microRNA‑194‑5p inhibits hypopharyngeal carcinoma cell proliferation, migration and invasion by targeting SMURF1 via the mTOR signaling pathway

Hypopharyngeal carcinoma (HPC) is an aggressive malignancy with the worst prognosis among all head and neck cancers. MicroRNAs (miRNAs) are involved in the development of many human cancers, and may function as oncogenes or tumor suppressors. The present study aimed to evaluate the effects of miRNA (miR)-194-5p on the proliferation and invasion of HPC cells and to identify the potential regulatory mechanism. First, miR-194-5p and Smad ubiquitin regulatory factor 1 (SMURF1) expression levels were examined in HPC tissues. Subsequently, to explore the effects of miR-194-5p on SMURF1, a dual-luciferase reporter gene assay was performed to verify the target relationship. To define the role of miR-194-5p in HPC progression, miR-194-5p upregulation and depletion were used to evaluate its effects on cell viability, invasion and migration. SMURF1 silencing and rapamycin [an inhibitor of the mammalian target of rapamycin (mTOR) signaling pathway] treatment were also used to analyze the regulatory mechanism in HPC. Finally, tumor growth was assessed in xenografted tumors in nude mice. SMURF1 was demonstrated to be highly expressed, whereas miR-194-5p was poorly expressed in HPC tissues; SMURF1 was identified as a target gene of miR-194-5p. FaDu hypopharyngeal squamous cell carcinoma cells treated with miR-194-5p mimics exhibited decreased viability, invasion and migration. The results indicated that miR-194-5p may inactivate the mTOR signaling pathway by targeting SMURF1. In addition, the in vivo experiments further verified these regulatory effects. These data suggested that miR-194-5p-targeted SMURF1 inhibition may be involved in the disruption of HPC progression through the repression of the mTOR signaling pathway.

Salvage surgery for advanced stage head and neck squamous cell carcinoma following radiotherapy or chemoradiation

PURPOSE

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma (HNSCC) is known to result in poor prognosis. As there are only small and heterogeneous studies available with wide variety in outcome measures, our purpose was to select and pool literature according to specific criteria.

METHODS

Systematic review and meta-analysis of clinical outcome after salvage surgery for recurrent advanced stage HNSCC following primary radiotherapy or chemoradiation.

RESULTS

16 of 3956 screened studies were included for analysis (729 patients). Pooled 5-year OS was 37% (95% CI 30-45%, 12 studies, 17 outcome measurements, 540 patients). Outcome was presented for larynx (6 studies, 397 patients), hypopharynx (2 studies, 47 patients), larynx and hypopharynx combined (3 studies, 69 patients) or separately (1 study, 134 patients), oral cavity (1 study, 11 patients), oropharynx (1 study, 34 patients) and multiple subsites combined (2 studies, 37 patients). There was no significant difference in survival outcome between subsites (p_{heterogeneity} = 0.8116). The pooled tumor-positive resection margin rate was 32% and pooled re-operation rate 17%. Complication rates from the pooled data were: fistulas 33%, wound infections 24% and flap failure 3%. Treatment-related mortality rate was 1% and mean hospital stay was 23 days.

CONCLUSIONS

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma after primary (chemo)radiotherapy is a good last resort curative treatment option, resulting in 37% overall survival at 5 years. As data from advanced stage non-laryngeal tumors were sparse, no solid conclusions can be drawn with regard to outcome differences between tumor subsites.

Free jejunal flap transfer containing multiple vascular pedicles for pharyngoesophageal reconstruction in conjunction with anterior mediastinal tracheostomy

BACKGROUND

When pharyngoesophagectomy is performed in conjunction with anterior mediastinal tracheostomy, reconstructing both the trachea and alimentary tract is extremely difficult. We developed a novel 1-stage reconstructive procedure using a single free jejunal flap containing multiple vascular pedicles to decrease postoperative morbidity and mortality. Free jejunal flap transfer with multiple vascular pedicles could offer a viable option for reducing associated life-threatening complications.

METHODS

We performed a retrospective review of 34 patients who underwent free jejunal flap transfer with multiple vascular pedicles in anterior mediastinal tracheostomy and pharyngoesophagectomy due to lesions involving both the airway and esophagus. In all cases, 1-stage reconstruction of the digestive tract and trachea was performed. Technical details and outcomes were analyzed.

RESULTS

All 34 jejunal flaps (100%) survived. Major morbidity classified as Clavien-Dindo grades III and IV occurred in 10 (29.4%) and 0 (0%) patients, respectively during hospitalization. With regard to common complications, anastomotic leakage from transferred jejunal flaps and surgical site infections occurred in 0 (0%) and 7 (20.6%) patients, respectively. Five (14.7%) patients experienced tracheal stoma dehiscence. Donor site morbidity was observed in 2 (5.9%) patients. The overall in-hospital mortality rate was 2.9%.

CONCLUSIONS

Our 1-stage reconstruction procedure achieved low morbidity and low mortality rates following anterior mediastinal tracheostomy and pharyngoesophagectomy. Only 1 jejunal flap transfer is needed to simultaneously reconstruct the trachea and alimentary tract in a safe and reliable manner with this procedure.

Postoperative mechanical bowel obstruction after pharyngolaryngectomy for hypopharyngeal cancer: Retrospective analysis using a Japanese inpatient database

BACKGROUND

Data have been limited on donor-site mechanical bowel obstruction after pharyngolaryngectomy with free jejunum graft reconstruction.

METHODS

Using a nationwide Japanese inpatient database, we extracted data on patients who underwent pharyngolaryngectomy for hypopharyngeal cancer between July 2007 and March 2014. A Cox proportional hazard model was used to determine the association between background characteristics and the occurrence of mechanical bowel obstruction.

RESULTS

Among the 3320 eligible patients from 332 hospitals, 108 patients (3.3%) developed mechanical bowel obstruction after a median 88 (interquartile range 26-217) postoperative days. Multivariable Cox regression analysis revealed that older age (≥60 years old) was independently associated with an increased risk of mechanical bowel obstruction, whereas sex, body mass index [BMI], smoking status, comorbidity at admission, blood transfusion, history of surgery, and hospital type were not.

CONCLUSION

In pharyngolaryngectomy, careful attention should be paid to the risk of abdominal complications and, thus, to the graft choice, especially in elderly patients.

Thirty-five years of single surgeon experience in the reconstruction of esophagus and voice with free ileocolon flap following total pharyngolaryngectomy

BACKGROUND

Several surgical options exist for the reconstruction of total pharyngolaryngectomy defect. The purpose of this report is to present our experience with ileocolon flap for simultaneous reconstruction of both esophagus and voice.

METHODS

Demographic data, clinical information, and outcomes of 205 patients who underwent the ileocolon flap procedure over the last 35 years were examined. Preoperative evaluation, intraoperative details, and postoperative management were analyzed. The types of additional procedures performed to improve outcomes were explored.

RESULTS

Of the 205 patients, 191 had a free ileocolon flap and the remaining 14 a pedicled flap. Ninety-seven percent of the flaps were successful with a fistula rate of 5.4%. Seven patients required reexploration and six flaps failed. Seventy-eight percent of the patients reported their swallowing function to be very good to excellent. Speech function was rated as good in 64% of patients and moderate in 21%. Three patients develop bowel obstruction, two of which required enterolysis. Five patients had postoperative diarrhea that responded to conservative measures.

CONCLUSION

Reconstruction of pharyngoesophageal defects with ileocolon flap permits resumption of swallowing and production of speech without the need for voice prosthesis and with minimal complications.

Clinicopathological Features of Cervical Esophageal Cancer: Retrospective Analysis of 63 Consecutive Patients Who Underwent Surgical Resection

OBJECTIVE

The objectives of this retrospective study were to elucidate the clinicopathological features and recent surgical results of cervical esophageal cancer.

SUMMARY BACKGROUND DATA

Cervical esophageal cancer has been reported to have a dismal prognosis. Accurate knowledge of the clinical characteristics of cervical esophageal cancer is warranted to establish appropriate therapeutic strategies.

METHODS

The clinicopathological features and treatment results of 63 consecutive patients with cervical esophageal cancer (Ce group) who underwent surgical resection from 1980 to 2013 were analyzed and compared with 977 patients with thoracic or abdominal esophageal cancer (T/A group) who underwent surgical resection during that time.

RESULTS

Among the patients who received curative resection, the 5-year overall and disease-specific survival rates of the Ce patients were significantly better than those of the T/A patients (overall: 77.3% vs 46.5%, respectively, P = 0.0067; disease-specific: 81.9% vs 55.8%, respectively, P = 0.0135). Although total pharyngo-laryngo-esophagectomy procedures were less frequently performed in the recent period, the rate of curative surgical procedures was markedly higher in the recent period (2000-1013) than that in the early period (1980-1999) (44.4% vs 88.9%, P = 0.0001). The 5-year overall survival rate in the recent period (71.5%) was significantly better than that in the early period (40.7%, P = 0.0342).

CONCLUSIONS

Curative resection for cervical esophageal cancer contributes to favorable outcomes compared with other esophageal cancers. Recent surgical results for cervical esophageal cancer have improved, and include an increased rate of curative resection and decreased rate of extensive surgery.

Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

OBJECTIVES/HYPOTHESIS

Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies.

STUDY DESIGN

Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies.

METHODS

Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT.

RESULTS

In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate.

CONCLUSIONS

First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2731-2737, 2017.

Comparison of Salvage Total Pharyngolaryngectomy and Cervical Esophagectomy Between Hypopharyngeal Cancer and Cervical Esophageal Cancer

BACKGROUND

Total pharyngolaryngectomy and cervical esophagectomy (TPLCE) after chemoradiotherapy remains a challenge because of the high rate of complications and few available data on outcomes and safety. The purpose of this study was to evaluate the clinical significance of salvage TPLCE and to compare treatment outcomes between hypopharyngeal cancer and cervical esophageal cancer.

METHODS

Data from 37 consecutive patients who were diagnosed with potentially resectable hypopharyngeal and cervical esophageal cancer after chemoradiotherapy were retrospectively analyzed. The survival and surgical outcomes were investigated between the hypopharyngeal cancer and cervical esophageal cancer groups.

RESULTS

Twenty-six patients were included in hypopharyngeal cancer group and 11 patients were included in cervical esophageal cancer group. The baseline characteristics were balanced between the two groups. Compared to the hypopharyngeal cancer group, the cervical esophageal cancer group had significantly more frequent tracheal-related complications (p < 0.05) and stronger association of distal margin of the cervical esophagus and radiation field with tracheal ischemia after salvage surgery.

CONCLUSIONS

Salvage TPLCE can offer the exclusive chance of prolonged survival. Association of tracheal ischemia with salvage TPLCE was seen more frequently for cervical esophageal cancer. Therefore, the indication for salvage TPLCE must be carefully considered to maintain the balance between curability and safety.

Salvage surgery after head and neck squamous cell carcinoma treated with bioradiotherapy

BACKGROUND

The purpose of this study was to describe the results and complications of primary site salvage surgery after head and neck squamous cell carcinoma (HNSCC) treated with bioradiotherapy.

METHODS

We conducted a retrospective chart review of 268 patients treated with bioradiotherapy between March 2006 and December 2013 at the Hospital Universitari de Bellvitge-ICO.

RESULTS

Fifty-nine patients developed local recurrence or had residual disease with a 1-year and 3-year overall survival of 47% and 15.4%, respectively. Salvage surgery was feasible in 22 patients (37.3%). There were 16 complications in these 22 patients (72.7%), 11 (50%) of which were major. Bilateral neck dissection was identified as a risk factor for complications.

CONCLUSION

Salvage surgery after bioradiotherapy is associated with a high rate of complications. Neck dissection seems to be related to an increased rate of complications with no survival improvement. © 2016 Wiley Periodicals, Inc. Head Neck 39: 116-121, 2017.

Salvage surgery after local recurrence in patients with head and neck carcinoma treated with chemoradiotherapy or bioradiotherapy

OBJECTIVE

To analyze the oncologic outcomes and surgical complications after salvage surgery for recurrence following chemoradiotherapy or bioradiotherapy for advanced head and neck squamous cell carcinoma.

METHODS

From 2007 to 2011, 187 patients were treated with chemoradiotherapy (n=154) or bioradiotherapy (n=33). Patients treated with bioradiotherapy were older and showed a tendency to poorer general condition. During the follow-up, 43 patients treated with chemoradiotherapy (27.9%) and 13 patients treated with bioradiotherapy (39.3%) had a local recurrence of the tumor. We analyzed the patient candidates to salvage surgery, and the associated complications and outcome of these surgeries.

RESULTS

Sixteen patients treated with chemoradiotherapy (37.2%) and eight treated with bioradiotherapy (61.5%) had salvage surgery. Multivariate analysis showed that the variable most strongly related to salvage surgery after local recurrence of the tumor was the type of initial treatment. The frequency of postoperative complications was higher in patients who received chemoradiotherapy (62.5% versus 12.5%, P=0.03). Five-year adjusted-survival after salvage surgery was 26.0% for patients receiving chemoradiotherapy and 70.0% for patients undergoing bioradiotherapy (P=0.156).

CONCLUSION

Patients who presented recurrence after bioradiotherapy were more likely candidates to salvage surgery than those who had chemoradiotherapy. Patients undergoing salvage surgery had fewer postoperative complications and better adjusted survival after bioradiotherapy than after chemoradiotherapy.

The use of short segment free jejunal transfer as salvage surgery for cervical esophageal and hypopharyngeal cancer

Background

Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy.

Methods

We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates.

Results

The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %.

Conclusions

Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.

Clinical significance of surgical resection for the recurrence of esophageal cancer after radical esophagectomy

BACKGROUND

This study aimed to clarify the clinical significance of surgical resection for recurrent lesions after esophagectomy for esophageal cancer.

METHODS

Recurrence was detected in 113 of 365 consecutive patients who underwent surgical resection for esophageal cancer, and some treatment was performed for recurrence in 100 of the 113 patients. The treatments were classified into two groups: chemotherapy and/or radiation with surgery (surgery group, n = 14) and chemotherapy and/or radiation without surgery (no surgery group, n = 86). The outcomes were retrospectively analyzed.

RESULTS

Of the 14 patients in the surgery group, 3 underwent repeated resection. Thus, a total of 22 resections were performed for these patients. The resected organs were the lymph nodes in nine patients, the lungs in six patients, local recurrence in two patients, subcutaneous recurrence in two patients, the liver in one patient, the brain in one patient, and the parotid gland in one patient. Among the 22 recurrent cases, 20 involved solitary lesions or multiple lesions located in a small resectable region. When the two groups were compared, the surgery group showed a more favorable prognosis in terms of both survival after esophagectomy (median survival time, 103.3 vs 23.1 months; p = 0.0060) and survival after initial recurrence (92.1 vs 12.2 months; p = 0.0057).

CONCLUSIONS

Multimodal treatment provides a significant benefit for patients with recurrence after esophagectomy for esophageal cancer. Surgical intervention should be aggressively included in the treatment strategy when the recurrent lesion is solitary or localized.

Effects of radiation therapy on postoperative complications and adverse events in patients with head and neck reconstruction with flaps

BACKGROUND

Radiation therapy is an essential treatment for head and neck cancer. However, the condition of the operative field is entirely altered after radiation therapy. This study aimed to examine the effects of preoperative radiation therapy on complications in patients who underwent head and neck reconstruction with flaps.

METHODS

We retrospectively reviewed 252 instances of head and neck reconstruction with flaps in 240 patients between October 2000 and May 2011 at Okayama University Hospital. Of the participants, 51 had preoperative radiation exposure (21.3%) and 189 had no radiation exposure (78.7%). Postoperative complications were divided into three categories: minor complications that healed with conservative medical treatment within 4 weeks without a need for surgery; major complications requiring reoperation within 1 week after surgery (reoperation); and major complications needing additional operation later than 1 week after surgery (additional operation).

RESULTS

Preoperative radiation therapy was only associated with major complications requiring reoperation later than 1 week after surgery (P < 0.001), open cervical wounds (P = 0.0030), and skin grafting for cervical skin necrosis (P = 0.0031) when compared to no radiation exposure. The results of flap failure were not significantly different between both groups (P = 0.3820).

CONCLUSIONS

Minor complications and reoperation in the early postoperative period were not influenced by radiation exposure. The complications of radiation tend to be protracted and associated with additional operation later than 1 week after the initial surgery. It was thought that shortening of the duration of treatment was successful when we needed to perform early additional operations.

Technical improvement of total pharyngo-laryngo-esophagectomy for esophageal cancer and head and neck cancer

PURPOSE

Total pharyngo-laryngo-esophagectomy (PLE) is highly invasive, and the subsequent reconstruction is difficult. The purpose of this study was to clarify the techniques that can decrease the surgical stress and allow for safe reconstruction after this operation.

METHODS

The surgical method and clinical outcomes of total PLE were reviewed in 12 patients with either cervicothoracic esophageal cancer or double cancer of the esophagus and pharynx. Microscopic venous anastomosis was principally performed, and arterial anastomosis was added, if needed.

RESULTS

A narrow gastric tube was used in ten patients, including two patients who underwent free jejunal interposition, while the colon was used as the main reconstructed organ in two other patients. Staged operations were performed in three high-risk patients. All six patients treated after 2010 were able to undergo thoracoscopic and/or laparoscopic surgery. No critical postoperative complications developed, although minor anastomotic leakage developed in two patients who were successfully treated conservatively.

CONCLUSION

When performing PLE, it is important to decrease the surgical stress and ensure a reliable reconstruction by adopting techniques that are appropriate for each case, such as thoracoscopic and laparoscopic surgery, staged operations, microvascular anastomosis, and muscular flaps.

Surgical strategies for esophageal cancer associated with head and neck cancer

Esophageal cancer is frequently associated with squamous cell carcinoma in the head and neck. Both cigarette smoking and alcohol consumption are risk factors for multiple cancers of the head and neck, as well as the esophagus. Routine screening and close follow-up for second cancers are important in patients with esophageal cancer or head and neck cancer. For this purpose, endoscopy with Lugol's staining, as well as narrow-band imaging combined with magnifying endoscopy, is a powerful tool for the early detection of esophageal cancer. Multimodal therapy is essential for patients with double cancers. When considering surgical treatment, the curability of both cancers must be carefully evaluated. If both tumors are potentially curable, each lesion should be treated individually. In patients with metachronous double cancers, the prior treatment of the first primary carcinoma often affects the treatment of the second cancer. Close cooperation among medical staff members is essential for complicated surgeries for double cancers. Techniques that are appropriate for each case must be adopted, such as careful dissection, staged operations, muscular flaps and microvascular anastomosis.

Decision making in the management of recurrent head and neck cancer

Despite substantial improvements in head and neck squamous cell carcinoma (HNSCC) treatment, the major obstacle to long-term survival remains disease recurrence. Salvage options are often limited due to prior therapy and the escalated morbidity of retreatment. The costs of treatment must be measured against the anticipated quality and quantity of life recovered, even with resectable disease. This review surveys the recurrent HNSCC literature to better guide decision making. Across multiple studies, negative prognostic factors include impaired performance status, advanced recurrent stage, brief disease-free interval, previous chemotherapy, and nonlaryngeal sites of recurrence. When possible, surgical salvage remains the principal option for durable disease control, quality of life preservation, and cure. Nonsurgical therapies have also demonstrated measurable improvements in locoregional control. Interpretation of salvage literature must be tempered by recognition of significant selection bias. The decision for salvage therapy must be individualized, with management that involves well-informed patients resulting in the best outcomes.

Surgical resection for esophageal cancer synchronously or metachronously associated with head and neck cancer

BACKGROUND

Esophageal cancer is frequently associated with head and neck cancer, and esophagectomy is usually difficult in such a case. The purpose of this study was to clarify the clinical significance of esophagectomy for patients with esophageal cancer associated either synchronously or metachronously with head and neck cancer.

METHODS

The clinical outcomes of surgical resections for esophageal cancer were compared between 26 patients with head and neck cancer (double cancer group) and 176 without head and neck cancer (control group).

RESULTS

Staged operations were performed in 5 patients in the double cancer group, while microvascular anastomosis as well as a muscle flap was added for 3 and 4 patients, respectively. The mortality and morbidity of the double cancer group were 0 and 35 %, respectively, which were not significantly different from those of the control group (3 and 31 %, respectively). There were no significant differences in overall survival in the double cancer and control groups, which had 5-year survival rates of 59 and 49 %, respectively.

CONCLUSIONS

Esophagectomy can be an effective treatment when techniques are adopted that are appropriate for each case, such as staged operations, muscular flaps, and microvascular anastomosis, even in patients with double cancers of the esophagus and the head and neck.

Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy

OBJECTIVE

To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma.

MATERIALS/METHODS

A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated.

RESULTS

33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively).

CONCLUSION

Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.

Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy

PURPOSE OF REVIEW

The present review is focused on the main reconstructive options currently used after partial or circumferential resection of the hypopharynx and cervical esophagus. The advantages and disadvantages of pectoralis major myocutaneous (PMMC) pedicled flap, fasciocutaneous free flaps as radial forearm and anterolateral thigh (ALT), and visceral free grafts like jejunum and gastro-omental are overviewed.

RECENT FINDINGS

For partial hypopharyngeal defects with limited extension to the cervical esophagus, no specific pedicled or free flap is deemed superior over others: the patient's body habitus and surgeon's preference remain the most important factors affecting the reconstructive choice. In contrast, after circumferential hypopharyngectomy, pharyngocutaneous fistula (PCF) and stricture rates of PMMC are higher than those obtained by free flaps. In the most recent series applying ALT and jejunum, PCF and stricture occurrence is comparable, whereas reduced mortality, overall complication rate, and donor-site morbidity of ALT and its better swallowing and speech outcomes have contributed to make this option progressively more popular. On the other hand, gastro-omental seems to offer an unparalleled amount of highly vascularized tissue to manage the difficult situation of salvage surgery after chemoradiation, even though complication rates remain not negligible and this technique has not been widely adopted.

SUMMARY

The reconstructive armamentarium of head and neck surgeons involved in hypopharyngeal and cervical esophagus reconstruction should encompass every option described herein in order to appropriately deal with specific clinical needs and patient requirements. However, fasciocutaneous free flaps (especially ALT) seem to play an ever greater role in restoration of pharyngoesophageal continuity.

Current reconstructive techniques following head and neck cancer resection using microvascular surgery

Various techniques have been developed to reconstruct head and neck defects following surgery to restore function and cosmetics. Free tissue transfer using microvascular anastomosis has transformed surgical outcomes and the quality of life for head and neck cancer patients because this technique has made it possible for surgeons to perform more aggressive ablative surgery, but there is room for improvement to achieve a satisfactory survival rate. Reconstruction using the free tissue transfer technique is closely related to cardiovascular surgery because the anastomosis techniques used by head and neck surgeons are based on those of cardiovascular surgeons; thus, suggestions from cardiovascular surgeons might lead to further development of this field. The aim of this article is to present the recent general concepts of reconstruction procedures and our experiences of reconstructive surgeries of the oral cavity, mandible, maxilla, oropharynx and hypopharynx to help cardiovascular surgeons understand the reconstructions and share knowledge among themselves and with neck surgeons to develop future directions in head and neck reconstruction.