Complications following gastric transposition after total laryngo-pharyngectomy

Larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction: A promising treatment for selected cervical esophageal squamous cell carcinoma

BACKGROUND/AIMS

There is no consensus on treatment for cervical esophageal squamous cell carcinoma (ESCC). Our aim is to evaluate the feasibility and outcome of larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction for the treatment of cervical ESCC without tumor involvement of the larynx and hypopharynx.

MATERIALS AND METHODS

Retrospective analysis of patients with cervical ESCC who underwent R0 surgical resection from 2006 to 2011 in our center was performed. Kaplan-Meier method was used to calculate the survival time for patients.

RESULTS

In total, 74 cervical ESCC patients were enrolled in the study. The mortality rate in 30 days was 8.1%, the total complication rate (at least one) was 47.3%, anastomosis leakage occurrence was 37.8%, mechanical ventilation ratewas12.2%, the rate of normal oral diet within 15 days was 71.6%, and the anastomosis recurrence rate in follow-up was 8.1%. Detailed analysis showed that the anastomosis leakage, pulmonary infection, laryngeal recurrent nerve injury, and chylothorax were the most common complications in surgical patients. Finally, the survival data showed that the median survival time was 31.83 months (95% CI=12.39-51.28 months) and the 3-year and 5-year survival rates were 49.1% and 35.5%, respectively.

CONCLUSION

Larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction might be a feasible and effective surgical alternative for the cervical ESCC patients whose tumor does not involve the larynx and hypopharynx.

Outcomes and prognostic factors for patients with cervical esophageal cancer undergoing definitive radiotherapy or chemoradiotherapy

Cervical esophageal cancer (CEC) is uncommon, accounting for less than 5% of all esophageal cancers. The management of CEC is controversial. This study investigated treatment outcomes and prognostic factors of survival in CEC patients undergoing definitive radiotherapy or concurrent chemoradiotherapy (CCRT). Ninety-one CEC patients were treated by intensity-modulated radiation therapy (IMRT) and three-dimensional conformal radiation therapy (3DCRT) between July 2007 and September 2017. The mean prescription dose was 64 Gy (range 54-70 Gy) delivered as 1.8-2.2 Gy per fraction per day, 5 days a week. Out of 91 patients, 34 received concurrent cisplatin-based chemotherapy (CT) including 18 patients who also received neoadjuvant CT. Overall survival (OS), locoregional failure-free survival (LRFFS), and progression-free survival (PFS) were estimated by the Kaplan-Meier method. Prognostic factors of survival were determined in univariate (log-rank test) and multivariate (Cox proportional hazard model) analysis. Treatment-related toxicity was also assessed. Median follow-up time for all patients was 19 months. Two-year OS, LRFFS and PFS of all patients were 58.2%, 52.5% and 48.1%, respectively. Clinical stage was an independent prognostic factor for OS (HR = 2.35, 95% CI: 1.03-5.37, p = 0.042), LRFFS (HR = 3.84, 95% CI: 1.38-10.69, p = 0.011), and PFS (HR = 2.68, 95% CI: 1.11-6.45, p = 0.028). Hoarseness was an independent prognostic factor for OS (HR = 2.10, 95% CI: 1.05-4.19, p = 0.036). CCRT was independently associated with better LRFFS (HR = 0.33, 95% CI: 0.14-0.79, p = 0.012). 3DCRT and IMRT with concurrent CT is well-tolerated and may improve local tumor control in CEC patients. Advanced clinical stage and hoarseness are adverse prognostic factors for OS, LRFFS, and PFS in CEC.

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.

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.

External monitoring of buried radial forearm free flaps in hypopharyngeal reconstruction

CONCLUSION

The radial forearm free flap (RFFF) is one of the optimal choices for hypopharyngeal reconstruction. Our series demonstrates that the technique of an indicator flap for the monitoring of the buried flap is simple, reliable, and inexpensive. The condition of the indicator flap can be easily interpreted by the physicians and the nursing staff. Therefore, the success rate of this microsurgical reconstruction may be improved.

OBJECTIVES

The RFFF is increasingly applied in reconstruction of the hypopharynx after radical resection for advanced hypopharyngeal cancer. However, postoperative monitoring of the buried free flap is extremely difficult. We designed a small external component as an indicator flap to monitor the perfusion of the buried vascular pedicle.

METHODS

Eight consecutive patients with hypopharyngeal cancer underwent radical surgery and hypopharyngeal reconstruction using RFFF at the Sun Yat-sen University Cancer Center between January 2005 and January 2007. The indicator flap was sutured to the surface of the neck for postoperative monitoring.

RESULTS

All of the indicator flaps remained viable. One patient experienced vascular compromise and was successfully salvaged. The success rate of the buried flaps was 100%. Pharyngocutaneous fistula occurred in one patient. All patients resumed an oral diet eventually.

Results after radical surgical treatment for advanced carcinoma of hypopharynx

The aim of the study was to investigate patients with hypopharyngeal cancer. And this study focuses on a case series with hypopharynx cancer and cervical oesophageal cancer invading the hypopharynx. There were 13 cases over a period of 8 years, treated with pharyngo-laryngo-esophagectomy (PLE) and cervical lymph node dissection. In 10 of the patients, reconstruction was done with gastric pull-up (GP). In 3 of the 10 patients gastric reconstruction was added to aid in pyloric drainage (2 pyloromyotomy and 1 pyloroplasty) but the remaining 7 patients did not receive such procedures. The reconstruction of the digestive system after PLE is still a matter of debate. GP method is the most frequently preferred method for reconstruction. We believe that a more important problem than gastric drainage is the reflux of the gastric content and pyloric drainage which will not have a positive effect for solving this clinical situation. But we need bigger series for analyze of this specific condition.

Reconstruction of the hypopharynx after surgical treatment of squamous cell carcinoma

Squamous cell carcinoma of the hypopharynx (HPSCC) tends to present with an advanced stage. Surgery with postoperative radiation or chemoradiation therapy has been the standard treatment for HPSCC. Radical surgery may result in a large surgical defect of the hypopharyngeal and cervical esophageal regions. Reconstruction of the surgical defect is also important after ablation procedures. Many reconstructive methods have been developed. However, each method has its own advantages and disadvantages. The ideal method for hypopharyngeal reconstruction should have the following attributes if possible: single-stage procedure, high success rate of tissue transfer, low donor-site morbidity, low fistula and stenosis rates, restoration of the ability to speak and swallow, able to achieve successful reconstruction in a heavily radiated area and tolerance of postoperative radiotherapy. In this review article, we discuss the indications and drawbacks of several reconstructive methods that have been frequently used in our clinical practice. Finally, we will introduce the technique of laryngotracheal flap reconstruction, which was developed in our institution and has proved to be a simple and reliable method for hypopharyngeal reconstruction.

Sudden death after major head and neck surgery

PURPOSE OF REVIEW

This review will discuss the mortality after major ear, nose and throat surgery, particularly sudden death. It will also discuss the postoperative follow-up of patients.

RECENT FINDINGS

Sudden death is a rare event after major ear, nose and throat surgery, and occurs mainly during the first three postoperative days.

SUMMARY

In more recent studies, the mortality rate after neck dissection was below 4%, which is at a lower value than reported in previous studies. Sudden deaths have been described, however, mainly during the first three postoperative days. Alcoholism and perioperative hypotension are two predictive factors for cardiac complications. Careful follow-up of these patients during the early postoperative period should be performed to reduce the mortality by shortening the delay of care.

[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.