Coloplasty and free intestinal transplants in the treatment of extensive cancers of the pharyngo-oesophageal junction

Summary The authors report their surgical experiences with 55 extensive tumours of the pharyngoesophageal junction. Thirty-three of these cases were managed by circular pharyngolaryngectomy, total oesophagectomy with stripping and left coloplasty, and 22 were treated with circular pharyngolaryngectomy with free intestinal transplants. A comparative study of the post-operative courses of the patients and their oncological and functional outcomes shows the advantages, disadvantages and indications of these two techniques.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

Reconstruction of circumferential pharyngolaryngectomy using a 'horseshoe-shaped' pectoralis major myocutaneous flap

Eighteen patients underwent a circumferential pharyngolaryngectomy reconstruction post pharyngolaryngectomy. All tumours showed pharyngo-oesophageal junction invasion or circular involvement of the hypopharynx, requiring total, circumferential pharyngolaryngectomy. A pectoralis major myocutaneous flap was directly sutured to the pre-vertebral fascia. A Montgomery salivary bypass tube was introduced into the oesophagus, and a nasogastric tube was placed within it. No post-operative complications occurred for 14 patients and only minor ones for the other four. Average post-operative stay was 12 days. For 15 patients, feeding returned to normal throughout the follow-up period. No fistulae were noted and neopharyngeal stenosis occurred in three patients (16 per cent). Thirteen had complete resection with normal margins. Thirteen were still alive after one to three years of follow up. The local recurrence rate was 16 per cent. The use of a pectoralis major myocutaneous flap with Spriano's technique provides a simple, reliable method for circumferential hypopharyngeal resection. It has been applied to a wide range of patients, especially elderly ones and those with poor general status, as well as to cases in which widespread involvement was detected during surgery.     

The voice of laryngectomized patients after receiving colonic or other intestinal transplant]

This study reports the experience of our Rehabilitation Centre for laryngectomees un Albi regarding the acquisition of an esophageal voice in cases of circular total pharyngolaryngectomy, with restoration of continuity through intestinal or colic transplantation. Among eight rehabilitated patients, we obtained six good results with a voice allowing a conversation easily understood by relatives and friends. Thus, we think this continuity restoration method gives good phoniatric results.     

Rehabilitation of the voice after pharyngolaryngectomy and skin repair. I: Cineradiography

Eleven patients who had undergone pharyngolaryngectomy and who had poor or no speech were studied to find out why. An absent oesophageal stripping wave and the presence of a ‘sump effect’ are described. It is concluded that these are two positive anatomical factors mitigating against the acquisition of oesophageal speech in pharyngolaryngectomized patients.     

Evaluation of total pharyngolaryngectomy for hypopharyngeal cancer.

In 37 patients with hypopharyngeal cancer treated by total pharyngolaryngectomy and radical neck dissection, the 5 year cure rate was 30%. Among these patients, T-1 and T-2 tumors had a 57% and 47% 5 year cure rate respectively. Better results were obtained in those patients with tumor of the posterior pharyngeal wall and tumor of sinus pyriformis extending toward postcricoid region or toward the larynx. In 14 patients treated with various approaches of partial pharyngolaryngectomy, the 5 year cure was 53%. It is concluded that the conservation surgery is the operation of choice for the tumors of T-1 and T-2 in securing the total cure and preserving the laryngeal function.     

Functional speech outcomes after laryngectomy and pharyngolaryngectomy

OBJECTIVE: To compare and contrast functional speech outcomes of patients having undergone total laryngectomy and pharyngolaryngectomy who use tracheoesophageal speech as their primary mode of communication. DESIGN: Group comparison design. SETTING: Adult acute tertiary care hospital. PATIENTS: Thirty patients who underwent total laryngectomy and 13 who underwent pharyngolaryngectomy with free jejunal interposition reconstruction. All patients used tracheoesophageal speech. INTERVENTION: Group comparisons across measures of speech intelligibility, voice quality, tracheoesophageal speech use, voice satisfaction and levels of perceived voice disability, handicap, and well-being/distress. MAIN OUTCOME MEASURE: The existence of any significant differences between the 2 groups on measures of intelligibility, voice quality, tracheoesophageal speech use, and voice satisfaction and levels of voice disability, handicap, and well-being/distress. RESULTS: Statistical comparisons confirmed reduced functional intelligibility (P<.05), reduced vocal quality (P<.01), and higher levels of disability (P<.05) in the pharyngolaryngectomy group. However, no significant difference was observed between the proportion of patients classified as "successful" tracheoesophageal speech users in either group. Low levels of handicap and high levels of patient well-being were recorded in both groups. CONCLUSION: Despite the perceptual differences in voice quality and intelligibility observed between the 2 groups, tracheoesophageal speech that is functional, effective, and perceived by the patients as satisfactory can be achieved after total laryngectomy and pharyngolaryngectomy with free jejunal interposition reconstruction.     

Rehabilitation of the voice after pharyngolaryngectomy and skin repair. I. Cineradiography.

Eleven patients who had undergone pharyngolaryngectomy and who had poor or no speech were studied to find out why. An absent oesophageal stripping wave and the presence of a 'sump effect' are described. It is concluded that these are two positive anatomical factors mitigating against the acquisition of oesophageal speech in pharyngolaryngectomized patients.     

Reconstruction after pharyngolaryngooesophagectomy using delto-pectoral flap

Fifty patients with hypopharyngeal cancer treated with total pharyngolaryngectomy and staged reconstruction using delto-pectoral flaps in the years from 1967–1976 were studied. The main complications were fistulae and stricture formation; these are described. The hospital mortality was low, and postoperative deaths only occurred in previously irradiated patients. The crude 5-year survival was 35%.     

Voice restoration after circumferential pharyngolaryngectomy with free jejunum repair

Speech restoration after circumferential pharyngolaryngectomy with free jejunal repair for advanced tumors of the hypopharyngo-esophageal tract remains a difficult problem to solve. We report here the results of secondary voice restoration in six patients who received a Provox 2 type prosthesis and intensive speech therapy after circumferential pharyngolaryngectomy with free jejunum repair. No patient had operative or post-operative complications due to insertion of the prosthesis. No patient had to have the prosthesis removed during the follow-up (8 to 14 months). Analysis of some acoustic parameters of voice (fundamental frequency, waveform perturbations) and qualitative characteristics of speech (intelligibility, pleasantness and acceptability) demonstrated that all the patients were able to produce satisfactory speech after tracheojejunum puncture and speech therapy and were satisfied with their own ability to communicate. Our results are reassuring and we therefore advise that in patients undergoing free jejunum flap reconstruction of the hypopharyngo-esophageal tract voice restoration should be attempted by placing a voice prosthesis through a secondary tracheo-esophageal puncture and providing intensive speech training. Received: 17 December 1998 / Accepted: 29 January 2001     

Total pharyngolaryngectomy for squamous cell carcinoma of the hypopharynx: a review

OBJECTIVES: To evaluate our experience with total pharyngolaryngectomy in the treatment of hypopharyngeal squamous cell carcinoma. STUDY DESIGN: Retrospective analysis of consecutively treated patients in an academic otolaryngology, head and neck department. METHODS: One hundred eighty patients who had total pharyngolaryngectomy performed for hypopharyngeal carcinoma were included in this study. Patients with a history of previous head and neck cancer were excluded. Clinicopathologic parameters were recorded and survival calculated using the Kaplan-Meier method. RESULTS: One hundred sixty-two (90%) of the patients were male, and the patients had a mean age of 62 years. The majority (91%) of patients had advanced overall clinical stage disease (stage 3,4). Thirty-one (17.8%) and 43 (24%) patients developed locoregional and metastatic disease recurrence, respectively. The 2- and 5-year disease-specific survival rates were 72% and 52%, respectively. Advanced nodal stage, perineural invasion, lymphovascular invasion, and positive margins were predictors of poor survival on univariate analysis, and lymphovascular invasion was an independent prognostic factor on multivariate analysis. CONCLUSION: Surgery and postoperative radiotherapy remains the treatment against which other modalities should be compared for advanced stage hypopharyngeal squamous cell carcinoma.     

Subtotal pharyngolaryngectomy conservation surgery for carcinoma of sinus pyriformis extending toward the larynx.

In newly developed surgery for pyriform sinus tumor extending toward the larynx, the supraglottic portion of the larynx and the vertical half of the larynx on the tumor side are included in the area of resection. The arytenoid and cricoid cartilages on the tumor side and the vertical half of the hypopharyngeal wall are resected. Three out of seven patients remain cured at the end of 5 years and this ratio is the same as that for total pharyngolaryngectomy for pyriform sinus tumor. The resulting voice is somewhat hoarse, however, verbal communication is not remarkably affected. It is concluded that in surgical repair for pyriform sinus tumor extending toward the larynx, subtotal pharyngolaryngectomy is the procedure of choice to preserve the laryngeal function and anticipate reasonable prospects for a cure.     

Delayed pharyngoesophageal reconstruction with combined local and regional flaps: a case report

We describe an unusual technique for performing delayed pharyngoesophageal reconstruction following circumferential pharyngolaryngectomy. The patient was a 52-year-old man who underwent a circumferential pharyngolaryngectomy for the treatment of hypopharyngeal carcinoma. In view of the patient's poor clinical status, we opted to perform a pharyngostomy and an esophagostomy and to postpone pharyngoesophageal reconstruction for a more appropriate occasion. After the patient's clinical condition had sufficiently improved, the repair was planned. Microsurgical flaps were contraindicated because the blood flow through the cervical vessels was unreliable. Pharyngoesophageal continuity was restored with a cervical flap vascularized by the prevertebral fascia, a pectoralis major myocutaneous flap, and a deltopectoralis flap. A reasonable degree of deglutition was achieved, and no signs of stricture were detected. Although our technique was unusual, we believed that it might provide a valid alternative when a delayed pharyngoesophageal reconstruction is required and free flaps are contraindicated for any reason.     

Free flap combined with pectoralis major flap for reconstruction after total laryngopharyngectomy in patients with advanced hypopharyngeal carcinoma

Conclusion: The findings suggest that a pectoralis major flap combined with a free flap is a safe and reliable method of reconstruction after total pharyngolaryngectomy; with this technique, one can help these patients remain disease free, with normal swallowing function, for a relatively acceptable survival duration. Objectives: To determine the functional and oncological outcomes of a combined flap for the extensive defects after total pharyngolaryngectomy in patients with advanced squamous cell carcinoma of the hypopharynx (SCCHP). Method: This study determined the perioperative morbidity and functional and oncologic outcomes of 21 patients with advanced SCCHP who underwent total laryngopharyngectomy and reconstruction using a combination of a pectoralis major flap and a free flap. Results: The free flap and pectoralis major flap were used to reconstruct the defects for all 21 patients. Fourteen patients were reconstructed with jejunal free flaps and pectoralis major flaps; in the remaining seven patients, anterolateral thigh flaps and pectoralis major flaps were used. All the combined flaps worked well, and patients recovered normal swallowing function a mean 19.4 days after surgery. After an overall mean follow-up time of 31.3 months, 30% of patients were still alive at the time of this analysis, with no evidence of disease.     

Swallowing outcomes following laryngectomy and pharyngolaryngectomy

OBJECTIVES: To determine the incidence of dysphagia (defined as the inability to manage a diet of normal consistencies) at hospital discharge and beyond 1 year postsurgery and examine the impact of persistent dysphagia on levels of disability, handicap, and well-being in patients. DESIGN: Retrospective review and patient contact. SETTING: Adult acute care tertiary hospital. PATIENTS: The study group, consecutively sampled from January 1993 to December 1997, comprised 55 patients who underwent total laryngectomy and 37 patients who underwent pharyngolaryngectomy with free jejunal reconstruction. Follow-up with 36 of 55 laryngectomy and 14 of 37 pharyngolaryngectomy patients was conducted 1 to 6 years postsurgery. MAIN OUTCOME MEASURES: Number of days until the resumption of oral intake; swallowing complications prior to and following discharge; types of diets managed at discharge and follow-up; and ratings of disability, handicap, and distress levels related to swallowing. RESULTS: Fifty four (98%) of the laryngectomy and 37 (100%) of the pharyngolaryngectomy patients experienced dysphagia at discharge. By approximately 3 years postsurgery, 21 (58%) of the laryngectomy and 7 (50%) of the pharyngolaryngectomy patients managed a normal diet. Pharyngolaryngectomy patients experienced increased duration of nasogastric feeding, time to resume oral intake, and incidence of early complications affecting swallowing. Patients experiencing long-term dysphagia identified significantly increased levels of disability, handicap, and distress. Patients without dysphagia also experienced slight levels of handicap and distress resulting from taste changes and increased durations required to complete meals of normal consistency. CONCLUSIONS: The true incidence of patients experiencing a compromise in swallowing following surgery has been underestimated. The significant impact of impaired swallowing on a patient's level of perceived disability, handicap, and distress highlights the importance of providing optimal management of this negative consequence of surgery to maximize the patient's quality of life.     

Supracricoid hemilaryngopharyngectomy in selected pyriform sinus carcinoma staged as T2

From 1964 to 1985 supracricoid hemilaryngo-pharyngectomy (SCHLP) was performed at the authors' institution for 34 selected pyriform sinus carcinomas staged as T2. Tumors involved the anterior part of the pyriform sinus, the lateral wall, the medial wall, and the whole aryepiglottic fold in all cases. Tumors with invasion of the apex of the pyriform sinus, of the retrocricoid region, of the posterior pharyngeal wall, or with fixation of the true vocal cord were excluded from the study. Such a technique was aimed at preserving physiologic phonation, respiration, and swallowing while achieving the same local control rate as pharyngolaryngectomy. Patients were monitored for at least 6 years or until death. No patients were lost to follow-up. The 5-year cause-specific survival rate was 55.8%. The main cause of death was second primary tumor. The 5-year actuarial local recurrence rate was 3.4%. The authors' experience with the SCHLP technique challenges the traditional teaching of pharyngolaryngectomy and establishes this technique as a safe method of voice preservation in selected cases of pyriform sinus carcinomas.     

Surgery for radiation-induced carcinoma of the hypopharynx

Eighteen radiation-induced tumors of the hypopharynx examined during a 20-year period are described. These tumors represent slightly less than 5 per cent of all tumors of the hypopharynx examined during the same period. Most were due to irradiation for thyrotoxicosis, and the mean latent period was 35 years. Five patients were not treated, and 13 patients were treated, mainly by pharyngolaryngectomy followed by skin flap repair (deltopectoral or pectoralis major). Despite a fairly high complication rate, an adjusted five-year survival of 35 per cent was achieved.     

Esophagotracheal fistula of the cervico-thoracic area--problem solution using a combined trans-cervical and transthoracic approach]

Closure of oesophagotracheal fistulae in the cervicothoracic region using a cervical approach often fails. We report a patient with carcinoma of the larynx who underwent pharyngolaryngectomy, postoperative radiotherapy and several operations for reconstruction of the hypopharynx and cervical oesophagus elsewhere. Finally we were asked to close an oesophagotracheal fistula in the cervicothoracic region. We were successful using a pectoralis major muscle flap via a combined transcervical-transthoracal approach. This interdisciplinary procedure seems to be the method of choice in difficult cases of achieving safe closure of fistulae in this region.     

Assessment of swallowing function after circumferential pharyngolaryngectomy. A multicenter study by the GETTEC group

Objective

Circumferential pharyngolaryngectomy is performed for advanced pharyngeal tumor or in a context of postradiation recurrence. Several free or pedicle flaps have been described for pharyngeal defect reconstruction, with choice at the surgeon's discretion. The aim of this study was to evaluate long-term swallowing function according to the type of flap used for reconstruction.

A “watch window” technique for monitoring buried free jejunum flaps during circumferential pharyngolaryngectomy reconstruction

The free jejunum flap approach is the optimal option for circumferential pharyngolaryngectomy reconstruction. In this study, we designed a “watch window” for monitoring buried free jejunum flaps, thereby allowing us to assess graft viability. From 2007 to 2011, 14 patients with hypopharyngeal cancer underwent circumferential pharyngolaryngectomy that was reconstructed using a free jejunum flap at the Sun Yat-sen University Cancer Centre. During the closing of the neck incision, a “watch window” was designed for postoperative monitoring. Two patients experienced thrombosis of the pedicle. One was detected early and successfully rescued by removal of the thrombosis, the other one managed with a second free jejunum flap. The success rate of the buried flaps was 92.9%. No pharyngocutaneous fistulas or strictures occurred. All patients eventually resumed oral feeding and swallowing. The “watch window” technique for monitoring buried free jejunum flaps is simple, reliable and useful for finding vascular problems. Level of evidence Case series     

New Options for Aerodigestive Tract Replacement After Extended Pharyngolaryngectomy

Objectives Assess the results of a new type of reconstruction of the aerodigestive tract after extended pharyngolaryngectomy. Study Design Follow‐up of a total of eight patients who had surgery using ileocolic free graft. Methods The surgical technique is described. Five patients underwent pharyngolaryngectomy/cervical esophagectomy, and three patients had total laryngectomy with subtotal pharyngectomy. Patients were monitored to assess complications and recovery of satisfactory swallowing and speech. Results The technique, thanks to the use of material from the colon, proved to be extremely useful for the reconstruction of the digestive tract. At the same time, ileal anastomosis with the tracheal stump enabled aerodigestive crossing restoration, protected by the ileocecal valve. All patients recovered good swallowing capacity and phoniatric expression, which were obtained by digital occlusion of the tracheostomy, forcing the expiratory air through the ileum and ileocecal valve. Manometric tests also showed that after a while there was a gradual synchronization of swallowing between the transplanted colic segment and the residual esophagus. Conclusions The technique described in the present study may be regarded, also in the light of possible further applications, as a new and interesting option for the reconstruction of the aerodigestive tract.