Abstract
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.
1
Introduction
Carcinoma of the hypopharynx is associated with the poorest survival of all head and neck primary sites, primarily because tumors of this region typically remain silent until disease has reached an advanced stage. Approximately 80% of hypopharyngeal cancer is stage III or IV at presentation and often invade cervical esophagus. Similarly, cervical esophageal cancer is also a very aggressive cancer with a poor prognosis.
These 2 kinds of cancer both have similar characteristics with the high incidence of multifocal mucosal involvement and the high incidence of submucosal lymphatic spread . For this reason, the best opportunity for local control of hypopharyngeal cancer invading cervical esophagus and cervical esophageal cancer depends on complete extirpation of the esophagus. Total pharyngolaryngoesophagectomy (PLE) and gastric pull-up reconstruction are reliable methods of reconstruction for resection of the carcinoma. Their advantage is not only complete extirpation of the esophagus, but also there is a single anastomosis in the cervical area . However, it still has a significantly high morbidity and mortality.
The purpose of the study is to review the complication after gastric pull-up reconstruction in patients with hypopharyngeal cancer invading cervical esophagus and cervical esophageal cancer in a Chinese institute.
2
Materials and methods
This study and its methods have been approved by the institutional review board.
2.1
Data collection
We reviewed retrospectively the medical records and follow-up data of all patients who underwent PLE and gastric pull-up reconstruction for squamous cell carcinoma of hypopharyngus invading cervical esophagus and cervical esophagus identified from the computerized database at the Department of Head and Neck Surgery of the Affiliated Provincial Hospital of Anhui Medical University in China from 1988 to 2007. Clinical data were obtained for all patients using the clinical record notes. Those cases who underwent resection of the total esophagus and were reconstructed by colonic transposition or other techniques were not included.
2.2
Patient characteristics
A total of 208 patients were reviewed. Of 208 patients, 124 patients had hypopharyngeal carcinoma invading cervical esophagus; and 84 patients had cervical esophageal carcinoma. All patients consented to the reconstruction technique before surgery. All patients underwent preoperative evaluation and received nutritional support after the operation. Follow-up was continued until death, and only patients who died of esophageal carcinoma were included in the tumor-related deaths. The interval of the follow-up after operation ranged from 2 years to 15 years and 2 months with a mean of 4 years and 8 months.
2.3
Operative procedures
Surgical resection was performed by 2 teams: the head and neck team and the abdominal surgical team.
2.3.1
The head and neck team procedures
Because of the high incidence of lymphatic spread of this kind of cancer, bilateral neck dissection is mandatory and performed first. Lymph nodes are resected from the upper mediastinum through the cervical expose. The extent of pharyngeal resection, partial or total, is dictated by the site and local extent of the primary. The larynx is removed to minimize the recurrence and morbidity related to it.
2.3.2
The abdominal surgical team procedures
When the head and neck team determines that the tumor is resectable, the second team begins the abdominal portion of the procedure. The mobilization of the stomach is accomplished by dividing the left gastric, left short gastric, and left gastroepiploic arteries and veins. The right gastric and right gastroepiploic vessels are preserved. Blunt dissection around the esophagus is done from the thoracic inlet above and hiatus below for complete mobilization of the oesophagus. If necessary, pyloromyotomy or pyloroplasty is performed to achieve adequate gastric drainage. Most of the peritracheal dissection can be performed under direct vision because of the wide cervical exposure available after bilateral neck dissection, laryngectomy, and superior mediastinal dissection. The stomach is brought up through the posterior mediastinum into the neck, and pharyngogastric anastomosis is performed.
A jejunostomy tube is brought out through the abdominal wall after full mobilization and advancement of the gastric tube. A nasogastric tube is placed to facilitate decompression of the gut. A cervical drainage is placed around the pharyngogastgric anastomosis.
2.3.3
Postoperative management
After no leakage shown by gastrograffin swallowing for 7 days, the nasogastric tube is removed and an oral diet is begun. If the condition of the patient precludes early resumption of oral intake, then total parenteral nutrition via a central venous catheter can be used during the interim. Patients are advised to swallow a small amount of their meal and to sit in an upright position after the meal for about 30 minutes during the early postoperative period. The cervical drainage tube is removed when there is no liquid drainage.
2
Materials and methods
This study and its methods have been approved by the institutional review board.
2.1
Data collection
We reviewed retrospectively the medical records and follow-up data of all patients who underwent PLE and gastric pull-up reconstruction for squamous cell carcinoma of hypopharyngus invading cervical esophagus and cervical esophagus identified from the computerized database at the Department of Head and Neck Surgery of the Affiliated Provincial Hospital of Anhui Medical University in China from 1988 to 2007. Clinical data were obtained for all patients using the clinical record notes. Those cases who underwent resection of the total esophagus and were reconstructed by colonic transposition or other techniques were not included.
2.2
Patient characteristics
A total of 208 patients were reviewed. Of 208 patients, 124 patients had hypopharyngeal carcinoma invading cervical esophagus; and 84 patients had cervical esophageal carcinoma. All patients consented to the reconstruction technique before surgery. All patients underwent preoperative evaluation and received nutritional support after the operation. Follow-up was continued until death, and only patients who died of esophageal carcinoma were included in the tumor-related deaths. The interval of the follow-up after operation ranged from 2 years to 15 years and 2 months with a mean of 4 years and 8 months.
2.3
Operative procedures
Surgical resection was performed by 2 teams: the head and neck team and the abdominal surgical team.
2.3.1
The head and neck team procedures
Because of the high incidence of lymphatic spread of this kind of cancer, bilateral neck dissection is mandatory and performed first. Lymph nodes are resected from the upper mediastinum through the cervical expose. The extent of pharyngeal resection, partial or total, is dictated by the site and local extent of the primary. The larynx is removed to minimize the recurrence and morbidity related to it.
2.3.2
The abdominal surgical team procedures
When the head and neck team determines that the tumor is resectable, the second team begins the abdominal portion of the procedure. The mobilization of the stomach is accomplished by dividing the left gastric, left short gastric, and left gastroepiploic arteries and veins. The right gastric and right gastroepiploic vessels are preserved. Blunt dissection around the esophagus is done from the thoracic inlet above and hiatus below for complete mobilization of the oesophagus. If necessary, pyloromyotomy or pyloroplasty is performed to achieve adequate gastric drainage. Most of the peritracheal dissection can be performed under direct vision because of the wide cervical exposure available after bilateral neck dissection, laryngectomy, and superior mediastinal dissection. The stomach is brought up through the posterior mediastinum into the neck, and pharyngogastric anastomosis is performed.
A jejunostomy tube is brought out through the abdominal wall after full mobilization and advancement of the gastric tube. A nasogastric tube is placed to facilitate decompression of the gut. A cervical drainage is placed around the pharyngogastgric anastomosis.
2.3.3
Postoperative management
After no leakage shown by gastrograffin swallowing for 7 days, the nasogastric tube is removed and an oral diet is begun. If the condition of the patient precludes early resumption of oral intake, then total parenteral nutrition via a central venous catheter can be used during the interim. Patients are advised to swallow a small amount of their meal and to sit in an upright position after the meal for about 30 minutes during the early postoperative period. The cervical drainage tube is removed when there is no liquid drainage.
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