Surgical Treatment Resection

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The difficulty in surgical treatment of advanced carcinoma of the hypopharynx and cervical esophagus arises from the common requirement for laryngectomy as part of the procedure. The larynx is removed because of direct or submucosal tumor extension and significant risk of chronic or life-threatening aspiration. Histopathologic studies of hypopharyn-geal cancer have shown that assessment of the extent of laryngeal disease based on endoscopic findings in the hypopharynx is inaccurate.50 Therefore, laryn-geal conservation surgery for hypopharynx cancer risks a high incidence of positive margins. However, for the rare patient who presents with early-stage hypopharyngeal disease, laryngeal preservation surgery can be performed with excellent functional results.51 Endoscopic pharyngectomy is possible for small lesions that are easily accessible through an operating laryngoscope. Partial pharyngectomy for posterior pharyngeal or small lateral pharyngeal lesions can be approached through a lateral or tran-shyoid pharyngotomy.52

Partial laryngopharyngectomy (PLP) is indicated for lesions of the pyriform sinus that invade the lateral hypopharyngeal wall and consists of resecting half the larynx and half the hypopharynx (Figure 10-6). The lesion should be confined to the ipsilateral pyri-form sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false vocal fold. The hyoid bone, thyroid ala, arytenoid cartilage, epiglottis, aryepiglottic fold, arytenoid eminence and false fold are removed on the affected side. Hemi- and supra-cricoid laryngopharyngectomy can be performed for hypopharynx tumors involving the aryepiglottic fold, and anterior, medial, and lateral wall of the pyriform sinus.53 The surgical specimen includes the ipsilateral half of the hypopharynx, larynx, and cricoid ring (Figure 10-7). Contraindications to these procedures include invasion of the pyriform sinus apex or post-cricoid region, invasion of the posterior pharyngeal wall, and vocal cord paralysis.

Figure 10-6. Fiberoptic endoscopic appearance of a patient with a carcinoma of the right pyriform sinus suitable for a partial laryn-gopharyngectomy.

Pearson's near-total laryngectomy with permanent tracheopharyngeal shunt (NTL-PTPS) has been used successfully by a limited number of clinicians with good locoregional control rates and infrequent aspira-tion.54 Lung-powered "shunt" speech is acquired in many patients following this procedure. The major disadvantage of partial laryngopharyngectomy is an inability to predict postoperative speech and swallowing function, although newer reconstructive techniques may improve outcome.55

Many patients are not amenable to partial laryn-geal or pharyngeal surgery and require total laryn-gectomy in combination with total or partial pharyn-gectomy and cervical esophagectomy via a cervical approach. Larynx-preserving procedures with resection of the cervical esophagus via median ster-notomy or trans-tracheal approach have been described.56 The major risk of esophagectomy without laryngectomy is uncontrollable aspiration. Trans-hiatal esophagectomy can be performed in combination with laryngopharyngoesophagectomy when there is tumor extension below the cervical esophagus or second esophageal primary malig-nancy.57 Frozen-section evaluation should be obtained due to submucosal tumor extension. Bilateral neck dissections should be performed at resection because of the high risk of regional lymph node metastases.58 A selective neck dissection of levels II, III, and IV is appropriate in the clinically negative


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Figure 10-7. Operative specimen of the patient in Figure 10-6 shows the extent of resection at partial laryngopharyngectomy.

Figure 10-7. Operative specimen of the patient in Figure 10-6 shows the extent of resection at partial laryngopharyngectomy.

neck because of the low risk of metastatic disease in the submandibular triangle (level I) and posterior triangle (level V).59 Primary tracheoesophageal puncture can be performed regardless of reconstruction technique for speech restoration.60


The selection of technique to reconstruct the pharynx and cervical esophagus following ablative surgery is largely determined by the size of the defect, presence or absence of laryngeal structures, and the availability of microvascular expertise. Small defects following endoscopic resection will heal by secondary intention. External partial pha-ryngectomy can be repaired by primary closure, tongue flap, local rotation flap, and skin, dermal, or mucosal grafts.61 The Wookey procedure has historical significance, and may be employed in salvaging multiple failures of other procedures.62 Although cervical skin, platysma, latissimus dorsi, and del-topectoral flaps have been used, pectoralis major myocutaneous (Figure 10-8) or revascularized radial forearm flaps are the most common choices for reconstruction of larger pharyngeal defects, following total laryngectomy with partial pharyngectomy.

Reconstruction becomes more challenging following partial resection of the larynx for hypopharynx and cervical esophagus carcinoma. Primary closure or local rotation flaps using residual laryngeal/ hypopharyngeal mucosa, cervical skin, and sternohyoid myofascia have been described.63 Many techniques use remaining laryngeal structures in combination with regional myocutaneous flaps or gastric pull-up to preserve laryngeal function. A single layer closure does not have higher fistula rates and speech restoration and swallowing are improved compared to multiple layer closure.64 Cricopharyngeal myotomy is often performed to improve swallowing and acquisition of tracheoesophageal speech.65 Although reported complication rates are low, patients should be prepared for the possibility of a permanent tracheostomy.

Circumferential defects of the upper aerodiges-tive tract require circumferential tissue replacement

Pictures Esophageal Reconstruction
Figure 10-8. A, B, C and D, Partial defects of the pharynx can be reconstructed using a pectoralis major myocutaneous flap.

to reestablish continuity between the residual pharynx and esophagus. Both regional and free fascio-cutaneous and musculocutaneous flaps can be tubed, but the preferred methods are free radial forearm, free jejunal interposition, or pharyngogas-trostomy after pull-through esophagectomy (gastric pull-up).66 Each of these techniques has their proponents, and the choice of technique is based on the preferred method of the operating surgeons and the size of the defect.

The advantages of radial forearm flaps include ease of harvest and avoidance of intra-abdominal surgery. Free jejunal transplantation (Figure 10-9) has the advantage of fewer mucosal sutures and can be harvested endoscopically. In addition, longer segments of jejunum can be harvested for defects which extend into the nasopharynx. Gastric pull-up is indicated for lesions extending into the thoracic esophagus or when total esophagectomy is indicated (Figure 10-10). A combination of techniques is occasionally required when additional structures, such as anterior neck skin, oropharynx, and oral cavity are included in the ablation. Among the three methods of recon struction, free jejunal transplantation is recommended for primary reconstruction following laryn-gopharyngoesophagectomy.



As stated previously, chemotherapy for patients with head and neck cancer has evolved from palliation to primary combined-modality treatment in the last decade. Prospective, randomized studies comparing induction chemotherapy plus definitive radiation therapy with conventional treatment (total laryngectomy, pharyngectomy, neck dissection, and postoperative irradiation) have shown that larynx preservation without decreased survival is possible in patients with cancer of the hypopharynx.35 These protocols require frequent endoscopic evaluation, and those patients with limited or no response to treatment proceed to salvage surgery with postoperative radiation. Salvage surgery is also performed when patients relapse after chemotherapy and irradiation.

Escudo Nacional Panama Sin ColorPharyngectomy

Figure 10-9. A, B, and C, Microvascular jejunal interposition is an excellent method for reconstructing a circumferential defect of the pharynx.

Total Pharyngectomy

Figure 10-9. A, B, and C, Microvascular jejunal interposition is an excellent method for reconstructing a circumferential defect of the pharynx.

Gastric Interposition

Figure 10-10. A, B, C and D, Pharyngogastrostomy after gastric pull-up for reconstructing a circumferential defect of the pharynx.

Survival is comparable in surgical and nonsurgical groups for the following reasons: chemotherapy appears to decrease the rate of distant failure, and patients who undergo successful surgical salvage following chemoradiation are included in the nonsurgical group with respect to survival.67 The 5-year estimate of retaining a functional larynx is about 35 percent.35 Intra-arterial chemotherapy has been employed to increase the intra-tumor dose and limit systemic exposure.68 Several arteries, including lingual, ascending pharyngeal, facial and superior thyroidal arteries are available for drug delivery. Selective arterial infusion combined with external radiation therapy is a feasible alternative to standard chemoradiation protocols and offers comparable rates of disease control and survival. For many institutions and clinicians, induction chemotherapy followed by radiation with surgical salvage is offered as standard treatment for patients with advanced carcinoma of the hypopharynx.35 Because there are no prospective randomized trials comparing treatment options for carcinoma of the cervical esophagus, the approach to these lesions is more varied.

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