Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases

Abstract

Background: Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx, especially with proximal neoplastic lesions, whereas gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when resection extends below the thoracic inlet.

Hypothesis: Surgical ablation is a viable option for advanced hypopharyngeal and cervical esophageal neoplasms, with stomach interposition a safe and preferred method of reconstruction.

Design: Retrospective analysis.

Setting: University hospital that is a regional referral institution for esophageal cancer treatment and complex digestive reconstructions after esophagectomy.

Patients: We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and July 1999. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical esophageal in 78 cases.

Interventions: Pharyngolaryngectomy and total esophagectomy with pharyngogastric anastomoses (n = 127); pharyngolaryngectomy, cervical esophagectomy, and reconstruction with free jejunal transplant (n = 77); and pharyngolaryngectomy and total esophagectomy with pharyngocolic anastomoses (n = 5).

Main outcome measures: Postoperative mortality and morbidity, long-term survival, and prognostic factors influencing survival.

Results: The postoperative in-hospital mortality rate was 4.8% (10 patients), with a postoperative morbidity rate of 38.3%. 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 (33% vs 47%, P<.05). The significant adverse factors affecting survival were tumor cervical localization, postoperative complications, disease stages pT3 and pT4 for the cervical esophageal tumors, microscopic pharyngeal penetration, or incomplete resection. The significant beneficial factors were tumor hypopharyngeal localization and postoperative radiotherapy.

Conclusions: Surgical ablation is a viable option for advanced hypopharyngeal and cervical esophageal neoplasms, with stomach interposition the preferred method of reconstruction. Although the prognosis is poor, satisfactory short-term palliation can be achieved. The significant adverse factors affecting survival should be taken into account to select the candidates for surgery.