Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy

Abstract

Objective: To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma.

Materials/methods: A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated.

Results: 33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively).

Conclusion: Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.

Figure 1. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy.

(A) Preoperative marking. (B) After salvage pharyngolaryngectomy with neck dissection, an “empty” neck was noted. (C) A chimeric flap was composed of a skin paddle and a piece of vastus lateralis (VL) muscle. The skin paddle was tubularized to form a neoesophagus and the VL muscle was used to increase tissue bulk and to obliterate the dead space. (D) Immediate photograph after reconstruction.

Figure 2. Kaplan-Meier survival analysis in patients with recurrent hypopharyngeal cancers after concurrent chemoradiotherapy receiving ablating salvage surgery and anterolateral thigh flap reconstruction.

(A) & (B), Kaplan-Meier plots indicated that 5-year overall survival (OS) and disease-free survival (DFS) were 51.8% and 53.7%, respectively.

Figure 3. Kaplan-Meier plot analyses of the overall survival (OS) and disease-free survival (DFS) of patient subgroups stratified by pathological nodal status (pN), BMI values, and surgical margins (mm).

The inlets indicate statistically significant differences measured by log-rank test.