Reconstruction of the Hypopharynx and Esophagus

Patient Population at Presentation

Most patients who require reconstruction of the hypopharynx and esophagus harbor a malignancy at those sites. Most patients present for reconstruction of their hypopharynx or cervical esophagus after failure of chemoradiation for advanced stage squamous cell carcinoma of the larynx, pharynx, or trachea. Primary resection is reserved for patients who do not respond to induction selection chemotherapy or who have a destructive malignancy of the larynx or hypopharynx such that organ preservation with chemoradiation could not be reasonably expected. Patients who undergo surgical resection and pharyngeal reconstruction have the highest postsurgical complication rate when compared with any other site in the upper aerodigestive tract. Carcinomas of the larynx tend to be less aggressive than carcinomas of the hypopharynx. Hypopharyngeal carcinomas are known to demonstrate aggressive behavior with a high incidence of submucosal spread, satellite lesions, and subsequent invasion of adjacent structures. Careful assessment of the lungs is also important; the management of metastasis has evolved and there are several options, including resection, oligometastatic radiation, conventional chemotherapy, or immunotherapy. This patient population has a high prevalence of tobacco and alcohol abuse; patients often have related comorbidities such as cardiovascular disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and nutritional deficiency. Because of these underlying comorbidities and the disease process, treatment of this patient population is more difficult. Although extirpation of malignancy is the most common indication for hypopharyngeal reconstruction, several other situations can require hypopharyngeal reconstruction, such as osteoradionecrosis of the larynx or cervical spine, stenosis from prior radiation or caustic injection, or erosion of cervical spine hardware.

Perioperative Counseling

Nursing, social work, speech pathology, dentistry, cessation counseling, nutrition, and appointment scheduling are all part of the pretreatment workup. Because of the many disciplines involved, the treatment and rehabilitation experience can be bewildering for the patient. This has put the nurse clinical coordinator at the core of the patient care experience. It is not uncommon for these patients to have a poor pre-disease diet, and when coupled with a painful obstructive disease process that involves the upper aerodigestive tract, this can lead to significant malnutrition. Nutritional status must be addressed prior to treatment so that the patient is anabolic at the time of surgery. This requires education with respect to high-protein nutritional supplements or insertion of a feeding tube. In the preoperative period, frequent communication with patients may be required to ensure that they are gaining weight. Preoperative counseling with the speech pathologist is an essential part of patient education and shaping expectations. The speech pathologist is often regarded by the patient as the individual who will restore function after treatment. The greatest counseling challenge in this patient group is overcoming poor coping skills. The speech pathologist must contend with the patient's coping mechanisms in order to assist rehabilitation. Psychosocial counseling, which speech pathologists often do on an ad hoc basis, has been shown to benefit head and neck cancer patients when compared with controls. The speech pathologist must describe the expected long-term functional outcomes, identify the communicative and swallowing strategies that will be necessary, and indicate an interest in supporting the patient throughout treatment and rehabilitation. With the proliferation of home care agencies that provide in-home rehabilitation, the ability to provide specialized care for the patient who has undergone laryngectomy has diminished. The surgeon will need to ensure that patients return to a care provider who understands specialized care for laryngectomy patients. This may mean that the home care agency will need to be contacted and instructed not to provide home speech services, because this precludes other speech pathologists from providing services. Rehabilitation can be difficult, because the incidence rate of the use of tobacco, alcohol, and illicit drugs is higher in this patient population than in the general population; an addicted patient is unlikely to be effectively rehabilitated. Smoking is highly correlated with alcohol intake and depression; however, smoking cessation interventions, particularly those that take into consideration alcohol intake and depression, have been shown to be efficacious for this patient population.

It is important to emphasize that there are many different ways to quit smoking, that alcohol is a facilitator, and that nicotine is not a carcinogen. All these issues should be comprehensively addressed, and in so doing, providers and patients are often rewarded by the productive role patients assume for themselves, with their families, and in the workplace. To help patients prepare and recover from treatment, the use of patient volunteers who have completed treatment is an important resource.

Preoperative Evaluation

A thorough preoperative evaluation that includes endoscopy and radiographic studies must be performed to assess the extent of the primary tumor and to detect the presence of regional or distant metastasis. If possible, esophagoscopy should be considered. The degree of involvement of the cervical esophagus should be assessed, keeping in mind the propensity for submucosal spread and skip lesions. The presence of a tumor adjacent to the thoracic esophagus may necessitate a total esophagectomy. It is generally not possible to preserve the larynx with advanced lesions, although laryngeal-sparing surgery may be an option for a select few patients. Partial laryngeal procedures and the associated reconstructive approaches are discussed in another chapter.

The ideal margin for hypopharyngeal lesions is still controversial. Some authors advocate distal margins of up to 3 to 6 cm. Although routine total esophagectomy had been recommended in the past for management of carcinoma involving the hypopharynx, this approach is no longer the standard of care. In addition to the assessment of the esophagus, it is important to assess the cervical skin. If the patient has been previously treated with chemotherapy and RT, the quality of the cervical skin can be poor, and the skin may need to be replaced as part of the reconstructive procedure. It is also important to assess thyroid function preoperatively, because the patient can be hypothyroid as a result of prior irradiation. Hypothyroidism causes delayed healing and contributes to postoperative wound complications.

Goals and Principles of Reconstruction

The goals of reconstruction are a healed wound with protection of the great vessels, restoration of a pharyngeal conduit, protection of the airway, and rehabilitation of the voice. The principles of pharyngeal reconstruction are that (1) if the area has undergone prior CRT, vascularized tissue from outside of the radiation field should be used to close or reinforce the pharyngeal closure; (2) if the pharyngeal reconstruction needs to be tubed, the thickness of the donor tissue should be less than 2 cm; (3) if aspiration pneumonia affects the patient's quality of life, the trachea must be separated from the aerodigestive tract; (4) if the patient is going to be fitted with a tracheoesophageal speech prosthesis, a cricopharyngeal myotomy should be considered; (5) if risk for stenosis after reconstruction is present, close postoperative monitoring with esophagoscopy should be performed; (6) it is possible that a stent such as a feeding tube, nasogastric tube, or salivary bypass tube in the early postoperative period could reduce the stenosis or fistula rate (7) if the patient does not have laryngeal speech, they must be placed in a program for rehabilitation for alaryngeal speech.

Defect Classification

Pharyngoesophageal defects are classified according to the degree of involvement of the pharynx (partial, near-total, and total), oropharynx (base of tongue, lateral pharyngeal wall, posterior pharyngeal wall, soft palate), esophagus, and skin. Partial pharyngeal defects are those that arise from a laryngeal extirpation that may have included some pharyngeal mucosa, and such defects can be closed primarily without stenosis, or they may require a small graft to reconstruct less than 50% of the circumference of the pharynx. Near-total pharyngeal defects leave only a thin strip of pharynx (1 to 2 cm), and these require a graft to reconstruct more than 50% of the circumference of the pharynx. Total pharyngeal defects describe complete absence of a segment of the pharynx. For the purposes of this chapter, we do not discuss partial laryngeal defects or reconstruction of hypopharyngeal defects with an intact larynx, because this topic is covered elsewhere in this text. Stenosis of the pharynx with an intact larynx can occur after chemoradiation; efforts to reconstruct these patients have met with limited success because the stenosis is associated with impairment of the pharyngeal plexus. Reconstruction of the stenotic segment can increase patient comfort by improving the management of secretions, but restoration of oral intake and elimination of a gastric feeding is less common.

Defects that extend into the oropharynx may need additional reconstructive planning, particularly those defects that involve the soft palate; these will require a pharyngoplasty and additional tissue to resurface the palate and tonsil. Defects of the tonsil can generally be closed primarily. Associated defects of the tongue base can be partial or total, and partial defects that involve up to 50% of the tongue base do not require reconstruction. Primary closure of these defects is achieved by advancing the tongue base across the defect and suturing it to the resected edge of the oropharynx. This approach results in a sensate, functional tongue-base reconstruction. Defects of the entire tongue base are more concerning and may require reconstruction with a graft, particularly if the patient has a near total or total pharyngeal defect and has had recent CRT. Although it has been suggested that patients who have undergone laryngectomy do not require reconstruction of the base of the tongue, loss of the entire tongue base diminishes the ability of the patient to propel the bolus through the pharyngeal segment; therefore it can limit dietary intake to only liquids. If the resection of the pharynx extends into the mediastinum and a reliable distal anastomosis cannot be sutured, a visceral transposition is the reconstruction of choice. For a visceral transposition, the patient will undergo a complete esophagectomy, dissection of the mediastinum, and an open abdominal approach. In all cases, the cervical skin must be assessed for tumor involvement and viability. A cervical skin defect in combination with a pharyngeal defect significantly affects the reconstructive approach.

Reconstructive Decision Making

Reconstruction of the hypopharynx and cervical esophagus is associated with a high risk of morbidity and mortality. A wound at this site can expose the carotid and internal jugular vein, which can lead to life-threatening hemorrhages. Wound breakdown of the common wall between the trachea and esophagus usually results in aspiration pneumonia and is associated with a high mortality rate. Hypopharyngeal reconstruction should be designed to make a safe wound and to provide a pharyngeal conduit that assists swallowing and speech. If the patient is high risk, or the reconstructive plan was not appropriate given the intraoperative findings, the patient can be closed with a pharyngostomy, an esophagostomy, and a tracheostomy. This is a safe, staged approach. In addition to safety, the patient is interested in returning to pretreatment levels of social interaction and occupation. For this reason, the pharynx is reconstructed despite some increase in risk and mortality. Fortunately, many options are available for hypopharyngeal reconstruction ( Fig. 103.2A and B ). These options include local and regional cervical skin flaps and deltopectoral, pectoralis, and latissimus flaps; gastric and colonic interpositions; and revascularized fascial and gastroomental autogenous transplants. Recent retrospective reviews have shown that the fistula rate is reduced if vascularized tissue is used for the reconstruction when the patient history includes RT.

The following factors must be considered when choosing a reconstructive option:

• 1

  The condition of the local tissue, which includes the pharynx, the overlying cervical skin, or radiation chondritis of the larynx.

• 2

  The likelihood of a total versus a partial versus a primary hypopharyngeal closure

• 3

  The likelihood of extension into the esophagus

• 4

  The likelihood of oropharyngeal extension

• 5

  The vascular access in the cervical region

• 6

  The overall comorbid status of the patient

• 7

  The thickness of the donor site

Patients who present for hypopharyngeal reconstruction are rarely obese, but if they are, adjustments in donor-site choice must be made. Thick cutaneous tissue will not make a good tube. If the patient does not have a good cutaneous donor site, a gastroomental jejunal donor site can be considered if no other comorbid conditions prevent this.

Voice rehabilitation also needs to be addressed with respect to primary versus secondary tracheoesophageal puncture (TEP). The author has chosen to perform secondary TEP around the fourth postoperative week. The procedure can be performed using office esophagoscopy that borrows techniques from percutaneous tracheostomy; this approach improves the site of placement and is performed in a healed wound.

Local and Regional Skin Flaps

From 1877 through 1904, Czerny, Mikulicz, and Trotter described the first techniques to restore continuity to the pharynx. These were multiple-stage procedures that used cervical skin flaps for reconstruction. In the 1940s, Wookey improved on these techniques when he used a two-stage repair for pharyngoesophageal defects with a laterally based rectangular cervical flap. In the first stage, the cervical skin was redraped over the prevertebral fascia and was interposed between the pharyngeal and cervical esophageal stomas to create the posterior wall of the pharyngeal reconstruction. The approach exteriorized salivary and gastric secretions, protected the vascular space, and controlled infection. The continuity of the pharynx and cervical esophagus was returned at a second stage, usually 2 or 3 months later. Rectangular skin flaps with a base along the reconstructed posterior pharyngeal wall were fashioned from the cervical skin on the right and left sides. These flaps were tubed and closed vertically in the midline to create a skin-lined pharyngoesophageal segment. A skin graft was placed on the reconstructed pharynx and on the donor sites of the rotated cervical flaps. All these methods that used local skin flaps required multiple steps and were associated with a high frequency of complications. Although this approach created a safe wound, the functional outcomes of speech and swallowing were compromised because of the difficulty of reconstructing a pharynx that would not fistulize or stenose. The use of radiation increases the complication rate of this reconstructive approach. Although it is important to be aware of this approach, it is mostly of historic interest. The concept of a two-layer closure, one for the pharynx and one for neck cervical skin, using local flaps for mature pharyngocutaneous fistula, has its conceptual roots in this approach. To improve the success rate of pharyngeal closure, nonirradiated tissue with an axial blood supply was necessary.

The description of the deltopectoral flap by Bakamjian in 1965 represented a significant advance over previous methods. Unlike local flaps that rely on a random blood supply, this regional chest skin flap is based on a more reliable axial-pattern blood supply through the perforating branches of the internal mammary artery. It provides well-vascularized tissue from a donor site that lies outside the typical radiation fields used for head and neck cancer. The deltopectoral flap has a consistent vascular supply and can be reliably used without the need for surgical delay of the flap, if it is limited to the area medial to the deltopectoral groove. Uses of this donor site continue to evolve. New approaches involve mobilizing the internal mammary artery by removing the costochondral junction to improve the mobility and transposability of the flap.

Like the Wookey approach, the deltopectoral flap is created in a multistage procedure that requires the initial creation of a controlled fistula. With the deltopectoral flap, the fistula is used to form the pharyngeal tube, and the cervical skin is draped over the deltopectoral inset. At the first stage, a medially based skin flap is elevated and tubed to the superior cut edge of the pharyngeal resection. The posterior wall of the inferior cut edge is sutured to the deltopectoral flap, and the controlled fistula is fashioned with the anterior wall of the inferior edge of the pharyngeal resection. The flap pedicle is divided at least 6 weeks later, and closure of the fistula and skin grafting to the donor site occurs at this time. The deltopectoral flap was an improvement, but an unacceptably high rate of fistula formation, flap necrosis, and stenosis remained. Given these limitations, this approach is not commonly used, although these techniques may still occasionally be useful in certain patients who have failed or are unable to undergo alternative reconstructive approaches. At present, this donor site is most commonly used for the closure of a fistula after hypopharyngeal reconstruction ( Fig. 103.3 ).

Exciting new axial pattern alternatives are being explored that are supplied by branches of the second segment of the subclavian artery. The branching patterns, variability, and reliability are currently being evaluated. Donor sites can be from the shoulder region or the anterior thorax. These flaps are called supraclavicular flaps . They are supplied by the transverse cervical artery, and in some cases they may be supplied by less commonly identified branches of the second segment of the subclavian artery. Although numerous publications have addressed the elevation and inset of this donor site, some outstanding issues exist with respect to tip necrosis that likely relate to variability in vascular anatomy that will need to be further finessed for visceral reconstruction. This donor site (1) can supply tissue from as far as the tip of the deltoid, which provides an adequate arc of rotation to reach the hypopharyngeal recipient site and overlying skin; (2) seems to have large primary and also secondary angiosomes; and (3) can be closed primarily. The base seems to be along the posterior aspect of the segment of the sternocleidomastoid, which is supplied by the transverse cervical artery. The venous drainage seems to be a branch of the external jugular vein, and the skin paddle is robust if it bleeds well with elevation. The donor site can be used to close partial pharyngeal and cutaneous defects that overlie the hypopharyngeal site and to provide one layer of a two-layer closure-controlled fistula.

At present, the impact of neck dissection in level V on the reliability of this system of flaps is not known. It is likely that techniques will be developed that will allow elevation of the flap in the patient who has undergone dissection of level V. It also seems that the patient retains sensation of this site and can feel food passing by the reconstructed segment. It is possible that this donor site will replace some of the indications for revascularized tissue transfer or pectoralis flaps.