Proximal Esophagectomy Without Laryngectomy Followed by Free Jejunal Transfer for Esophageal Cancer at the Cervicothoracic Junction

THE SURGEON AT WORK Proximal Esophagectomy Without Laryngectomy Followed by Free Jejunal Transfer for Esophageal Cancer at the Cervicothoracic Junction Hiromasa Fujita, MD,* Hideaki Yamana, MD,* Susumu Sueyoshi, MD,* Ichiro Shima, MD,* Teruhiko Fujii, MD,* Kazuo Shirouzu, MD,* Yojiro Inoue, MD,† Hiroko Yanaga Tanabe, MD,† Kensuke Kiyokawa, MD,† Yoshiaki Tai, MD,† and Kazunori Mori, MD‡ A sufficient and satisfactory management for an esophageal cancer at the cervicothoracic junction is difficult to achieve compared with that for a hypopharyngeal cancer or a cancer in the thoracic esophagus. Pharyngolaryngoesophagectomy—total esophagectomy with laryngectomy— or near total esophagectomy without laryngectomy is commonly adopted for a cancer at this junction (1). The high incidence of mortality and morbidity, the low rate of longterm survival, and the poor quality of life are characteristics of patients after surgery because discovery is usually delayed until the onset of dysphagia, by which time the tumor often involves the trachea (2, 3). In particular, patients who undergo pharyngolaryngoesophagectomy with mediastinal tracheostomy tend to develop postoperative tracheal necrosis, which has a high risk for a rupture in a cervical great vessel, a generally fatal complication (2–5). To prevent such a complication, some authors have reported the use of a pectoralis major myocutaneous flap (2–5) or the adoption of proximal esophagectomy (2, 3). We have occasionally experienced an esophageal tumor at the cervicothoracic junction not

involving the larynx, trachea, and distal esophagus. Formerly, such patients had undergone laryngectomy to prevent aspiration (6), or near total esophagectomy for esophageal reconstruction using a gastric pedicle (1). Most patients want the larynx preserved for phonation, and some of these patients would rather refuse the surgery than suffer aphony. For these patients, we have attempted proximal esophagectomy preserving the larynx with a curative intent. In this paper we present and discuss our procedure, proximal esophagectomy without laryngectomy associated with cervical and upper mediastinal lymphadenectomy through an upper median sternotomy followed by free jejunal transfer. Methods

Approach. A collar incision is made in the neck, followed by a short median incision in the chest. After transection of the bilateral sternocleidomastoid, sternohyoid, and sternothyroid muscles, an upper median sternotomy of the reversed T-shape is performed down to the level of the second or third intercostal space. Cervical and upper mediastinal lymphadenectomy. Modified radical lymphadenectomy is performed for the bilateral neck and upper mediastinum. The upper border of lymphadenectomy is the mandibular glands, and its lower border is the brachiocephalic and subclavian veins on the ven-

Received June 20, 1997; Accepted August 25, 1997. From the *Department of Surgery, †Department of Plastic and Reconstructive Surgery, and ‡Department of Otolaryngology–Head and Neck Surgery, Kurume University School of Medicine, Kurume, Japan. Correspondence address: Hiromasa Fujita, MD, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume City, Fukuoka 830, Japan. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.

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FIG 1. Cervical and upper mediastinal lymphadenectomy through an upper median sternotomy.

tral side and the lower margin of the aortic arch on the dorsal side. The lateral borders are the brachial plexus. The internal jugular nodes, parapharyngeal nodes, supraclavicular nodes, cervical paraesophageal and paratracheal nodes, right recurrent nerve nodes, and left paratracheal nodes are resected during this procedure (7). The pretracheal nodes (the right paratracheal nodes) are not resected when metastasis is not found by preoperative staging and intraoperative macroscopic findings in these nodes. The recurrent nerves, phrenic nerves, thoracic duct, cervical transverse arteries, and external jugular veins, as well as the common carotid arteries, internal jugular veins, and vagus nerves, are preserved. The lymph nodes along the recurrent nerves must be meticulously dissected; then we tape the left recurrent nerve to avoid severe injury. The inferior thyroid arteries and veins are resected during lymphadenectomy, whereas the superior thyroid arteries and veins are preserved. The thyroid gland is preserved when there is no tumor involvement. Figure 1 demonstrates the situation after completion of the cervical and upper mediastinal lymphadenectomy through upper median sternotomy. Proximal esophagectomy. During lymphadenectomy, the pharynx, larynx, and esophagus are isolated from the adjacent organs from the level of

the superior thyroid vessels to that of the aortic arch. The esophagus between the level of the cricoid cartilage and that of the lower border of the aortic arch is isolated from the trachea, together with the tumor. During this maneuver, care should be taken not to injure the recurrent nerves. The esophagus is then clamped using a pursestring instrument and transected at the level of the aortic arch. A tissue specimen from the distal esophageal margin is immediately submitted to histologic examination, and if any tumor cell is observed in this specimen, proximal esophagectomy is converted to total esophagectomy. The anvil of a circular stapler is inserted into the distal esophagus, and the purse-string sutures are ligated. Esophageal reconstruction using a free jejunal graft. Through a laparotomy, 20 cm of the jejunum is resected with a pedicle containing the second or third jejunal vessels. Proximal anastomosis is manually performed just below the larynx in an endto-side fashion. First, the proximal portion of the jejunal graft is sutured onto the posterior wall of the hypopharynx. Then, the posterior wall of the esophagus just below the larynx and the anterior wall of the free jejunal graft are incised and anastomosed using interrupted sutures (Fig. 2). Next, the anterior wall of the esophagus is severed and the esophagus is removed, together with the tu-

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FIG 2. Proximal esophagectomy and esophagojejunostomy. The proximal esophagus is transected just below the larynx and is anastomosed to the free jejunal graft in an end-to-side fashion. Lt., left.

FIG 3. Jejunoesophagostomy. The free jejunal graft is anastomosed to the distal esophagus using an instrument in an end-to-side fashion. Rt., right.

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FIG 4. Proximal esophagectomy without laryngectomy followed by free jejunal transfer.

mor. The anterior half of the esophagojejunal anastomosis is then completed in the same fashion. Last, the jejunal graft is sutured to the thyroid gland and trachea to cover the anastomotic line. During this maneuver, care should be taken not to injure the left recurrent nerve. Distal anastomosis is performed using an instrument. A circular stapler is inserted into the distal end of a jejunal graft (Fig. 3). Jejunoesophagostomy is performed in an end-to-side fashion. The excess tissue at the proximal and distal end of the jejunal graft is resected using a linear stapler. Microvascular surgery. Vascular anastomoses between the jejunal artery and the left cervical transverse artery and between the jejunal vein and the left external jugular vein are performed by a plastic surgeon with the use of a microscope. Figure 4 illustrates the situation after completion of the proximal esophagectomy without laryngectomy and esophageal reconstruction using a free jejunal graft. Wrapping the trachea using an omental flap. An omental flap with a pedicle containing gastroepiploic vessels is made and pulled up into the neck

through the retrosternal space. The trachea and the cervical great vessels are then separately wrapped by this flap and isolated from each other. Tracheal fenestration. Before the wound is closed, tracheal fenestration is made through the omental flap into the cervical trachea caudal to the thyroid gland. This procedure is not always necessary for all patients, but is useful for patients at high risk of repeated aspiration pneumonia. Postoperative esophagogram. The jejunum is interposed between the hypopharynx and the thoracic esophagus (Fig. 5). The proximal anastomosis is situated just below the larynx, and the distal anastomosis is situated at the level of the aortic arch. An esophagogram is taken to confirm no aspiration and no anastomotic stricture. Results

From 1989 to 1997, six patients underwent proximal esophagectomy without laryngectomy in Kurume University Hospital. Table 1 summarizes the clinical characteristics of these patients. There was no patient with a tumor involving the trachea

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FIG 5. Postoperative esophagogram. A jejunal segment is interposed between the hypopharynx and the thoracic esophagus at the level of the aortic arch.

and/or larynx. The left recurrent nerve had to be resected in two patients because of tumor involvement. Microscopic residual tumor (R1) (8) was discovered in the resected specimen from the distal surgical margin in one patient (no. 6) who had received preoperative radiotherapy. Table 2 summarizes the incidence(s) of any postoperative complication or additional surgery and the outcome. Two patients underwent tracheostomy or tracheal fenestration during surgery. Another two underwent tracheostomy after surgery. Overall, four of the six patients needed tracheostomy. Paralysis in the bilateral recurrent nerves appeared to be permanent in one patient (no. 3) who underwent laryngectomy at 5 months after the primary operation because of repeated aspiration pneumonia.

Two patients suffered tracheal necrosis. One (no. 6) died of consequent mediastinitis, sepsis, and respiratory failure on the 25th postoperative day (and accounts for 17% [1/6] of the hospital mortality rate). This patient had undergone preoperative radiotherapy at a dosage of 40 Gy. The other (no. 1) developed a tracheal stricture that was successfully managed by implanting an expandable metallic stent. The mean followup was 25 months (range, 1– 65 months). Two patients died without cancer during the followup period, one of postoperative complication and the other of unknown cause. Another two patients are alive with recurrence, one with recurrence in the cervical nodes and the other with local recurrence. The former refused treatment, citing concerns about old age; the latter

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Table 1. Characteristics of Patients Who Underwent Partial Esophagectomy Without Laryngectomy Pt. Age Length No. (y) Sex Location* (cm) 1 2 3 4 5 6

49 76 62 71 70 47

M F F M M M

Ce . Iu Ce . Iu Ce . Iu Iu . Ce Ce . Iu Ce . Iu

4 3 4 5 5 5

Stage (pTNM)† T2, T4\ T2, T3, T1, T4\

N1, N0, N1, N0, N0, N0,

M1-lym, Stage IV M0, Stage III M0, Stage IIB M0, Stage IIA M0, Stage I M0, Stage III

Residual tumor (6)‡

Adjuvant therapy§

R0 R0 R0 R0 R0 R1¶

Postoperative chemotherapy (CDDP 1 5Fu) — Postoperative chemotherapy (CDDP 1 PEP) At recurrence, radiotherapy (54 Gy), chemotherapy (CDDP 1 5Fu) — Preoperative radiotherapy (40 Gy)

*Ce . Iu, the cervical portion of the tumor was larger than its thoracic portion; Iu . Ce, the thoracic portion of the tumor was larger than its cervical portion. † TNM classification of the American Joint Cancer Committee and the International Union Against Cancer (8). ‡ Number in parentheses is reference. § CDDP, cisplatin, 5Fu, fluorouracil, PEP, pepleomycin sulfate. \ The left recurrent nerve was involved by the tumor. ¶ Microscopic residual tumor at the distal surgical margin. Pt. No., patient number.

underwent laser therapy and chemoradiotherapy by which recurrence was controlled. Four of the six patients have recovered both peroral intake and phonation. Discussion

The larynx can be preserved, not only technically but also oncologically, when a cancer does not involve the larynx and trachea. If patients suffer from repeated aspiration pneumonia after preservation of the larynx, then they often lose abilities of phonation and of peroral intake. They later require secondary laryngectomy to obtain at least peroral intake. Laryngectomy is added beforehand to proximal or to total esophagectomy for the purpose of preventing recurrent aspiration after surgery (9). Patients essentially want the larynx to be preserved if possible, provided that curability can be ensured. They want to preserve peroral intake and phonation; proximal esophagectomy without laryngectomy is the procedure to preserve both capabilities. This surgery requires satisfaction of two conditions. One is oncologic, and the other is technical. This procedure cannot be adopted oncologically in the following situations: (1) if the larynx,

trachea, pharynx, or esophagus distal from the aortic arch is involved by the tumor; (2) if intramural metastasis or multiple primary cancer(s) is found in the distal esophagus; or (3) if lymph node metastasis is found in the lower mediastinum and abdomen. Such findings should be ruled out by the examinations for preoperative staging. Care should be taken to avoid serious complications such as tracheal necrosis and aspiration pneumonia. The most essential maneuver to prevent tracheal ischemia is preservation of the branches of the tracheoesophageal arteries and the paratracheal sheath (9). In patients with a locally advanced tumor and in those with large metastasis in the lymph nodes along the trachea, this is not always possible. We add the step of wrapping the trachea using an omental flap to reinforce the tracheal blood flow and to isolate the trachea from the cervical great vessels (10). Preoperative radiotherapy should be avoided for potentially resectable tumors, although preoperative chemoradiotherapy is needed and used for locally advanced tumors (11). Repeated aspiration pneumonia has frequently occurred in patients with paralysis in the bilateral recurrent nerves. Although we tape the left recur-

Table 2. Postoperative Complications, Additional Surgery, and Prognosis After Proximal Esophagectomy Without Laryngectomy Patient No.

Complication

Additional surgery

Prognosis

1 2 3 4 5 6

Aspiration pneumonia, tracheal necrosis, and stricture Left RNP Bilateral RNP, Aspiration pneumonia Left RNP, Osteomyelitis of the sternum Left RNP Tracheal necrosis, mediastinitis, sepsis, ARDS, left RNP

Tracheostomy,* EMS — Tracheostomy,‡ Laryngectomy Tracheal fenestration‡ — Tracheostomy*

65 mo; alive 44 mo; alive with recurrence† 21 mo; non-cancer death 19 mo; alive with recurrence§ 1 mo; alive 25 days; complication death

*Tracheostomy after surgery. † Recurrence in the right supraclavicular lymph nodes. ‡ Tracheostomy during surgery. § Local recurrence in the tracheal membrane. EMS, expandable metallic stent(s); RNP, recurrent nerve paralysis; ARDS, adult respiratory distress syndrome.

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rent nerve to avoid its injury, most patients seem to develop paralysis in this nerve. The lymph nodes along the recurrent nerves must be dissected meticulously, and the recurrent nerve is occasionally involved by the tumor. When the viability of the right recurrent nerve is ensured, avoiding permanent paralysis of the bilateral nerves, repeated aspiration pneumonia after surgery is usually prevented. Conversely, laryngeal preservation should be abandoned when the right recurrent nerve is involved by the tumor. Currently, surgeons must consider the quality of life, as well as survival, of patients after surgery. Almost all patients want phonation through laryngeal preservation, and longterm survival through curative surgery. Proximal esophagectomy without laryngectomy associated with cervical and upper mediastinal lymphadenectomy through an upper median sternotomy followed by free jejunal transfer is a useful technique for achieving such patient objectives in carefully selected situations. References 1. Marmuse JP, Koka VN, Guedon C, and Benhamou G. Surgical treatment of carcinoma of the proximal esophagus. Am J Surg 1995;169:386 –390. 2. Fujita H, Kakegawa T, Inoue Y, et al. Upper esophagectomy

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