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Reconstruction of upper digestive tract: Reducing morbidity by laparoscopic pull-up
Otolaryngology–Head and Neck Surgery (2006) 135, 710-713
ORIGINAL RESEARCH
Reconstruction of upper digestive tract: Reducing morbidity by laparoscopic pull-up Aureo L. DePaula, MD, Antonio L.V. Macedo, MD, Claudio R. Cernea, MD, Vladimir Schraibman, MD, Jacques Pinus, MD, José R. Milanez, MD, José E. Succi, MD, Flávio C. Hojaij, MD, Dorival de Carlucci, Jr, MD, and Sunao Nishio, MD, São Paulo, Brazil; and Goiânia, Brazil
n spite of the description of nonsurgical organ preservation protocols,1 surgery still has an important role in the treatment of pharyngoesophageal carcinomas. However, reconstruction of the upper digestive tract represents one of the most difficult challenges for the head and neck surgeon.
The majority of the patients ultimately have a poor outcome. Hence, the ideal reconstructive method should have some features: one-stage procedure, low morbidity and mortality, good rehabilitation of swallowing and phonation, and early discharge from the hospital. In addition, hypopharyngeal carcinomas have a marked tendency to extend submucosally well beyond visible boundaries of the tumor,2 precluding safe preservation of cervical or even thoracic esophagus in some cases. Several laryngopharyngeal reconstructive techniques have been described in the literature, employing conventional flaps,3 myocutaneous flaps,4 cutaneous free flaps,5-7 jejunum free flaps,8-10 and gastric pull-up.11,12 Each one of them shows advantages and disadvantages. In a poll involving 128 British surgeons, Ayshford et al13 observed that 58% preferred gastric pull-up. In spite of its efficacy, conventional gastric pull-up is not a simple operation, because it involves access to the three major visceral cavities; consequently, operative morbidity and mortality are relatively high in several series. Chu and Chang14 found a 64% overall complication rate in their patients. During the last decade of the last century, laparoscopic and thoracoscopic procedures became the state-of-the-art therapy of several abdominal and thoracic diseases. Reduction in morbidity and mortality was evident. Nevertheless, very few authors published series dealing with laryngopharyngeal reconstruction using these new endoscopic tech-
From the Department of Surgery, Albert Einstein Jewish Hospital, São Paulo (Drs DePaula, Macedo, Cernea, Schraibman, Pinus, Milanez, Succi, Hojaij, Carlucci, and Nishio); and the Department of Surgery, Clinical Specialties Hospital, Goiânia (Drs De Paula and Macedo). Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, Los Angeles, CA, September 25-28, 2005. Reprint requests: Claudio R. Cernea, MD, Alameda Franca, 267, room 21, CEP 01422-000, São Paulo, Brazil. E-mail address: [email protected].
BACKGROUND: Gastric pull-up is a useful method for reconstruction of the upper digestive tract, with considerable morbidity/ mortality, especially in esophageal cancers (EC). OBJECTIVE: To analyze the experience of a multidisciplinary team with a laparoscopic gastric pull-up (LGPU) method, with or without thoracoscopy, in a series of 120 patients with EC. STUDY DESIGN: Retrospective. PATIENTS AND METHODS: From 1992 to 2004, 120 EC [cervical/cervicothoracic (3.0%), middle third (15.0%), and inferior third (82.0%)]. Most were squamous cell carcinomas (47.0%) and adenocarcinomas (34.0%). Stomach was dissected and mobilized exclusively by laparoscopy. Occasionally, laparoscopic approach was extended cranially, until connecting with cervical dissection. In other cases, dissection of thoracic esophagus was accomplished through a thoracoscopic approach. RESULTS: Eighty-one patients (68.0%) had LGPU; 39 (32.0%) needed thoracoscopy. Mortality was 5.9%. Complications were fistula (10.0%) and pneumonia (10.0%). All fistulae closed spontaneously; 89.2% of patients could swallow a normal oral diet. CONCLUSION: Low morbidity/mortality of LGPU for EC compared favorably with conventional techniques. © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
I
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.04.019
DePaula et al
Reconstruction of upper digestive tract: Reducing . . .
niques. In fact, most authors used laparoscopic approaches just to harvest jejunal segments to be microscopically transplanted to the cervical area.15,16 One of us (ALDP) was the first to publish a series with laparoscopic transhiatal esophagectomy with gastroplasty.17 On the other hand, thoracoscopic approach for dissection of thoracic esophagus after laryngopharyngoesophagectomy was reported by Law et al.18 The objective of this study was to analyze the experience of a multidisciplinary team in two institutions with laparoscopic gastric pull-up (LGPU), associated or not with a thoracoscopic approach, in a consecutive series of 120 patients with esophageal cancers, focusing mainly on complication rate and functional outcome.
MATERIALS AND METHODS Patients A retrospective review of the cases with esophageal cancers treated at two different institutions (Albert Einstein Jewish Hospital, São Paulo, Brazil, and Clinical Specialties Hospital, Goiânia, Brazil) was performed. During a 13-year period (1992-2004), 120 consecutive patients with esophageal primary cancers underwent reconstruction with a LGPU (76.0% male/24.0% female; median age: 59.4 years old). Locations of the primary esophageal lesions were: cervical or cervicothoracic (3.0%), middle third of thoracic esophagus (15.0%), or inferior third (82.0%). Most prevalent histological types were squamous cell carcinomas (47.0%) and adenocarcinomas (34.0%). Nearly one-third of the patients received preoperative chemo and/or radiation therapy. All patients had their stomach dissected and mobilized exclusively by laparoscopy (Fig 1). In some cases, the laparoscopic approach was extended cranially, through the medi-
711
Table 1 Complications Complication
%
Pneumonia Fistula Transient dysphonia Bleeding (requiring transfusion) Sepsis Cardiovascular Tension penumothorax Duodenal perforation Conversion to open thoracotomy Right phrenic nerve paralysis Total
10.0% 10.0% 5.8% 4.8% 3.2% 2.9% 1.6% 1.6% 1.6% 0.8% 42.3%
astinum, in order to manage the thoracic esophagus. After a complete mobilization under direct vision, including staple suture and section of the azigus vein, a connection was established with the cervical dissection, done simultaneously by a second head and neck surgical team. In these instances, the thoracic esophagus was entirely dissected by this approach. In some cases, dissection of thoracic esophagus was accomplished through a thoracoscopic approach. The main indications for thoracoscopy were: advanced stage, difficult access to superior mediastinum, and concomitant morbid obesity. It is important to emphasize that, in all cases of the present series, the larynx was not resected, and an esophagogastric anastomosis, rather than a pharyngogastric anastomosis, was then performed.
Methods This is a retrospective study, involving a previously reported method by the first author of this study17 in a much larger series. Therefore, no experimental new technique was employed, and no additional specific statement of Institutional Review Board was produced.
RESULTS
Figure 1 Intraoperative picture of a laparoscopic gastric pullup, showing the endoscopes in place and the transposed esophagus and gastric tube ready to be anastomosed to the cervical esophagus.
Eighty-one patients (68.0%) underwent only LGPU with cervicotomy, whereas 39 (32.0%) also needed thoracoscopy, in addition to the laparoscopic dissection of the stomach. Mean operative time was 216 minutes. Mean hospital stay was 7.2 days. Perioperative mortality (until 30th postoperative day) was 5.9%. Main causes of death were sepsis and pulmonary complications. No laryngectomy was required. Operative morbidity is depicted in Table 1. Overall morbidity was 23.0% for LGPU and 56.0% for LGPU ⫹ thoracoscopy. Most frequent complications were fistula (10.0%) and pneumonia (10.0%). All fistulae closed spontaneously. Regarding long-term functional result, 89.2% could swallow a normal oral diet. Overall 5-year survival rate was 31.6% for the whole series (60.2% for R0-N0 cases). Locoregional control rate was 85.3%.
712
Otolaryngology–Head and Neck Surgery, Vol 135, No 5, November 2006
DISCUSSION Reconstruction of the upper digestive tract after hypopharyngeal and/or esophageal cancer resection is a very difficult problem. Due to the poor prognosis of these patients, it is important to offer a safe one-stage procedure, with low morbidity and acceptable operative mortality, as well as good functional rehabilitation, permitting a reasonable quality of life. Unfortunately, all available reconstructive techniques show several advantages, but also important drawbacks. Conventional flaps, like the deltopectoral,3 were very useful in the past, but usually require at least one second surgical procedure to complete the continuity of the neopharynx. Myocutaneous flaps, such as the pectoralis major,4 may be harvested and tubed as a single-stage procedure, but usually become bulky; in addition, incidence of stenosis of distal anastomosis is not negligible. Microvascular reconstruction, employing either jejunum segments8-10 or skin flaps (forearm5 or anterolateral thigh6,7) are very useful methods, with several advantages: single stage operations, acceptable morbidity and mortality, good swallowing, and reasonable voice rehabilitation. However, all the above-mentioned surgical procedures need a cervical esophageal stump. Wei and Sham2 clearly demonstrated that hypopharyngeal carcinomas can present a surprisingly extensive caudal submucosal invasion, sometimes reaching many centimeters beyond visible boundaries of the tumor. In these situations, in order to obtain a safe resection margin, the inferior suture line would have to be placed in the superior mediastinum. Then, an eventual fistula would open directly in the mediastinum, leading to a potentially fatal mediastinitis. Moreover, the risk of second esophageal primaries, pointed out by some authors,19 suggests that any reconstructive method that preserves the thoracic esophagus could impair adequate oncological control. Ayshford et al13 published the results of a poll answered by 128 British surgeons. The majority of them (58%) elected gastric pull-up as their favorite method of pharyngoesophageal reconstruction. In fact, conventional gastric pull-up is an excellent reconstructive option. It is a onestage procedure; the gastric tube, if properly mobilized, can reach even the oropharynx, with a very wide anastomosis; the gastric tube can be harvested simultaneously by a second team, while the cancer resection takes place; quality of deglutition is usually very good. However, it is a very aggressive procedure, because it involves surgical manipulation of the three major visceral cavities. It is not surprising that operative morbidity and mortality are important in several series. Since the 1990s, the development of laparoscopic and thoracoscopic techniques has markedly reduced operative morbidity and mortality in several fields of surgical specialties, from colecistectomy to resection of mediastinal lesions. However, to our knowledge, these advances were not applied to pharyngoesophageal reconstruction yet. In a comprehen-
sive MEDLINE search, some authors used laparoscopic approaches only to harvest jejunal segments to be microscopically transplanted to the cervical area.15,16 The first author published the first series of laparoscopic transhiatal esophagectomy with esophagogastroplasty in 1995,17 which comprised 12 patients (with two esophageal cancers). The present study evaluated the experience of a multidisciplinary team, including general surgeons, head and neck surgeons, thoracic surgeons, clinical oncologists, and radiation oncologists, in two institutions with a series of 120 patients with esophageal cancers who underwent LGPU, associated or not with a thoracoscopy. The main focus of this analysis was on morbidity and mortality rates. Even when dealing with a potentially debilitating disease, such as esophageal cancer, the use of laparoscopic technique to harvest the gastric tube obviously decreased surgical injury in these patients. In addition, our mortality and morbidity rates were similar to a smaller series of 22 patients submitted to laparoscopic gastric pull-up recently reported by Avital et al.20 They found 4.5% mortality and 27.2% morbidity rates. The thoracoscopic dissection of the thoracic esophagus during gastric pull-up has been described previously by Law et al.18 In the present series, when a thoracoscopy had to be added, to enable a safer dissection of the thoracic esophagus, morbidity still remained at an acceptable level. Both results (23% and 56% morbidity rates, respectively) compared favorably with a recent series published by Chu and Chang,14 including conventional gastric pull-up (64% morbidity rate). We noted several technical details that favored this endoscopic approach: practically bloodless abdominal operation; dissection of the thoracic esophagus under direct vision (either by laparoscopy or thoracoscopy), avoiding potentially hazardous hemorrhages (stapling and sectioning of azigus vein was particularly important in this regard), and offering a direct visual communication with the head and neck surgical team; and finally, conduction of the gastric tube to the neck under direct monitoring. It is important to emphasize that no patient in the present series had a hypopharyngeal cancer. Nonetheless, we believe that it is relevant to present these results to the head and neck surgeon, in order to offer a sound oncological reconstructive option, with a clear reduction in both operative mortality and morbidity rates. As a matter of fact, it is easier to dissect an uninvolved esophagus, probably reducing the need for thoracoscopy in many more instances than in the present series, decreasing the morbidity even further. In conclusion, our results demonstrated that laparoscopic gastric pull-up is a safe and reliable method for reconstruction of the upper digestive tract and could be considered as an option for rehabilitation after resection of hypopharyngeal and cervical esophageal cancers, especially if the thoracic esophagus needs to be excised as well, due to oncological reasons.
DePaula et al
Reconstruction of upper digestive tract: Reducing . . .
REFERENCES 1. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J Natl Cancer Inst 1996;88: 890 –9. 2. Wei WI, Sham JST. Extent of resection of hypopharyngeal cancer. In: Wei WI, Sham JST, editors. Cancer of the larynx and hypopharynx. Oxford, UK: Isis Media Medical Ltd.; 2000. p. 95–104. 3. Bakamjiam VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965; 36:173– 84. 4. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73– 81. 5. Haller JR. Concepts in pharyngoesophageal reconstruction. Otolaryngol Clin North Am 1997;30:655– 61. 6. Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg 2005;131:796 –9. 7. Yu P. One-stage reconstruction of complex pharyngoesophageal, tracheal, and anterior neck defects. Plast Reconstr Surg 2005;116:949 –56. 8. Morais-Besteiro J, Cernea CR, dos Santos LR, et al. Microvascular flaps in head and neck reconstruction. Head Neck 1990;12:21–30. 9. Kroll SS, Schusterman MA, Reece GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 199;98:459-63. 10. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after circumferential pharyngoesophageal reconstruction. Laryngoscope 2005;115:1266 –71.
713
11. Mehta SA, Sarkar S, Mehta AR, et al. Mortality and morbidity of primary pharyngogastric anastomosis following circumferential excision for hypopharyngeal malignancies. J Surg Oncol 1990;43:24 –7. 12. Shriver CD, Spiro RH, Burt M. A new technique for gastric pullthrough. Surg Gynecol Obstet 1993;177:519 –20. 13. Ayshford CA, Walsh RM, Watkinson JC. Reconstructive techniques currently used following resection of hypopharyngeal carcinoma. J Laryngol Otol 1999;113:145– 8. 14. Chu PY, Chang SY. Reconstruction after resection of hypopharyngeal carcinoma: comparison of the postoperative complications and oncologic results of different methods. Head Neck 2005;27:901– 8. 15. Staley CA, Miller M, King TJ, et al. Laparoscopic intracorporeal harvest of jejunal tissue for autologous transplantation. Surg Laparosc Endosc 1994;4:192–5. 16. Wadsworth JT, Futran N, Eubanks TR. Laparoscopic harvest of the jejunal free flap for reconstruction of hypopharyngeal and cervical esophageal defects. Arch Otolaryngol Head Neck Surg 2002;128: 1384 –7. 17. DePaula AL, Hashiba K, Ferreira EA, et al. Laparoscopic transhiatal esophagectomy with esophagogastroplasty. Surg Laparosc Endosc 1995;5:1–5. 18. Law SY, Fok M, Wei WI, et al. Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy. Ann Thorac Surg 2000 Aug; 70(2):418 –22. 19. Hujala K, Sipila J, Grenman R. Panendoscopy and synchronous second primary tumors in head and neck cancer patients. Eur Arch Otorhinolaryngol 2005;262:17–20. 20. Avital S, Zundel N, Szomstein S, et al. Laparoscopic transhiatal esophagectomy for esophageal cancer. Am J Surg 2005;190:69 –74.
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ORIGINAL RESEARCH
Reconstruction of upper digestive tract: Reducing morbidity by laparoscopic pull-up Aureo L. DePaula, MD, Antonio L.V. Macedo, MD, Claudio R. Cernea, MD, Vladimir Schraibman, MD, Jacques Pinus, MD, José R. Milanez, MD, José E. Succi, MD, Flávio C. Hojaij, MD, Dorival de Carlucci, Jr, MD, and Sunao Nishio, MD, São Paulo, Brazil; and Goiânia, Brazil
n spite of the description of nonsurgical organ preservation protocols,1 surgery still has an important role in the treatment of pharyngoesophageal carcinomas. However, reconstruction of the upper digestive tract represents one of the most difficult challenges for the head and neck surgeon.
The majority of the patients ultimately have a poor outcome. Hence, the ideal reconstructive method should have some features: one-stage procedure, low morbidity and mortality, good rehabilitation of swallowing and phonation, and early discharge from the hospital. In addition, hypopharyngeal carcinomas have a marked tendency to extend submucosally well beyond visible boundaries of the tumor,2 precluding safe preservation of cervical or even thoracic esophagus in some cases. Several laryngopharyngeal reconstructive techniques have been described in the literature, employing conventional flaps,3 myocutaneous flaps,4 cutaneous free flaps,5-7 jejunum free flaps,8-10 and gastric pull-up.11,12 Each one of them shows advantages and disadvantages. In a poll involving 128 British surgeons, Ayshford et al13 observed that 58% preferred gastric pull-up. In spite of its efficacy, conventional gastric pull-up is not a simple operation, because it involves access to the three major visceral cavities; consequently, operative morbidity and mortality are relatively high in several series. Chu and Chang14 found a 64% overall complication rate in their patients. During the last decade of the last century, laparoscopic and thoracoscopic procedures became the state-of-the-art therapy of several abdominal and thoracic diseases. Reduction in morbidity and mortality was evident. Nevertheless, very few authors published series dealing with laryngopharyngeal reconstruction using these new endoscopic tech-
From the Department of Surgery, Albert Einstein Jewish Hospital, São Paulo (Drs DePaula, Macedo, Cernea, Schraibman, Pinus, Milanez, Succi, Hojaij, Carlucci, and Nishio); and the Department of Surgery, Clinical Specialties Hospital, Goiânia (Drs De Paula and Macedo). Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, Los Angeles, CA, September 25-28, 2005. Reprint requests: Claudio R. Cernea, MD, Alameda Franca, 267, room 21, CEP 01422-000, São Paulo, Brazil. E-mail address: [email protected].
BACKGROUND: Gastric pull-up is a useful method for reconstruction of the upper digestive tract, with considerable morbidity/ mortality, especially in esophageal cancers (EC). OBJECTIVE: To analyze the experience of a multidisciplinary team with a laparoscopic gastric pull-up (LGPU) method, with or without thoracoscopy, in a series of 120 patients with EC. STUDY DESIGN: Retrospective. PATIENTS AND METHODS: From 1992 to 2004, 120 EC [cervical/cervicothoracic (3.0%), middle third (15.0%), and inferior third (82.0%)]. Most were squamous cell carcinomas (47.0%) and adenocarcinomas (34.0%). Stomach was dissected and mobilized exclusively by laparoscopy. Occasionally, laparoscopic approach was extended cranially, until connecting with cervical dissection. In other cases, dissection of thoracic esophagus was accomplished through a thoracoscopic approach. RESULTS: Eighty-one patients (68.0%) had LGPU; 39 (32.0%) needed thoracoscopy. Mortality was 5.9%. Complications were fistula (10.0%) and pneumonia (10.0%). All fistulae closed spontaneously; 89.2% of patients could swallow a normal oral diet. CONCLUSION: Low morbidity/mortality of LGPU for EC compared favorably with conventional techniques. © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
I
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.04.019
DePaula et al
Reconstruction of upper digestive tract: Reducing . . .
niques. In fact, most authors used laparoscopic approaches just to harvest jejunal segments to be microscopically transplanted to the cervical area.15,16 One of us (ALDP) was the first to publish a series with laparoscopic transhiatal esophagectomy with gastroplasty.17 On the other hand, thoracoscopic approach for dissection of thoracic esophagus after laryngopharyngoesophagectomy was reported by Law et al.18 The objective of this study was to analyze the experience of a multidisciplinary team in two institutions with laparoscopic gastric pull-up (LGPU), associated or not with a thoracoscopic approach, in a consecutive series of 120 patients with esophageal cancers, focusing mainly on complication rate and functional outcome.
MATERIALS AND METHODS Patients A retrospective review of the cases with esophageal cancers treated at two different institutions (Albert Einstein Jewish Hospital, São Paulo, Brazil, and Clinical Specialties Hospital, Goiânia, Brazil) was performed. During a 13-year period (1992-2004), 120 consecutive patients with esophageal primary cancers underwent reconstruction with a LGPU (76.0% male/24.0% female; median age: 59.4 years old). Locations of the primary esophageal lesions were: cervical or cervicothoracic (3.0%), middle third of thoracic esophagus (15.0%), or inferior third (82.0%). Most prevalent histological types were squamous cell carcinomas (47.0%) and adenocarcinomas (34.0%). Nearly one-third of the patients received preoperative chemo and/or radiation therapy. All patients had their stomach dissected and mobilized exclusively by laparoscopy (Fig 1). In some cases, the laparoscopic approach was extended cranially, through the medi-
711
Table 1 Complications Complication
%
Pneumonia Fistula Transient dysphonia Bleeding (requiring transfusion) Sepsis Cardiovascular Tension penumothorax Duodenal perforation Conversion to open thoracotomy Right phrenic nerve paralysis Total
10.0% 10.0% 5.8% 4.8% 3.2% 2.9% 1.6% 1.6% 1.6% 0.8% 42.3%
astinum, in order to manage the thoracic esophagus. After a complete mobilization under direct vision, including staple suture and section of the azigus vein, a connection was established with the cervical dissection, done simultaneously by a second head and neck surgical team. In these instances, the thoracic esophagus was entirely dissected by this approach. In some cases, dissection of thoracic esophagus was accomplished through a thoracoscopic approach. The main indications for thoracoscopy were: advanced stage, difficult access to superior mediastinum, and concomitant morbid obesity. It is important to emphasize that, in all cases of the present series, the larynx was not resected, and an esophagogastric anastomosis, rather than a pharyngogastric anastomosis, was then performed.
Methods This is a retrospective study, involving a previously reported method by the first author of this study17 in a much larger series. Therefore, no experimental new technique was employed, and no additional specific statement of Institutional Review Board was produced.
RESULTS
Figure 1 Intraoperative picture of a laparoscopic gastric pullup, showing the endoscopes in place and the transposed esophagus and gastric tube ready to be anastomosed to the cervical esophagus.
Eighty-one patients (68.0%) underwent only LGPU with cervicotomy, whereas 39 (32.0%) also needed thoracoscopy, in addition to the laparoscopic dissection of the stomach. Mean operative time was 216 minutes. Mean hospital stay was 7.2 days. Perioperative mortality (until 30th postoperative day) was 5.9%. Main causes of death were sepsis and pulmonary complications. No laryngectomy was required. Operative morbidity is depicted in Table 1. Overall morbidity was 23.0% for LGPU and 56.0% for LGPU ⫹ thoracoscopy. Most frequent complications were fistula (10.0%) and pneumonia (10.0%). All fistulae closed spontaneously. Regarding long-term functional result, 89.2% could swallow a normal oral diet. Overall 5-year survival rate was 31.6% for the whole series (60.2% for R0-N0 cases). Locoregional control rate was 85.3%.
712
Otolaryngology–Head and Neck Surgery, Vol 135, No 5, November 2006
DISCUSSION Reconstruction of the upper digestive tract after hypopharyngeal and/or esophageal cancer resection is a very difficult problem. Due to the poor prognosis of these patients, it is important to offer a safe one-stage procedure, with low morbidity and acceptable operative mortality, as well as good functional rehabilitation, permitting a reasonable quality of life. Unfortunately, all available reconstructive techniques show several advantages, but also important drawbacks. Conventional flaps, like the deltopectoral,3 were very useful in the past, but usually require at least one second surgical procedure to complete the continuity of the neopharynx. Myocutaneous flaps, such as the pectoralis major,4 may be harvested and tubed as a single-stage procedure, but usually become bulky; in addition, incidence of stenosis of distal anastomosis is not negligible. Microvascular reconstruction, employing either jejunum segments8-10 or skin flaps (forearm5 or anterolateral thigh6,7) are very useful methods, with several advantages: single stage operations, acceptable morbidity and mortality, good swallowing, and reasonable voice rehabilitation. However, all the above-mentioned surgical procedures need a cervical esophageal stump. Wei and Sham2 clearly demonstrated that hypopharyngeal carcinomas can present a surprisingly extensive caudal submucosal invasion, sometimes reaching many centimeters beyond visible boundaries of the tumor. In these situations, in order to obtain a safe resection margin, the inferior suture line would have to be placed in the superior mediastinum. Then, an eventual fistula would open directly in the mediastinum, leading to a potentially fatal mediastinitis. Moreover, the risk of second esophageal primaries, pointed out by some authors,19 suggests that any reconstructive method that preserves the thoracic esophagus could impair adequate oncological control. Ayshford et al13 published the results of a poll answered by 128 British surgeons. The majority of them (58%) elected gastric pull-up as their favorite method of pharyngoesophageal reconstruction. In fact, conventional gastric pull-up is an excellent reconstructive option. It is a onestage procedure; the gastric tube, if properly mobilized, can reach even the oropharynx, with a very wide anastomosis; the gastric tube can be harvested simultaneously by a second team, while the cancer resection takes place; quality of deglutition is usually very good. However, it is a very aggressive procedure, because it involves surgical manipulation of the three major visceral cavities. It is not surprising that operative morbidity and mortality are important in several series. Since the 1990s, the development of laparoscopic and thoracoscopic techniques has markedly reduced operative morbidity and mortality in several fields of surgical specialties, from colecistectomy to resection of mediastinal lesions. However, to our knowledge, these advances were not applied to pharyngoesophageal reconstruction yet. In a comprehen-
sive MEDLINE search, some authors used laparoscopic approaches only to harvest jejunal segments to be microscopically transplanted to the cervical area.15,16 The first author published the first series of laparoscopic transhiatal esophagectomy with esophagogastroplasty in 1995,17 which comprised 12 patients (with two esophageal cancers). The present study evaluated the experience of a multidisciplinary team, including general surgeons, head and neck surgeons, thoracic surgeons, clinical oncologists, and radiation oncologists, in two institutions with a series of 120 patients with esophageal cancers who underwent LGPU, associated or not with a thoracoscopy. The main focus of this analysis was on morbidity and mortality rates. Even when dealing with a potentially debilitating disease, such as esophageal cancer, the use of laparoscopic technique to harvest the gastric tube obviously decreased surgical injury in these patients. In addition, our mortality and morbidity rates were similar to a smaller series of 22 patients submitted to laparoscopic gastric pull-up recently reported by Avital et al.20 They found 4.5% mortality and 27.2% morbidity rates. The thoracoscopic dissection of the thoracic esophagus during gastric pull-up has been described previously by Law et al.18 In the present series, when a thoracoscopy had to be added, to enable a safer dissection of the thoracic esophagus, morbidity still remained at an acceptable level. Both results (23% and 56% morbidity rates, respectively) compared favorably with a recent series published by Chu and Chang,14 including conventional gastric pull-up (64% morbidity rate). We noted several technical details that favored this endoscopic approach: practically bloodless abdominal operation; dissection of the thoracic esophagus under direct vision (either by laparoscopy or thoracoscopy), avoiding potentially hazardous hemorrhages (stapling and sectioning of azigus vein was particularly important in this regard), and offering a direct visual communication with the head and neck surgical team; and finally, conduction of the gastric tube to the neck under direct monitoring. It is important to emphasize that no patient in the present series had a hypopharyngeal cancer. Nonetheless, we believe that it is relevant to present these results to the head and neck surgeon, in order to offer a sound oncological reconstructive option, with a clear reduction in both operative mortality and morbidity rates. As a matter of fact, it is easier to dissect an uninvolved esophagus, probably reducing the need for thoracoscopy in many more instances than in the present series, decreasing the morbidity even further. In conclusion, our results demonstrated that laparoscopic gastric pull-up is a safe and reliable method for reconstruction of the upper digestive tract and could be considered as an option for rehabilitation after resection of hypopharyngeal and cervical esophageal cancers, especially if the thoracic esophagus needs to be excised as well, due to oncological reasons.
DePaula et al
Reconstruction of upper digestive tract: Reducing . . .
REFERENCES 1. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J Natl Cancer Inst 1996;88: 890 –9. 2. Wei WI, Sham JST. Extent of resection of hypopharyngeal cancer. In: Wei WI, Sham JST, editors. Cancer of the larynx and hypopharynx. Oxford, UK: Isis Media Medical Ltd.; 2000. p. 95–104. 3. Bakamjiam VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965; 36:173– 84. 4. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73– 81. 5. Haller JR. Concepts in pharyngoesophageal reconstruction. Otolaryngol Clin North Am 1997;30:655– 61. 6. Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg 2005;131:796 –9. 7. Yu P. One-stage reconstruction of complex pharyngoesophageal, tracheal, and anterior neck defects. Plast Reconstr Surg 2005;116:949 –56. 8. Morais-Besteiro J, Cernea CR, dos Santos LR, et al. Microvascular flaps in head and neck reconstruction. Head Neck 1990;12:21–30. 9. Kroll SS, Schusterman MA, Reece GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 199;98:459-63. 10. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after circumferential pharyngoesophageal reconstruction. Laryngoscope 2005;115:1266 –71.
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