Total posterior tracheal wall resection and reconstruction with pharyngolaryngoesophagectomy

Extensive posterior tracheal wall invasion in pharyngoesophageal carcinomas is considered by many authors to be a contraindication for total pharyngolaryngoesophagectomy and gastric transposition (TPLEGT). The purpose of this report is to challenge this concept and to illustrate posterior tracheal wall resection in selected cases followed by reconstruction of the trachea by anastomosis of the remnant trachea to the anterior gastric wall without thoracotomy.

Four of 36 consecutive patients (11%) undergoing TPLEGT were treated with the following procedure: 3 patients had cervical esophageal carcinomas and 1 had a postcricoid carcinoma. All the patients had longitudinal involvement of the posterior wall of the trachea, which necessitated resection within 1.5 to 2.0 cm of the carina. The technique consisted of removing the specimen en bloc with the posterior wall of the trachea. Without the specimen in place, the surgical field at the thoracic inlet was large enough to permit a continuous running suture between the remnant tracheal wall and the serosa of the transposed stomach. The pharyngogastric anastomosis was subsequent to this procedure.

One patient died in the hospital after complications of chylothorax and sepsis, but this was unrelated to the gastrotracheal anastomosis. One patient died of pneumonia after a cerebrovascular accident 2 months after the procedure. Two patients had effective palliation for 9 and 18 months, respectively.

TPLEGT may be used in selected patients with pharyngoesophageal tumors. The anterior wall of the stomach is a suitable substitute for the posterior tracheal wall. The gastric bulging into the trachea is not enough to obstruct the lumen. However, we caution that tracheal involvement should be limited to the midline and that there is a potential for a gastrotracheal fistula.