Total reconstruction of the hypopharynx and cervical esophagus

Patients with extensive circumferential tumors of the hypopharynx and those with carcinomas of the cervical esophagus usually require resection of a cylindrical segment of the upper digestive tube. These patients present similar difficulties of reconstruction and also share a very poor prognosis. At times, the same complicated technical effort is required for palliation and definitive cure alike. From 1970 through 1982 at the University of Texas-M.D. Anderson Hospital at Houston, 78 patients underwent complete resection of the hypopharynx (54 patients) or the cervical esophagus (24 patients) for advanced malignant tumors. Seventy-three tumors were squamous cell carcinomas, and the remaining 5 were cancers that originated in the salivary gland. These large tumors were not staged according to the TNM system, since they frequently involved two different anatomic structures and a precise clinical assessment was not always possible. The only criterion for inclusion of patients in this series was the need to replace the entire pharynx or cervical esophagus after removal of the cancer. Of the 78 patients, 64 received their entire treatment at our institution, and of this group, 44 patients had only one surgical procedure. All patients in the series had circumferential resection as the final surgical step at our institution. The types of repair used in this group of patients were a cutaneous flap or graft in 44 patients, a colon bypass in 16 patients, a lateral trapezius musculocutaneous flap in 9 patients, and a pectoralis major musculocutaneous flap in 6 patients. In three additional patients, the reconstruction was initially delayed for various reasons and was ultimately abandoned. Technical considerations and a detailed analysis of the complications and palliative value of each procedure are presented. The merit of these procedures is judged according to the quality and the length of the patient's survival. Although the degree of palliation varies considerably according to the technique used, the survival rates were similar in all cases, the average being 43 percent at 5 years after the first treatment attempt and 27 percent at 5 years after the surgical resection that required a complete circumferential reconstruction.