Reconstruction of the pharynx and cervical esophagus

The recent twenty years have brought major advances in reconstruction of pharyngoesophageal defects. Early dependence on multiple staged procedures initially were replaced by colon interposition and gastric pull-up. Subsequent elucidation of the musculocutaneous concept has added useful techniques such as the sternocleidomastoid and pectoralis major musculocutaneous flaps. Increasing experience with microsurgical reconstruction and a larger number of flaps available have made free tissue transfer a common and reliable method of reconstruction of significant defects. The choice of reconstruction depends to greatest degree on the oncologic needs of the situation. If the entire esophagus or significant part of the thoracic esophagus is involved by tumor then total esophagectomy and gastric pull-up or colon interposition is indicated. For most hypopharyngeal and laryngopharyngeal tumors, and a significant number of cervical esophageal tumors, segmental resection of the area with the appropriate node dissection and replacement with a jejunal free autograft or radial forearm free flap gives a high likelihood of success. Thoracic musculocutaneous flaps may be useful if proper precautions are observed in the reconstructive technique. This article presents the accumulated experience with these techniques and management of the subsequent problems.