Pharyngectomy

Armamentarium

  • #15 Scalpel

  • Allis forceps

  • Appropriate sutures

  • Cat’s paw retractors

  • Dissecting forceps

  • Dissecting scissors

  • Freer elevator

  • Langenbeck retractors

  • Local anesthetic with vasoconstrictor

  • Monopolar and bipolar electrocautery

  • Nasogastric tube

  • Needle holder

  • Skin hooks

  • Suction drains of choice

  • Tooth and nontooth Adson forceps

History of the Procedure

The history of pharyngectomy dates back to 1878, when Cheever described lateral pharyngectomy with mandibulectomy and lymph node dissection for a large tonsil tumor. Unfortunately, the patient developed local and regional recurrence. Various techniques for resection of hypopharyngeal cancer have evolved since then. Sebileau, in 1904, described partial pharyngectomy via a lateral retrothyroid approach. This was followed by Trotter’s development of the lateral pharyngectomy in 1913. Supracricoid-hemilaryngo-pharyngectomy was subsequently described by Andre, Pinel, and Laccourreye (1962). Ogura, in 1965, developed extended supraglottic-laryngo-pharyngectomy. All of these procedures were suitable for T1 and T2 hypopharyngeal cancers. Following the refinement of radiation therapy techniques that evolved during the twentieth century, these tumors could well be treated with radical radiotherapy with similar oncologic outcomes and lower morbidity. Furthermore, owing to the high incidence of neck nodal metastasis even among T1 and T2 hypopharyngeal cancers, patients treated with partial pharyngectomy and neck dissection would often require adjuvant radiotherapy anyway. Thus, single modality radiotherapy or chemoradiotherapy was recommended to treat these patients, with surgery being reserved as a salvage procedure. Finally, hypopharyngeal cancers, because of their aggressive nature and tendency of submucosal spread (especially postcricoid cancers), require resection using wide surgical margins, which cannot be generally obtained by partial pharyngectomy. Today, the indication for conservative pharyngeal surgery is limited to endoscopic laser resection or transoral robotic surgery in a selected group of patients with early tumors (T1, T2, and rarely T3 tumors) performed by specially trained surgeons. Open surgery such as total laryngectomy with partial pharyngectomy, total laryngo-pharyngectomy, or total laryngo-pharyngo-esophagectomy with appropriate reconstruction is indicated for T4a cancers and recurrent/residual cancers after radiotherapy or chemoradiotherapy. Table 106-1 lists various treatment options for hypopharyngeal cancers.

Table 106-1
Pharyngectomy Reconstructive Options
Pectoralis Major Myocutaneous (PMMC) Flap ( Chapter 111 )
  • Introduced by Ariyian in 1979

  • First used by Whiters and colleagues in the same year for reconstruction of circumferential hypopharyngeal defects in a tubed form

Indications
  • Partial defects in the pharyngeal mucosa (the width of the flap is decided by the width of the remnant pharyngeal mucosa)

  • Circumferential defects in the pharyngeal mucosa (the width of the flap required is 8 to 10 cm)

Contraindications
  • Resection margin reaching beyond the thoracic inlet

  • Defects longer than 11 to 12 cm

Advantages
  • Operating time is reduced, which is especially important among emaciated and fragile hypopharyngeal cancer patients

  • Fan-shaped muscular portion of the flap is helpful for protecting the carotid artery, especially in post-radiotherapy patients

  • No microsurgical training is required

  • The flap donor site can be closed primarily with minimal morbidity

Disadvantages
  • This flap provides a suboptimal reconstructive choice when a significant part of the base of tongue or the lateral oropharyngeal wall has been resected; the weight and the downward traction of the flap significantly impair the mobility of the tongue, resulting in degradation of augmented speech and poorer swallowing function

  • The bulkiness of the flap makes it difficult to be sutured at the relatively narrow cervical esophageal stump, resulting in circumferential stenosis; this can be partially overcome by performing interdigitations to provide a zigzag configuration at the distal anastomosis

  • The bulkiness and rigidity of the PMMC flap reduce its vibratory properties, resulting in poor phonatory outcomes

  • The flap can result in distortion and blocking of the tracheostoma in obese patients and patients with a short neck

  • For circumferential defects, the three-point closure sites are prone to fistula formation and subsequent stenosis

  • Complication rates in relation to stenosis and pharyngocutaneous fistula are higher as compared to free flaps

  • May result in significant breast deformity in female patients

Remarks
  • As the muscle bulk sometimes prevents complete tubulization, Fabian and Spriano and colleagues modified the technique by using a U-shaped reconstruction of the circumferential hypopharyngeal defect by suturing the flap edges to the prevertebral fascia, either covering the fascia by a skin graft or leaving it bare

  • The PMMC flap can be considered a reconstructive option for thin male patients with partial hypopharyngeal defects and significant comorbidity where a prolonged operative time is to be avoided

Radial Forearm Free Flap (RFFF) ( Chapter 114 )
  • Introduced by Yang and colleagues in 1981

  • Used for hypopharyngeal reconstruction for the first time in 1985 by Harii

Indications
  • Partial defects in the pharyngeal mucosa

  • Circumferential defects in the pharyngeal mucosa

Contraindications Resection margin reaching beyond the thoracic inlet
Advantages
  • The pharyngocutaneous fistula rates are lower than those with the PMMC flap and comparable with other free flaps

  • Its long vascular pedicle, low donor site morbidity, good caliber vessels, tolerance to long ischemia times, and relative ease in harvesting make it a good option for pharyngeal reconstruction

  • The radial artery and the cephalic vein have a certain degree of independence from each other, which makes microvascular anastomosis possible on recipient vessels located at considerable distance from each other, even on opposite sides of the neck

  • A skin island of up to 12 to 14 cm 2 can easily be harvested without donor site problems

  • The good pliability of the flap has a definite advantage over PMMC and anterolateral thigh (ALT) flaps, especially among obese patients, resulting in superior voice and swallowing outcome

  • The low volume of the flap does not hamper primary closure of the neck

  • Hair growth even in men is exceedingly low on the volar aspect of the forearm as compared with the thigh and the chest

Disadvantages
  • Potential donor site morbidities including tendon exposure, partial loss of skin graft, hypovascularization with cold intolerance, and transient or permanent numbness of the first two fingers and dorsum of hand

  • The flap does not provide muscle for covering the carotids or reinforcing the pharyngeal closure

  • Three-point closure is required for circumferential defects

Anterolateral Thigh Flap (ALT) ( Chapter 119 ) Introduced by Song and colleagues in 1984
Indications
  • Partial defects in the pharyngeal mucosa

  • Circumferential defects in the pharyngeal mucosa

Contraindications Resection margin reaching beyond the thoracic inlet obvious severe peripheral vascular disease (preoperative angiography is warranted in these circumstances)
Advantages
  • The pharyngocutaneous fistula rate of the ALT flap is lower than that observed in RFFF; this may be related to the generous amount of vascularized fascia lata that can be harvested with the flap, which can be used as a second layer closure; a lower fistula rate is associated with a lower rate of stenosis formation

  • In selected patients, an extensive portion of the vastus lateralis muscle can be harvested with the skin or independently, and it can be used for a second layer closure over the suture line or for protecting the great vessels of the neck

  • Large skin paddles or two separate skin paddles can be harvested with minimal donor site morbidity

  • Remoteness of the thigh from the head and neck makes the two-surgical-team approach possible, thus reducing the operating time

  • As hypopharyngeal cancer patients are frequently emaciated, they have decreased thigh bulk, which facilitates tubing the flap for circumferential defects

  • The diameter of the tubed flap corresponds well with the diameter of the remnant oropharyngeal mucosa in circumferential defects

Disadvantages
  • In obese patients, the bulk of the flap impairs the vibratory property of the neopharynx, resulting in poor speech

  • Mismatch in lumen diameter between the tubed flap and the cervical esophagus in circumferential defects

  • Three-point closure is required for circumferential defects

Remarks As a general rule, the ALT free flap is the first-line reconstructive option for pharyngeal defects; the only limiting factors are the requirement for microvascular expertise and prolonged operating time
Jejunal Free Flaps Introduced by Seidenberg and colleagues in 1959
Indications Circumferential pharyngeal defects
Contraindications Resection margin reaching beyond the thoracic inlet
Advantages
  • Diameter of the jejunum matches with the esophageal stump mucosa

  • For circumferential defects, there is no three-point closure, as required in tubed fasciocutaneous or PMMC flaps

  • Mucosa is replaced by mucosa

  • Intrinsic peristaltic activity of the jejunum helps in bolus propulsion; however, the initial peristaltic movements are not coordinated, and patients usually complain of dysphagia in the early postoperative period

Disadvantages
  • Perioperative donor site complications are high; mortality ranges from 0% to 17% (mean, 2.5%), which is four times higher than for fasciocutaneous free flaps; morbidities of an abdominal surgery include bowel obstruction, abdominal bleeding, acute gastric dilatation, superior mesenteric syndrome, laparocele, wound infection or dehiscence, abdominal wall hematoma, and prolonged ileus

  • Limited ischemic tolerance of the jejunal flap commonly results in partial necrosis, pharyngocutaneous fistula, and subsequent stenosis.

  • The length of the vascular pedicle (10 to 15 cm) is roughly half that usually observed in RFFF and ALT free flaps

  • Voice (in patients with a tracheoesophageal puncture) is usually “wet and gurgly”

  • Tolerance of the jejunum to radiotherapy is only 50 Gy, which is lower than the recommended dose of postoperative adjuvant radiotherapy in head and neck cancer patients

  • Three intestinal and two microvascular anastomoses are required

  • The flimsy and friable nature of vessels (particularly the vein) as compared to fasciocutaneous flaps.

  • There is a frequent mismatch in diameter at the pharyngeal end

  • External skin defect, if present, requires another flap

Gastro-omental Flap Introduced by Baudet in 1979
Indications Circumferential pharyngeal defects
Contraindications Resection margin reaching beyond the thoracic inlet
Advantages
  • The main advantage over a jejunal free flap is the provision of a generous amount of highly vascularized greater omentum to be draped around the neopharyngeal conduit, covering the great vessels and filling dead space

  • Length of gut that can be obtained is about 30 cm

  • Good caliber vessels and superb independent mobility of the gastroepiploic vascular pedicle

Disadvantages High perioperative donor site complications (similar to jejunal flap)
Remarks
  • Gastro-omental free flap is currently recommended in the management of

  • select, complicated high-risk conditions in which a generally healthy patient (able to withstand the potential complications of an abdominal procedure) is associated with a serious local wound problem owing to infection, hypovascularization, or necrosis

Gastric Pull-Up Introduced by Ong and Lee, and was popularized by Le Quesne and Ranger in 1966
Indications Only reconstructive option when the tumor extends to the thoracic esophagus or the resection margin reaches beyond the thoracic inlet
Contraindications High upper limit of resection of pharynx (oropharynx or above) where reach of mobilized stomach is difficult
Advantages
  • One-stage procedure and a single intestinal anastomosis required

  • No microvascular expertise required

Disadvantages
  • Complications of abdominal surgery as previously mentioned

  • Gastric reflux and early satiety

History of the Procedure

The history of pharyngectomy dates back to 1878, when Cheever described lateral pharyngectomy with mandibulectomy and lymph node dissection for a large tonsil tumor. Unfortunately, the patient developed local and regional recurrence. Various techniques for resection of hypopharyngeal cancer have evolved since then. Sebileau, in 1904, described partial pharyngectomy via a lateral retrothyroid approach. This was followed by Trotter’s development of the lateral pharyngectomy in 1913. Supracricoid-hemilaryngo-pharyngectomy was subsequently described by Andre, Pinel, and Laccourreye (1962). Ogura, in 1965, developed extended supraglottic-laryngo-pharyngectomy. All of these procedures were suitable for T1 and T2 hypopharyngeal cancers. Following the refinement of radiation therapy techniques that evolved during the twentieth century, these tumors could well be treated with radical radiotherapy with similar oncologic outcomes and lower morbidity. Furthermore, owing to the high incidence of neck nodal metastasis even among T1 and T2 hypopharyngeal cancers, patients treated with partial pharyngectomy and neck dissection would often require adjuvant radiotherapy anyway. Thus, single modality radiotherapy or chemoradiotherapy was recommended to treat these patients, with surgery being reserved as a salvage procedure. Finally, hypopharyngeal cancers, because of their aggressive nature and tendency of submucosal spread (especially postcricoid cancers), require resection using wide surgical margins, which cannot be generally obtained by partial pharyngectomy. Today, the indication for conservative pharyngeal surgery is limited to endoscopic laser resection or transoral robotic surgery in a selected group of patients with early tumors (T1, T2, and rarely T3 tumors) performed by specially trained surgeons. Open surgery such as total laryngectomy with partial pharyngectomy, total laryngo-pharyngectomy, or total laryngo-pharyngo-esophagectomy with appropriate reconstruction is indicated for T4a cancers and recurrent/residual cancers after radiotherapy or chemoradiotherapy. Table 106-1 lists various treatment options for hypopharyngeal cancers.

Table 106-1
Pharyngectomy Reconstructive Options
Pectoralis Major Myocutaneous (PMMC) Flap ( Chapter 111 )
  • Introduced by Ariyian in 1979

  • First used by Whiters and colleagues in the same year for reconstruction of circumferential hypopharyngeal defects in a tubed form

Indications
  • Partial defects in the pharyngeal mucosa (the width of the flap is decided by the width of the remnant pharyngeal mucosa)

  • Circumferential defects in the pharyngeal mucosa (the width of the flap required is 8 to 10 cm)

Contraindications
  • Resection margin reaching beyond the thoracic inlet

  • Defects longer than 11 to 12 cm

Advantages
  • Operating time is reduced, which is especially important among emaciated and fragile hypopharyngeal cancer patients

  • Fan-shaped muscular portion of the flap is helpful for protecting the carotid artery, especially in post-radiotherapy patients

  • No microsurgical training is required

  • The flap donor site can be closed primarily with minimal morbidity

Disadvantages
  • This flap provides a suboptimal reconstructive choice when a significant part of the base of tongue or the lateral oropharyngeal wall has been resected; the weight and the downward traction of the flap significantly impair the mobility of the tongue, resulting in degradation of augmented speech and poorer swallowing function

  • The bulkiness of the flap makes it difficult to be sutured at the relatively narrow cervical esophageal stump, resulting in circumferential stenosis; this can be partially overcome by performing interdigitations to provide a zigzag configuration at the distal anastomosis

  • The bulkiness and rigidity of the PMMC flap reduce its vibratory properties, resulting in poor phonatory outcomes

  • The flap can result in distortion and blocking of the tracheostoma in obese patients and patients with a short neck

  • For circumferential defects, the three-point closure sites are prone to fistula formation and subsequent stenosis

  • Complication rates in relation to stenosis and pharyngocutaneous fistula are higher as compared to free flaps

  • May result in significant breast deformity in female patients

Remarks
  • As the muscle bulk sometimes prevents complete tubulization, Fabian and Spriano and colleagues modified the technique by using a U-shaped reconstruction of the circumferential hypopharyngeal defect by suturing the flap edges to the prevertebral fascia, either covering the fascia by a skin graft or leaving it bare

  • The PMMC flap can be considered a reconstructive option for thin male patients with partial hypopharyngeal defects and significant comorbidity where a prolonged operative time is to be avoided

Radial Forearm Free Flap (RFFF) ( Chapter 114 )
  • Introduced by Yang and colleagues in 1981

  • Used for hypopharyngeal reconstruction for the first time in 1985 by Harii

Indications
  • Partial defects in the pharyngeal mucosa

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Pharyngectomy
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