The surgical care of large and invasive proximal esophageal and upper airway tumors has evolved significantly over the last half century. Although beyond the scope of this article, a comprehensive review of early techniques for reconstruction of the laryngopharynx and cervical esophagus was published by Fabian.
Reconstruction of the laryngopharynx and cervical esophagus.
It offers a historical perspective and a logical timeline from the first survivable esophageal surgery and the early use of prosthetics through attempts at autografts and mucosal flaps, and finally the introduction of free tissue grafting. At that time, the 5-year survival rate for resection and reconstruction of the cervical esophagus and upper airway was 24%. The most complex lesions involving both trachea and esophagus, once thought inoperable, are now resected with good oncologic outcome followed by any of several well-accepted reconstruction options. These techniques include but are not limited to jejunal free flaps, pedicled local muscle flaps, and free anterolateral thigh flaps.
- Ghali S.
- Chang E.I.
- Rice D.C.
- et al.
Microsurgical reconstruction of combined tracheal and total esophageal defects.
Mediastinal tracheostomy is indicated in cases of extensive laryngotracheal resection where the residual trachea is too short to accommodate a cervical tracheostomy. This complex operation carries with it high morbidity rates between 20% and 70%, and mortality rate of up to 18%.
- Martinod Emmanuel
- Guillaume Jean-Yves
- Radu Dana M.
- et al.
A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea.
We describe mediastinal tracheostomy with vessel transposition and minimally invasive transhiatal esophagectomy. These procedures are useful for the thoracic surgeon in the treatment of both primary tracheal pathologies and secondary tracheal involvement as in the case of locally advanced head and neck cancers.
- Kamiyama R.
- Mitani H.
- Yonekawa H.
- et al.
A clinical study of pharyngolaryngectomy with total esophagectomy: Postoperative complications, countermeasures, and prognoses.
- Zhong Z.
- Zhao E.
- Xiao S.
- et al.
Surgical treatment for cervicothoracic esophageal carcinoma with tracheal involvement.
- Conti M.
- Benhamed L.
- Mortuaire G.
- et al.
Indications and results of anterior mediastinal tracheostomy for malignancies.
As originally published in 1992: Anterior mediastinal tracheostomy with and without cervical exenteration.
The rate of secondary head and neck malignancies after radiation treatment to neck is not trivial. In cases where the second tumor is ineligible for additional neck radiation, this procedure provides a definitive or palliative solution. The technique may also prove useful in the resection and reconstruction of tracheal anatomy for inoperable tumors. Mediastinal tracheostomy can be placed de novo during initial laryngotracheal resection, and it is also easily applied to the patient with a pre-existing tracheostomy in situ.
Careful multidisciplinary operative planning and informed consent are one of the keys to the success of these complex operations. Head and neck surgeons, medical oncologists, radiation oncologists, speech pathologists, and respiratory therapists are among the multidisciplinary team that would assist the thoracic surgeon. Intraoperatively, the team approach is also of paramount importance in decreasing operative time and minimizing morbidity related to positioning and airway control.
We describe a rare and complex procedure: resection and reconstruction of advanced cervical esophageal cancer in patients who are not candidates for the traditional therapeutic option of definitive chemotherapy and radiation. The successful undertaking of this operation requires open and direct communication between the members of the multidisciplinary team. Following the operation, the arduous recovery process requires a motivated patient and a skilled team familiar with the postoperative pitfalls.
Airway management is of foremost importance. The patient may be liberated from the ventilator immediately after the operation, or, depending on operative length and circumstances, shortly thereafter. The authors suggest an early postoperative chest radiograph to rule out pneumothorax in cases where the pleura was knowingly or inadvertently injured. Once off the ventilator, oxygen or room air should be delivered through a humidifier, and ultimately through a heat and moisture exchanger valve.
Pulmonary toilet with physical chest percussion, mucolytic nebulizers, and frequent suctioning would prevent mucous plugging. The patient and caregivers must be aware of positioning restrictions given the now obligate chest breather.
Drains are monitored for changes in volume and character to rule out chylothorax or deep space infections, and are removed sequentially once the output decreases. The perianastomotic drain is left in place until esophagram rules out a leak. The authors perform esophagrams on postoperative day 7, or day 14 in the previously irradiated neck.
Broad-spectrum perioperative antibiotic coverage is mandatory given obligate entry into the airway and gastrointestinal tract. In particular, when the entire gastric conduit is used, a longer antibiotic course may be warranted given the increased risk of ischemia and leak in the neck. Mitigating a mediastinal infection is paramount, but it must be weighed against the drawbacks of lengthy antibiotic use as well.
Given the lengthy procedure and the oncologic diagnosis, early prophylaxis for venous thromboembolism is encouraged. However, we consider this on a day-by-day basis as typically the postoperative hemoglobin levels in an esophagectomy patients would drift down. We have a high threshold for blood transfusions given the association with decreased survival in oncologic patients.
- Satomoto M.
- Suzuki A.
- Uchida T.
- et al.
Potential influence of pre and intraoperative factors on postoperative recurrence and survival in patients undergoing radical resection of esophageal cancer.
The confined space of the neck and position of the drains should help in early identification of an unlikely event of a bleeding complication.
Complications can extend far outside the immediate postoperative period. These patients would require careful long-term follow-up and multispecialty care regardless of the primary disease for which the resection was performed. In one case series prospectively collected over 9 years,
- Bagheri R.
- Rahim M.B.
- Majidi M.
- et al.
Anterior mediastinal tracheostomy for malignancy: Analysis of 12 cases.
12 patients underwent anterior mediastinal tracheostomy for recurrent tracheal disease, primary tracheal carcinomas with subglottic extension, or carcinoma of the tracheal esophagus (3/12). They were followed up for at least 1 year; the procedure was highly successful, with complete tumor excision in all patients, however, the morbidity rate was high; postoperative complications included atelectasis (3/10), stomal necrosis (1/10), and anastomotic leak (1/10), with a 16.6% in hospital mortality.
Complications were similar in a group of 10 patients with primary esophageal cancers who underwent total laryngopharyngoesophaectomy with gastric pull-up over a 10-year period. In all, 7 of 10 patients had preoperative radiotherapy. The most common complications were tracheal necrosis (60%) and anastomotic leakage in the neck (30%). Postoperative hemorrhage (20%) and anastomotic stricture (10%) were less common.
- Homma A.
- Nakamaru Y.
- Hatakeyama H.
- et al.
Early and long-term morbidity after minimally invasive total laryngo-pharyngo-esophagectomy with gastric pull-up reconstruction via thoracoscopy, laparoscopy and cervical incision.
Monitoring patients in the long term for further complications such as stricture of the tracheal stoma and tracheoinnominate fistula.
Finally, quality of life is a major consideration. A total of 29 patients who underwent pharyngolaryngoesophagectomy with pharyngogastric anastomosis for upper aerodigestive tract tumors completed questionnaires. All respondents were able to complete activities of daily living, and 70% reported acceptable voice rehabilitation.
- Affleck D.G.
- Karwande S.V.
- Bull D.A.
- et al.
Functional outcome and survival after pharyngolaryngoesophagectomy for cancer.
Treatment goals and patient expectations should weigh heavily in the decision to offer this complex operation, and they should be discussed at length preoperatively.