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Report of 351 Pharyngoesophageal Reconstructions, and an Algorithmic Approach
Jesse C. Selber, MD, MPH1, Amy Xue, M.D.2, Jun Lui, PhD1, Matthew Hanasono, MD1, Roman Skoracki, MD1, Peirong Yu, MD1.
1M,D, Anderson Cancer Center, Houston, TX, USA, 2Baylor School of Medicine, Houston, TX, USA.
PURPOSE: Traditionally, pharyngoesophageal reconstruction has been performed using free jejunem or radial forearm flaps. For the last decade, we have added the anterolateral thigh flap (ALT) and supercharged jejunum (SCJ). The purpose of this study was to analyze the long term clinical and functional outcomes achieved with all techniques in the largest series of pharyngoesophageal reconstructions ever reported.
METHODS: A retrospective review of a prospectively maintained database was performed. All 351 patients who underwent pharyngoesophageal reconstruction from March 2000 to June 2011 at MD Anderson Cancer Center were included in the study. Defects were categorized as partial or circumferential, and grouped by location including total laryngopharyngectomy with and without an oral component, isolated cervical esophagectomy and total esophagectomy. Data were collected from assessments by Plastic Surgery, Speech & Swallow Therapy and Nutrition. Patient data were examined for comorbidities, defect types, flap types, donor and recipient sites, hospitalization, and postoperative complications. Postoperative diet and tracheoesophageal puncture (TEP) speech were evaluated.
RESULTS: A total of 351 patients underwent pharyngoesophageal reconstructions. Eighty-eight (25%) were female and 263 (75%) were male. The average age was 60.1±11.1 years and BMI was 24.4±5.9 kg/m2. The follow up period was 15.4 ±17.5 months. Reconstruction was performed with an anterolateral flap (n=203;67.8%), supercharged jejunum (n=53;15.1%), radial forearm (n=41;11.7%), free jejunum (n=16;4.6%), pectoralis myocutaneous flap (n=21;6.0%), or alternative flaps (n=17;4.8%). One hundred and seventy-four patients (50%) had pre-operative radiation and 48(13.6%) had post-operative radiation. Forty-six patients (13.1%) had histology other than squamous cell carcinoma. Among 351 patients, 193 (55%) had circumferential defects and 158 (45%) had partial defects. The majority of defects were total laryngopharyngectomies (64%). One hundred and thirty-seven patients (39%) had complications. Eighty-one patients (23%) had receipt site and 51(14%) had donor site complications. The overall complication rates were not significantly different among defect locations. The fistula rate was significantly higher in laryngopharyngectomy defects with an oral component (mandible, tongue, etc.) than with other defect types (33.3%vs.8%,p=0.020). The overall complication rates were not significantly different between circumferential and partial defect patients. Fistula rate was slightly higher in circumferential defect patients, but the difference was not significant (11%vs.6% p=0.135). The stricture rate was significantly higher in circumferential defect patients (9.3%vs.3.8%,p=0.041). Among 351 patients, 308(88%) had an oral diet after reconstruction; 43 patients (12%) were completely tube fed. Among 125 TEP patients, 11(8.8%) had failures. Approximate 90% of patients had fluent TEP speech. Patients who underwent supercharged or free jejunal flaps had a significantly higher percentage of soft or regular diet (p<0.001) than other types of reconstructions.
CONCLUSIONS: This series demonstrates that pharyngoesophageal reconstruction can be achieved with excellent clinical and functional outcomes, and minimal donor site morbidity. Most patients will speak and swallow effectively, in spite of total laryngopharyngectomy defects. Fistula rate is higher with more extensive anatomic defects, and stricture rate is higher with circumferential defects. SCJ reconstructions result in regular diet more frequently than other reconstructions.
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