Eur J Cardiothorac Surg 2001;19:406-410
© 2001 Elsevier Science NL
Functional results following pharyngolaryngooesophagectomy with free jejunal graft reconstruction
G.C. Oniscua,
W.S. Walkera,
R. Sandersonb
a Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW, UK
b Department of Otorhynolaryngology, City Hospital, Edinburgh, UK
Received 21 November 2000;
received in revised form 11 February 2001;
accepted 11 February 2001.
Corresponding author. Tel.: +44-131-536-3457; fax: +44-131-536-4194
e-mail: gabriel{at}oniscu.dabsol.co.uk
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Abstract
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Objective: A free jejunal graft is used for reconstruction following pharyngolaryngooesophagectomy, due to the relative ease of harvesting, low donor site morbidity and a lumen diameter compatible with that of the oesophagus. Our aim is to evaluate the postoperative outcome and functional results of the procedure. Methods: Retrospective analysis of 20 consecutive patients, with a mean age of 62.5 years (range 48–76), who underwent free jejunal reconstruction following pharyngolaryngooesophagectomy for laryngeal malignancy. Surgery was performed secondary to radiotherapy or as the main stem of treatment. The functional results were assessed at 6 months and 1 year and correlated with postoperative morbidity. Chi-square test was used for statistical significance and Kaplan–Meyer to estimate survival. Results: There were six transient leaks and six cases with anastomotic stricture. There was no morbidity associated with the donor site and the perioperative mortality (30 days) was zero. At 6 months, 13 (87%) out of the 15 patients alive had satisfactory speech and 11 (78%) had satisfactory swallowing. At 1 year, 11 patients were alive and maintained a satisfactory speech, while nine (81%) of them were eating well. The incidence of leaks, strictures, or the moment of radiotherapy has no influence on the functional outcome. The 1- and 3-year survival rates were 52.3 and 33.2%, respectively. Conclusions: A free jejunal graft reconstruction is technically demanding, but provides a near-physiologic swallowing mechanism, avoiding the complications of a gastric pull-up procedure. Functional results are good and justify the procedure despite the relatively high co-morbidity.
Key Words: Pharyngo-laryngeal tumor • Pharyngolaryngooesophagectomy • Free jejunal graft • Functional results • Morbidity • Mortality
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1. Introduction
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Restoring digestive continuity following pharynolaryngooesophagectomy for hypopharyngeal and cervical oesophageal cancer is a significant surgical challenge. Several methods have been employed, depending on the extent of oesophageal resection, but many of them are limited in their ability to provide good functional results because of the adynamic nature of the tissue used [1,2]. Stomach transposition continues to be a popular method in some centres but has significant morbidity [3], requires resection of the entire thoracic oesophagus and empties well only in the upright position due to the associated vagotomy [4]. In 1959, Seidenberg introduced the reconstruction with a free jejunal graft [5] and the procedure became widely spread with the use of microvascular anastomosis techniques. It is a good alternative to gastric pull-up, due to its relatively ease of harvesting, low donor site morbidity and good size approximation to the oesophageal lumen. However, there are contradictory reports regarding the quality of speech [6,7], incidence of dysphagia [8,9] and the ability to tolerate postoperative radiotherapy [10,11].
Against this background we aim to review a series of 20 cases with free jejunal reconstruction and discuss the postoperative complications and the functional results of the procedure.
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2. Materials and methods
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Between January 1991 and November 1999, 20 patients (17 men, three women) with a median age of 62.5 years (range 48–76 years), underwent pharyngolaryngooesophagectomy with free jejunal graft reconstruction for squamous carcinomas of the hypopharynx. The graft artery was implanted end-to-side on a common carotid artery after a preoperative Doppler ultrasound confirmed it to be disease free, while the venous anastomosis was carried out in a similar manner with the corresponding internal jugular vein. The graft was implanted in an isoperistaltic position and anastomosed end-to-end with the oesophagus. The top end of the graft was cut obliquely, when necessary, to compensate for the calibre difference and allow a good end-to-end anastomosis to be carried out. A Bloom–Singer phonation valve was inserted within two weeks following the procedure, using a tracheo-oesophageal puncture fashioned during surgery.
Five cases were initially treated only with radiotherapy, but the tumour recurred after a median interval of 194 months (range 11.5–572 months) requiring surgery. Seven patients had a combined treatment, two receiving preoperative neo-adjuvant radiotherapy, while the other five had postoperative radiotherapy at a median interval of 3 months (range 48–168 days). The remaining eight cases were treated with surgery alone. Of the 15 primary tumours, eight were T4, four were T3 while the remaining three were T2 (two cases) and T1 (one case).
Patients were considered to have a satisfactory voice, when they had a good volume, some degree of pitch variation or fluent speech. Swallowing was considered to be good when patients were able to tolerate solid or mixed oral diet. The postoperative functional evaluations were carried out at 6 months and 1 year. The follow-up interval varied between 3 months and 5 years and the data were retrospectively collected from patients’ case notes. The length of survival was determined from the day of operation and was calculated by the Kaplan–Meier method. The statistical analysis was performed with the SPSS program (version 9.0), using Fischer's exact test and Chi-square where appropriate.
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3. Results
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No patient died in the postoperative period (30 days). The mean duration of the procedure was 340 min (range 200–520), with the extreme in a case that required a second graft, due to intra-operative jejunal thrombosis. The naso-gastric tube was removed on average at 13 days, oral feeding was restarted at 26 days (7–146) and patients discharged home at 28 days (0–146) following their surgery.
There were no complications related to the abdominal time of the procedure. All other complications are summarized in Table 1. Routine contrast swallowing identified six patients (30%), who developed transient anastomotic leaks at the pharyngo-jejunal anastomosis, within the first 14 postoperative days. Five of them healed spontaneously while one had an early re-intervention with primary closure. One patient developed a persistent fistula, which required a muscle flap at 56 days, followed by an omental patch at 140 days. Subsequently, he developed an anastomotic stenosis that was eventually resolved with dilatation. Five more patients developed an anastomotic stricture, three at the top end (one as a direct result of postoperative radiotherapy) and two at the jejuno-oesophageal anastomosis. Three of them were managed with dilatation and two required the insertion of a percutaneous endoscopic gastrostomy as definitive management. Other complications included seven neck wound infections and one re-intervention for a bleeding vessel in the neck.
Two patients had significant medical complications, as shown in Table 1. One had a severe bilateral pneumonia, which lead to patients’ death 6 weeks postoperatively, while a second one had a VF arrest, which was resuscitated, but unfortunately was associated with hypoxic brain damage. He died 6 months postoperatively.
The functional results were assessed at 6 months and 1 year. As shown in Table 2, swallowing was satisfactory in 11 out of 15 patients (78%) alive at 6 months, and in nine out of 11 (81%) at 1 year. The ability to speak was regained in 13 patients at 6 months and maintained in all the ones alive at 1 year. The occurrence of leaks or stenosis in the postoperative course had no effect on the swallowing or speech ability at either assessment intervals (Tables 3 and 4). There was no significant relationship between the moment of radiotherapy and the functional outcome at 6 months (P=0.844 for swallowing and P=0.139 for speech, Pearson Chi-square) or at 1 year (P=0.748 for swallowing, Pearson Chi-square).
In those cases where the tumour was completely removed, the interval free of tumour recurrence was on average 1.5 years (range 6–260 weeks), while the overall actuarial survival rate was 52.3% at 1 year and 33% at 3 years, respectively (Fig. 1) . The occurrence of postoperative complications or the moment of radiotherapy had no influence on the length of survival.
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Fig. 1. Survival of patients. Cum. Survival, cumulative survival; years, length of survival in years. ( ) censored cases.
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4. Discussion
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Several reconstructive techniques are available following total pharyngolaryngectomy [1,2,5]. There is no uniform agreement as to which has the least morbidity and offers the best functional results [12,13]. A free jejunal graft reconstruction following laryngeal malignancy is a technically demanding procedure, but has become widely popular following refinements in microvascular surgery. It has a failure rate of 5–10% [14], associated mainly with the microvascular transfer. Irrespective of the extent of neck dissection, anastomosis on the internal jugular vein and the common carotid artery are safe, providing a Doppler examination is performed to ensure adequate patency. The advantages of using these large vessels have been previously described [9,15], and they are reliable even when preoperative radiotherapy is employed.
In an attempt to reduce the rate of postoperative complications and to match the pharyngeal defect, various modifications of the jejunal graft have been described [16,17]. However, the jejunum is quite distensible and in most cases will allow an end-to-end anastomosis to be created, a ‘fishmouth’ slit [15] or an oblique cut of the top end of the graft compensating for wider pharyngeal defects. A short and linear graft constructed in this manner (Fig. 2)
is likely to minimize the incidence of dysphagia and saliva pooling and creates the premises of a successful functional outcome.
There were no perioperative deaths in our series, which is comparable with other similar sized studies [18]. However, on larger series, perioperative mortality rates of 1–5% have been reported [17,19], making the free jejunal graft comparable with other reconstructive alternatives [3].
The procedure has major advantages over other methods using enteric grafts with regard to the ease of graft harvesting (laparotomy or laparoscopic [20]) and minimal abdominal complication rate. There is, however, relatively high neck morbidity. In our series, all transient leaks were at the pharyngo-jejunal anastomosis and closed spontaneously in five out of six cases. A good blood supply of the revascularized jejunum and the lack of deforming weight contribute to the likelihood of spontaneous closure in contradiction with leaks following colonic interposition or gastric pull-up, which are usually due to ischaemia or suture line tension [21] and often require further surgery. Fistulas can be missed at an initial postoperative barium swallow [22], and if persistent may require several interventions or the use of a different reconstructive technique before complete resolution, as was the case for one patient in the current series.
Six patients developed anastomotic stenosis. Four of them were successfully resolved with mechanical dilatation, while two required the insertion of a percutaneous endoscopic gastrostomy. A persistent stenosis may compromise the functional result, but if successfully treated by dilatation, there seems to be no significant long-term effect.
An analysis of the functional results showed that 78% of the surviving patients have a satisfactory swallowing and 87% a satisfactory speech at 6 months. The results were consistent at 1 year. Some physiology studies have suggested that the jejunal interposition responds to chemical stimuli but does not necessarily contribute to the digestive transit [23]. A previous report on eight of the present series patients showed that there is no single manometric pattern to characterize these patients [24], but the best results are obtained with a short and linear graft. Some cases may exhibit inactivity in response to eating, while others may produce a peristaltic type of wave through the graft. Dysphagia due to a graft with residual motor activity may benefit from a trial of metoclopramide, while longitudinal myotomy appears to have no effect [25].
Speech restoration by valve insertion has emerged as an effective method [7], despite a series of complications [2]. It requires a straight jejunal graft to avoid saliva pooling, which can lead to a gurgling quality of the voice, and intensive speech therapy training. If good initial results are obtained, it is likely that they will persist, improving the patient's quality of life.
There does not seem to be any correlation between the functional results at 6 months or 1 year and the presence of postoperative complications or the moment of radiotherapy. Despite concerns regarding the tolerance of the jejunal graft, radiotherapy can be safely delivered [11] without an adverse effect on the functional end-results.
The goal of any reconstructive procedure following pharyngolaryngooesophagectomy is to restore patients’ functional abilities within a time commensurate to the natural history of the disease [8,9]. Several management options are available but the choice has to be tailored for each patient according to the tumour location and stage, and taking into account the morbidity and the functional outcome of each procedure. While techniques such as tubed skin flaps avoid a laparotomy, their complication rate may not be significantly better [12] and the functional results can be less consistent than those obtained with enteric flaps [13]. A gastric pull-up remains the choice when extensive oesophageal resection is required, but has frequent complications and its functional result is not as satisfactory as to a free jejunal flap, due to an altered gastric physiology, regurgitation, early satiety and dumping [18].
In summary, despite being technically demanding, the free jejunal graft is an excellent primary reconstructive method offering a good size approximation with tissue that is able to tolerate radiotherapy. The swallowing mechanism is near physiologic, while the vagus is preserved, contributing to a normal gastric emptying. The functional results are good and regardless of relatively high morbidity, offer the patient a real chance for a decent quality of life.
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Footnotes
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Presented at the 8th European Conference on General Thoracic Surgery, London, UK, November 1–3, 2000.
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Abstract
1. Introduction
