Minimally invasive pharyngo-laryngo-esophagectomy: a salvage procedure for recurrent postcricoid esophageal cancer

Abstract

Hypopharyngeal and cervical esophageal tumors represent 5-10% of all esophageal neoplasms and are challenging for both surgeons and oncologists, because the choice of the adequate therapeutic strategy is not clearly defined and therefore difficult. In fact, although surgical treatment represents the gold standard of therapy, chemo-radiotherapy, previously used as adjuvant treatment, has been more recently adopted with curative intent, leaving to surgery a salvage role only. When surgery is required it is advisable to reduce patients' trauma. The present study reports on a personal technique for minimally invasive pharyngo-laryngo-esophagectomy and reconstruction with the whole stomach. We use a laparoscopic approach for mobilization of the stomach, transhiatal esophageal dissection and to follow transhiatal gastric transposition to the neck combined to a cervicotomy to perform pharyngo-laryngectomy, proximal esophageal mobilization, and pharyngo-gastric anastomosis. We performed this technique on four patients with recurrent disease after initially curative primary chemo-radiotherapy. Mean operative time was 345 min (range: 300-384). There were no intraoperative complications. All patients were extubated immediately after the operation and were managed in postoperative care unit for a mean time of 10 days (range: 7-12). Enteral nutrition was begun on post-operative day (POD) 1. The nasogastric tube and drainages were removed on POD 11, and patients immediately started oral nutrition. One patient had a TIA (transient ischemic attack) on POD 2. All patients were discharged within 20 days (18-20). Initial experience with this minimally invasive technique in selected patients is encouraging because it seems to minimize postoperative complications and allows early rehabilitation.

Laparoscopic Gastric Mobilization in Postcricoid Cancer Surgery

“…This observation is comparable to what was reported by Wong et al 8 with a median total operative time of 8.5 hours (range, 5-11 hours) and a laparoscopic time of less than 4 hours. Mean duration of hospital stay in our patients was 13 days (range, 7-37 days), comparable to what reported by Rossi et al 9 and less than that by Wong et al, 8 where the mean hospital stay was 41 (range, 18-75) days.…”

Laparoscopically assisted esophagectomy and colon interposition for esophageal replacement in children: preliminary results of a novel technique

“…This ensures meticulous hemostasis, preservation of nerves, precise separation between the esophagus and trachea, pleural dissection, and no compression of major vessels or airways during dissection. These benefits of this approach have also been reported for laparoscopic gastric pull-up [5,6,9].…”

“…The first reports of laparoscopically assisted ER has been performed using the whole stomach, considering it to be technically easier and faster than using colon because it requires only one anastomosis, usually at the neck, after small sutures for pyloroplasty, closure of the gastrostomy, and the cardia [4][5][6][7]. Moreover, many reports have shown similar outcomes after either gastric or colonic conduits for conventional ER in children [17][18][19].…”

“…They present significant risks and operative morbidity because of surgical trauma, visceral exposition, peritoneal contamination, adhesions, antiesthetic scars, and also because of the blind dissection of the mediastinum when thoracotomy is not used. After Luketich's (1997) first report describing laparoscopic esophagectomy and gastric pull-up in adults [7], many articles have supported the use of this minimally invasive surgery for ER with very good results and decreased morbidity, either with or without thoracoscopic procedures [4][5][6]16].…”

“…However, an increasing number of reports have shown good outcomes in adults after laparoscopic gastric pull-ups (LAGAP), with the many advantages of minimally invasive surgery. It is technically easier to use the stomach than other organs with satisfactory nutritional results [5][6][7].…”