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Figure 2.5. Typical prevertebral soft tissue bulge following laryngectomy. (A) Lateral film from cervical esophagogram demonstrating a large posterior soft tissue bulge at the pharyn-

goesophageal junction. (B) Another lateral film, taken a few seconds later, showing marked changeability of the posterior soft tissue bulge, which indicates its benign nature.

may be seen in approximately 15% of all patients. When recurrence does occur, the neopharynx becomes narrowed and does not change during swallowing, an important differential feature with respect to the structural changes normally seen postoperatively [11]. Tumor recurrence in regional lymph nodes may also be seen.

Various functional changes have also been described. When groups with and without sectioning of the recurrent laryngeal nerve were compared, favorable swallowing results were, respectively, 70 and 88% [13]. Extension of the surgery to include resection of the base of the tongue led to a significantly increased number of swallowing problems, including decreased laryngeal elevation, loss of tongue propulsion of the bolus, and increased oropharyngeal transit time [13]. Damage to or sectioning of the pharyngeal branches of the vagus nerve may result in cricopharyngeal muscle dysfunction. This problem is secondary to the role these branches play in upper esophageal sphincter resting tone, relaxation, and contraction [11]. More distally, esophageal motility is usually unremarkable. However, when dysphagia is present postoper-

atively, it is critical to examine the entire esophagus to exclude distal strictures or even other foci of squamous cell carcinoma [11,12,14].

When a pharyngolaryngectomy has to be extended and the cervical esophagus is partially or completely resected, reestablishment of the continuity of the gastrointestinal tract is often attempted. One method is that of forming a tube from the pectoralis major muscle and its surrounding tissue (Fig. 2.6). This procedure may also be performed following serious complications and/or failure of a jejunal interposition [15], as discussed later. The major advantage of this type of reconstruction is that no laparotomy is needed [16]. Moreover, the anastomoses can be performed without using microvascular techniques. In one series of five cases, one patient had no complications, two had small anastomotic or suture line leaks, and one had a large breakdown of the flap requiring reoperation [16].

Much more commonly performed is interposition of a short segment of jejunum. In this procedure, a segment of jejunum is removed from the abdomen with a single supplying artery and draining vein. This segment is interposed (autotransplanted), with the blood vessels anastomosed to an external carotid artery branch and the internal jugular vein, respectively [17]. This surgery has the advantage over pectoralis

Figure 2.6. Pectoralis muscle flap. Two lateral films showing a long tubular conduit in the cervical region representing a pectoralis major muscle flap used to replace a portion of a resected esophagus.

major flaps and colonic interpositions of providing a propulsive conduit for food and saliva. When the blood supply is transplanted, there are fewer technical problems than are encountered when the stomach and/or colon is mobilized to reach the neck. The small bowel also more closely approximates the diameter of the esophagus and is more easily connected than those other wider conduits [17].

The radiographic appearance is just what would be expected from the description of the operative procedure. A short segment of jejunum is interposed between the hypopharynx and the distal cervical esophagus. End-to-end distal anastomoses are performed with either an end-to-side or end-to-end proximal one. The mucosal folds may be normal in appearance or thickened. Thickening may occur secondary to lym-phedema and is seen in the first three postoperative months [15].

Complications include fistula formation and strictures. The former could be at either the proximal or distal anastomoses, affecting both sites equally [15]. Leaks may develop in 25% of patients. In almost half of these patients, the leak corresponded with clinically evident pharyn-gocutaneous fistulas [18]. In the remainder, no fistulas developed. However, there was the delayed appearance of fistulas (at 2 weeks) in slightly more than 10% of patients with no evidence of leak on their barium studies. Therefore, barium swallows offered only fair correlation with the immediate postoperative clinical course and should be considered an adjunct, not a definitive examination [18].

Strictures, when they develop, involve the proximal and distal anastomotic sites in equal numbers. Strictures, due either to benign causes or to recurrent disease, occurred much later in the postoperative course than fistulas (mean of 7 months vs 1-2 weeks, respectively [15]). Benign strictures could not be differentiated from malignant ones when they occurred late in the postoperative period [15].

Although some propulsive function is preserved when the jejunum is engrafted, it does not completely replace the resected esophagus in that regard. Instead, many patients need to "flush" solids down by swallowing liquids at the same time [19]. As opposed to normal esophageal function, the act of swallowing does not induce peristaltic contractions in the engrafted small bowel. However, distal to the graft, normal stripping action is observed, confirming that the latter is a local reflex action [19]. However, the graft does show evidence of regular contractile activity (phase III) of the migratory motor complex of the small intestine. This was observed in slightly less than half of all patients in one study [20] and in almost all patients in another [19].

A large retrospective review revealed that almost half of all patients were able to swallow a soft diet without difficulty postoperatively [15]. Dysphagia, when present (slightly more than half of all patients) was related to a myriad of causes, including recurrent disease, stricture, brainstem metastases, or the extent of the original surgical resection. Lymphedema and a redundant jejunal segment were additional causes noted by others [21,22].

Following laryngectomy some patients opt for the placement of a special prosthesis that allows them to regain speech without having to use an external device or to learn esophageal speech. This tracheo-

Figure 2.7. Tracheoesophageal prosthesis. Lateral (A) and frontal (B) views of the cervical esophagus showing the radiopaque marker for a tracheoesophageal prosthesis. Note on the lateral film that the air channel between the trachea and esophagus is readily identifiable.

Figure 2.7. Tracheoesophageal prosthesis. Lateral (A) and frontal (B) views of the cervical esophagus showing the radiopaque marker for a tracheoesophageal prosthesis. Note on the lateral film that the air channel between the trachea and esophagus is readily identifiable.

esophageal prosthesis is implanted by creating a small fistula between the two lumina with a trochar. An introducer sheath is then placed to deliver the device itself. It can be recognized by a radiopaque ring at its base (Fig. 2.7). Occasionally the actual lumen within the device connecting the trachea and esophagus is visible (Fig. 2.7A).

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