CASE REPORTS JEFFREY M. BUMPOUS, MD Case Report Editor
Free transverse colon transfer for large pharyngostoma after pharyngolaryngoesophagectomy: A case report TORNG-SEN LIN, MD, CHENG-CHUAN CHANG, MD, HSIN-YUAN FANG, MD, WEN-YI YANG, MD, and YU-TANG YU, MD,
Changhua City, Taiwan, ROC
P
haryngoesophageal reconstruction continues to be a problem in the management of cancer involving the hypopharynx. The reconstructive methods includes direct gastric pull-up, colon interposition, various musculocutaneous flaps, and free intestinal transfer, etc.1-5 Up until now, free jejunum graft is more common than free colon graft. When hypopharyngeal carcinoma invades as far as the oropharynx, pharyngolaryngoesophagectomy might result in a larger pharyngostoma.3 A significant discrepancy between the diameter of the pharyngostoma and that of the jejunum may occur, whereas the transverse colon has a larger diameter and can offer a longer, straight intestinal tube, facilitating easy passage of a food bolus. Reports related to free transverse colon transfer for pharyngoesophageal defect are rare in English-language literature. We present a case describing a successful free transverse colon transfer after pharyngolaryngoesophagectomy and provide a discussion on the perioperative management. CASE REPORT
A 65-year-old man was admitted with a progressive swallowing disturbance of 3 months duration. A laryngoscopy disclosed a huge tumor over the oropharynx with invasion to the pyriform sinus. A biopsy revealed squamous cell carcinoma. The patient underwent partial pharyngoesophagectomy, total laryngectomy, and free transverse colon transfer for pharyngoesophageal reconstruction on April 8, 1998. The free transverse colon transfer procedure included end-to-end pharynFrom the Department of Surgery, Department of Otorhinolaryngology– Head and Neck Surgery; Changhua Christian Hospital; Chung Shan Medical and Dental College; Hung Kuang Institute of Technology. Reprint requests: Cheng Chuan-Chung, MD, No 135, Nanhsiao Street, Changhua City, Taiwan, ROC; e-mail,
[email protected]. Otolaryngol Head Neck Surg 2001;124:471-2. Copyright © 2001 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/78/114454 doi:10.1067/mhn.2001.114454
Fig 1. Drawing shows detailed operative methods.
gocolonostomy and cervical colonoesophagostomy. The middle colic artery was anastomosed to the right common carotid artery and the middle colic vein drained to the right internal jugular vein. After surgery, the patient was given 200 IU/kg of dalteparin sodium (Fragmin) per day via intravenous infusion for 5 days. Oral intake was begun on postoperative day 14; the patient was able to tolerate solid food well. Postoperative esophagoscopy disclosed patency of the anastomosis of pharyngocolonostomy and colonoesophagostomy. Right carotid artery angiogram also revealed patency of vas471
472
Otolaryngology– Head and Neck Surgery April 2001
LIN et al
cular anastomosis. The detailed surgical procedure is displayed in Fig 1. Postoperative radiotherapy consisting of 5000 cGy was given for local control to prevent tumor recurrence because of tumor staging T3N0M0. This patient was followed up more than 1 year and has had no difficulty in establishing a good oral intake. There was not any intra-abdominal problems such as diarrhea, constipation, or postprandial abdominal fullness associated with removing part of the colon in this patient. DISCUSSION
Surgery with either preoperative or postoperative radiotherapy is considered standard therapy in treating hypopharyngeal carcinoma. Pharyngoesophageal reconstruction is still a challenge for surgeons in the management of cancer involving the hypopharynx. The currently used reconstructive methods include gastric pull-up, colon interposition, radial forearm free flap, pectoralis major muscle flap, and deltopectoral myocutaneous flaps.1 The radial forearm and other fasciocutaneous free flaps, although capable of providing sensation, lack the compliance and secretory ability of a mucosal surface.3 Sometimes direct gastric pull-up and colon interposition may be unsuccessful because of the inadequate length of the gastric tube and poor vascular architecture of the colon. Free jejunal or colic graft is another practical method for reconstruction of pharyngoesophageal defect. As an alternative to free jejunum, the use of free colon grafts appears to have been largely ignored. However, the colon is tolerant of at least 2.5 hours of warm ischemia, making it a safer and more practical free transfer than the jejunal and gastro-omental free flaps.3 Smith et al4 reported the colon represents a potentially more natural functional replacement of the cervical esophagus than the jejunum in experimental work in dogs.
When hypopharyngeal carcinoma invades the oropharynx, the resection often results in a larger pharyngostoma than is normally seen after standard total pharyngolaryngoesophagectomy. In such cases, it can be difficult to achieve good swallowing function after reconstruction with the free jejunal transfer. This results primarily from a significant discrepancy between the diameter of the pharyngostoma and that of the jejunum.5 Compared to the jejunum, the transverse colon has a larger diameter with a longer vascular pedicle and can provide a longer, straight intestinal tube, facilitating easy passage of a food bolus.4,5 The major circulation to the transverse colon is delivered by means of the middle colic vessels of a far greater size. The colic artery communicates with the marginal artery that runs parallel to the mesenteric border of the colon. Therefore, it is imperative to divide the middle colic vessels as close to their origin as possible. In addition, the transverse colon has been our colon donor site of choice because of its ease of harvest and large size, the colon can be harvested easily through a 10-cm supraumbilical incision. Therefore, we would recommend the role of the colon as a free interposition graft for pharyngoesophageal defect, especially for a larger pharyngostoma. REFERENCES 1. Harrison DFN, Thompson AE. Pharyngolaryngoesophagectomy with pharyngogastric anastomosis for cancer of the hypopharynx: reviews of 101 operations. Head Neck 1986;8:418-28. 2. Theile DR, Robinson DW, Theile DE, et al. Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases. Head Neck 1995;17:83-8. 3. Jones TR, Lee G, Emami B, et al. Free colon transfer for resurfacing large oral cavity defects. Plast Reconstr Surg 1995;96:1092-9. 4. Smith RW, Garvey CJ, Taylor PCA, et al. Experimental assessment of free jejunal and colonic grafts of the esophagus. Arch Otolaryngol Head Neck Surg 1987;113:187-92. 5. Nakatsuka T, Harii K, Ebihara S, et al. Free colon transfer: a versatile method for reconstruction of pharyngoesophageal defects with a large pharyngostoma. Ann Plast Surg 1996;37:596-603.
