Flap reconstruction of the hypopharynx: a defect orientated approach.

The present retrospective analysis evaluated the outcomes of different flap reconstructions for several hypopharyngeal defects in 136 patients who underwent hypopharyngeal reconstruction with a free or pedicled flap after excision of pharyngeal or laryngeal carcinoma.Functional and oncological outcome were the main measures. Nine patients had a type I-a hypopharyngeal defect (partial with larynx preserved), 33 type I-b (partial without larynx preserved), 85 type II (circumferential), 5 type III (extensive superior) and 4 vertical hemipharyngolaryngectomy. The flaps used to reconstruct these defects were pectoralis major (n = 34), free radial forearm (n = 25), jejunum (n = 72), pedicled latissimus dorsi (n = 2), sternocleidomastoid (n = 1), lateral thigh (n = 1) and deltopectoral (n = 1). Twelve defects (9%) needed a secondary flap reconstruction. Surgical and medical complications were seen in 29% and 8% of patients, respectively; 18% of patients developed a fistula. No difference in complication rate or admission days was found for pre-operative versus no previous radiotherapy, type of defect or free versus pedicled flap. After 12 months follow-up, 38% of patients had a tracheo-oesophageal voice prosthesis, in 82% a fully oral diet was obtained and the average body weight gain was 0.9 kg. Five-year overall and disease-specific survival rates were 35% and 49%, respectively, while local and regional control rates were 65% and 91%, respectively. Considering these results, a defect orientated approach may be helpful for deciding which flap should be used for reconstruction of the hypopharynx. An algorithm is proposed with similar functional and oncological outcomes for the different groups. The choice of flap should be based on expected morbidity and functional outcome.

Functional outcomes in patients reconstructed with flaps following surgery for hypopharyngeal cancer.

Following oncologic surgery for advanced cancer of the hypopharynx, primary closure of the defect of the upper aerodigestive tract is difficult to achieve. Usually locoregional or free flaps are used, the choice being determined by the extent of the surgical defect, the expertise of the surgeons and the general condition of the patient. Aim of the present study was to evaluate the functional recovery of patients who underwent surgical reconstruction, following hypopharyngeal cancer resection, with pedicled or free flaps. A retrospective analysis was conducted examining hospital records of the patients submitted to surgical treatment for hypopharyngeal cancer and reconstruction with pedicled or free flaps in the period between January 1995 and July 2004. Free flaps showed less severe complications, shorter hospital stay, less time to resume oral feeding compared with pedicled flaps. For this reason, we consider free flaps the gold standard for hypopharyngeal reconstruction, while pedicled flaps as the pectoralis major or other locoregional flaps should be used in those cases in which free flap reconstruction is not feasible or contraindicated.

[Decisional algorithm in extended neoplasms of the hypopharynx and the cervical esophagus]. / L'algoritmo decisionale nelle neoplasie estese dell'ipofaringe ed esofago cervicale.

Hypopharynx reconstruction must deal with restoration of not a simple tubed conduit but a complex arrangement of constrictive and propulsive forces with fine sensory circuits. The chosen surgical approach should guarantee both complete removal of tumor and re-establishement of the two primary functions of the district: first swallowing and then phonation. We retrospectively reviewed data of 67 patients who had undergone oncologic reconstruction of hypopharynx with either pedicled or free flaps at the ENT Department of IRCCS Policlinico S Matteo, University of Pavia, between November 1994 and July 2004. Type and extension of the defect following cancer removal guided the selection of reconstructive procedure. Partial defects, with more than 50% mucosa spared, in absence of chance of being closed primarly, were covered with radial forearm free flaps as first choice; pedicled flaps such as pectoralis major and SCM rotational flaps were used instead if free flaps contraindicated by general and/or local conditions. With circumferential defects reconstruction was accomplished by means of jejunum free flap, as first choice. Adverse local abdominal conditions mandated the alternative use of either tubulized or tunnelized fasciocutaneous free flaps, such as radial forearm and lateral thigh. When free flaps use contraindicated, or in case of salvage surgery after flap loss, pectoralis major and latissimus dorsi pedicled flap were chosen. Both reconstructions with free and pedicled flaps were successful in an high percentage of cases (>85%). Analysis of incidence and causes of flap failure are reported in this work. In the free flaps group of patients a lower rate of complications were registered, allowing a faster patient discharge from hospital (36% versus 81.3%). An oral swallowing function was gained in 92% of free flaps and 62.5% of pedicled flaps. Excellent and exclusive oral nutrition (free diet), was obtained in 54% of free flaps and 25% of pedicled flaps. None of patients undergone laryngectomy coupled in both groups with pharyngectomy achieved an intelligible esophageal speech. Only patients in the free flaps group benefitted from voice prosthesis implant: in fact this procedure was avoided in pedicled flaps due to the excessive tissue bulk. In conclusion, the data collected suggest that free flaps rapresent the first choice for both partial and total oncologic hypopharyngeal reconstruction, while pedicled flaps should be taken into account when free ones contraindicated by general or vascular conditions.

[Reconstruction options after extensive ablation of the mouth]. / Opzioni ricostruttive dopo ampie demolizioni del cavo orale.

Surgical treatment of the advanced tumors of the oral cavity determines challenging anatomical and functional defects of the involved districts. The aim of our study was to supply reconstructive guidelines for the surgical treatment of the tumors of the oral cavity. Indications and conclusions were drawn following a retrospective review of data of 76 patients undergone oral and oromandibular reconstruction with either pedicled (17) or free flaps (59). The analysis included for both groups the registration of type of selected flap, success rate, early and late complications rate, functional results at 6 months to 1 year, ie oral feeding recovery and quality of oral feeding. The results obtained point out that the anatomical and functional complexity of the oral cavity needs a wide armamentarium of surgical techniques and skills at prompt disposal of the reconstructive surgeon. Free flaps should be kept in mind as the first choice for middle-sized to wide defects. An extended range of options in this group are available, and the selection should be based on type and extent of the defect following surgical oncologic ablation, but also on the surgeon experience itself. Pedicled flaps should be alternatively selected on case of general, vascular or local contraindications to major free flaps surgery, for the higher complications rate and worse functional outcomes to be faced.