Reconstruction of The Hypopharynx
Jayson Greenberg, M.D.
May 27, 1999

Circumferential pharyngoesophageal defects represent one of the biggest reconstructive challenges because of the complex properties of the epithelial lining and underlying muscle that are so vital to the function of this region. The primary goal is to re-establish the conduit connecting the oral cavity to the esophagus and thus re-establish the continuity of the alimentary tract.

When reconstruction is not attempted, tremendous problems are associated with complete removal of the hypopharynx. Patients are left with a cervical esophagostomy and an oropharyngeal cutaneous fistula through which saliva drains continuously. The multitude of reconstructive techniques that have been devised attest to the difficulty of this problem.

In the United States, laryngopharyngectomy for tumor ablation is the most common indication for reconstruction of the hypopharynx. Many of these are cases of advanced laryngeal cancer that have spread beyond the larynx, necessitating removal of both the larynx and the adjacent pharynx and oftentimes a portion of the cervical esophagus. Prognosis in these patients is extremely poor. This patient group often has a history of heavy tobacco and alcohol use. They often present in a malnourished and debilitated state. They have major comorbidities including chronic obstructive pulmonary disease, coronary artery disease, hypertension, liver disease, and peripheral vascular disease.

Patients requiring reconstruction of the hypopharynx must struggle with several issues: the presence of a serious malignancy, the need for multimodality therapy, the loss of natural speech, and the possible requirement of permanent non-oral feeding. For some patients, the loss of speech and swallowing are of greater significance than long term survival.

So, adequate tumor ablation is crucial for survival, but satisfactory reconstruction is as important for quality of life. Interestingly, despite technical surgical advances, 5-year survival rates have remained at less than 30%. Because of this poor prognosis for patients with locally advanced carcinoma of the cervical aerodigestive tract, many feel resection and subsequent reconstruction are considered palliative.

Most researchers agree that the ideal reconstructive procedure should be a reliable, one- stage procedure with the lowest possible morbidity and mortality, and which also allows the shortest hospitalization, along with the highest rate of, and most rapid interval to, successful alimentation. In addition, this technique should have the lowest possible stricture and fistula rates and the greatest potential for neopharyngeal or tracheoesophageal speech. Most of these patients have either had radiation pre-operatively or will receive it post-operatively, so these methods should tolerate post-operative radiotherapy and be successful when performed in radiated fields.

This presentation will focus on four reconstructive techniques: the pectoralis major myocutaneous flap, the free jejunal transfer, the gastric pull-up, and the radial forearm free flap.

The hypopharynx is a thin-walled muscular tube lined with squamous mucosa, which extends from the pharyngoepiglottic folds to the inferior margin of the cricoid cartilage. Important for resection and reconstruction is the shape of the hypopharynx. The configuration can be likened to that of a funnel, which has a wider upper end and a much narrower lower end. This gradual transition in shape is maintained by the u shaped hyoid bone and the spreading wings of the thyroid lamina, which is much wider from side to side above than below. The lumen of the upper hypopharynx can be twice as big as the lower hypopharynx. Similarly, the width at the opened up hypopharyngeal wall is much greater at the upper part as compared with the lower. Thus, there is more pharyngeal wall to spare in resection of the upper part than in the lower part. The cervical esophagus has even a smaller lumen and a shorter circumference.

The primary function of the pharynx is deglutition and the swallowing of oral secretions. When food is swallowed, local peristalsis above the food bolus and receptive relaxation below it allows efficient, painless swallowing. Studies have shown that the tongue is actually the major force propelling food through the pharynx, and that the pharyngeal constrictor muscles play a smaller role. Thus successful swallowing is possible after removal of the pharyngeal constrictors, provided tongue function remains intact.

There are three main types of hypopharyngeal defects, each requiring reconstruction of a different magnitude. One is the partial pharyngeal defect: non-circumferential, with a strip of full thickness pharyngeal wall bridging the oropharynx and the cervical esophagus, of inadequate width for direct reconstruction of a tube, but able to accept a patch-on graft sutured to its edges all around. Two is a circumferential pharyngeal defect: a full thickness gap of varying length between the oropharynx and cervical esophagus, able to accept a tubular graft that can be joined to the defect without undue difficulty in completing the inferior anastomosis. Three is a pharyngoesophageal defect: a defect lying between the oropharynx and the cardia of the stomach and requiring a long segment of reconstruction, which spans from the neck, through the thorax, to the abdomen.

A discussion of reconstruction of the hypopharynx would be incomplete without a look at historical evolution of reconstructive techniques. In 1877, Czerny reported the first successful resection of the cervical esophagus. Through a lateral neck incision, a 6 cm segment of cervical esophagus was excised. A distal cervicocutaneous esophagostomy provided a route for nutritional support. The patient survived for 15 months before dying of recurrent disease. Mikulicz reported the first successful cervical esophageal reconstruction in 1886. In this case, 4 months following a cervical esophagectomy, a planned neck fistula was closed. The patient was able to swallow food and survived for 16 months. During the 1940s and 1950s surgeons experimented with free tissue grafting and internal stenting. Negus proposed using a split thickness skin graft stented over a portex tube, while Eggerton and Conley advocated split thickness skin grafts over a tantalum mesh. These methods were fraught with high fistula and stricture rates.

Wookey described the first reliable regional reconstruction of pharyngolaryngectomy defects. In his method, a laterally based cervical flap was partially folded back on itself and sutured to the pharyngeal and esophageal lines of resection to form a tube, which was left open on one side like a pharyngostome. Several weeks later, the tubing of the flap was completed and the lateral skin defect was covered by a split thickness skin graft. In 1942, he described this technique in 4 patients, all of which swallowed. Numerous modifications of this technique soon appeared.

The major disadvantage of this technical group is the multistage, frequent hospitalizations that are required. Other drawbacks are the need to use highly radiated skin in second stage reconstruction and the high rate of fistulization. Surkin et al reviewed the literature in 1984, and found 9 publications discussing pharyngoesophageal reconstruction with cervical skin flaps. There were 148 patients. Ninety-four percent of patients had postoperative reconstructive complications of stenosis, fistula formation, or flap necrosis. The average interval to swallowing was 8 weeks. Each patient required an average of 3 procedures. Hospitalization ranged from 6 to 16 weeks.

A major advance occurred in 1965, when Bakamjian described an axial pattern chest flap based on perforators of the internal mammary artery. This deltopectoral flap provided the head and neck surgeon with first opportunity to reconstruct pharyngoesophageal defects with well-vascularized tissue originating outside of the irradiated field. As with reconstruction using cervical skin flaps, pharyngoesophageal reconstruction using the deltopectoral flap is not a single stage procedure. A controlled pharyngostome was left to divert salivary flow away from the inferior anastamosis. At the second stage, the flap is amputated from its pedicle, and the controlled fistula closed.

Surkin and colleagues review of the literature revealed 3.8 procedures were necessary to achieve the final desired result. The average interval to swallowing was 10 weeks, and hospitalization lasted 8 to 16 weeks. Despite better vascularity and improved quality of tissue, the complication rate was still 56%.

The pectoralis major myocutaneous flap (PMMF) allowed the head and neck surgeon, for the first time, to perform a one-stage reconstruction of a circumferential defect of the hypopharynx. Theogaraj et al in 1979 reported the successful use of the PMMF in 7 patients for the secondary reconstruction of the hypopharynx and cervical esophagus for correction of post-surgical stricture. In his technique, the posterior wall mucosa was preserved, and the anterior and lateral defect was reconstructed with partially tubed pectoralis major myocutaneous flap. Two years later, Withers et al reported the use of an entirely tubed PMMF in 9 patients for the immediate one stage ?hypopharyngeal and esophageal? reconstruction following laryngopharyngectomy.

To review, the pectoralis major myocutaneous flap is based on the pectoral branch of the thoracoacromial artery. This vessel passes deep through the clavipectoral fascia medial to the insertion of the pectoralis minor muscle. From here, it is located on the deep surface of the pectoralis major muscle. The muscle itself is a triangular muscle that originates from the medial clavicle, sternum, costal cartilages, and the external oblique aponeurosis. It attaches by a broad flat tendon into the intertubercular sulcus of the humerus.

So, circumferential and partial defects of the hypopharynx can be repaired using either a tube flap or onlay patch. For many surgeons, the pectoralis major myocutaneous flap is the reconstructive method of choice when a strip of mucosa remains after cancer resection. Of course, margins should not be compromised in an effort to preserve mucosa and facilitate closure. Difficulty and controversy arise when this flap is used for reconstruction of a circumferential defect. Folding this flap into a tube is analogous to rolling up a thick book. The early attempts using the pectoralis flap as a tube were uniformly unsuccessful with stenosis developing at the distal anastamosis, especially in patients who received postoperative radiation.

Various modifications have been proposed to eliminate this shortcoming. Some advocate skin grafting the prevertebral fascia, and then, instead of completely closing the myocutaneous flap skin upon itself, closing it in a "U" shape. The pectoralis flap serves as the anterior and lateral walls of the neopharynx with the skin graft as the posterior wall. Advocates of this technique claim it prevents stenosis. This modification may minimize stenosis, but critics say it is ineffective in relation to swallowing based on the large amount of adynamic tissue. Others have proposed using silastic salivary bypass tubes to increase successful swallowing rehabilitation.

In 1992 Fabian reviewed 30 patients over a 7-year period who underwent partial tubulation of the pectoralis flap for pharyngoesophageal defects. Of these, 8 required a cervical esophagectomy for long segment stenosis that developed after radiation. The flap was sutured to the prevertebral fascia around a salivary bypass tube. He used a 3 cm prevertebral posterior wall without overlying skin graft. Barium swallow was done after 2 weeks. If no leaks were demonstrated, the patient was started on clear liquids for 24 hours. If no fever or neck erythema developed, the salivary bypass tube was then removed at the bedside. On average, patients were tolerating a full liquid diet after 20 days. There were 5 post operative infections, one fistula, and one total graft failure. One patient developed stenosis. The average diet at follow-up was soft foods and semisolids.

In a Japanese study from 1991, Okamura et al reviewed the swallowing function of 3 patients without dysphagia following pectoralis major myocutaneous reconstruction after extensive resection for hypopharyngeal cancer. They performed fluoroscopy, endoscopy and manometric testing. Fluoroscopy and endoscopy revealed the formation of a sphincter like ring at the proximal end of the remaining intact esophagus. Intraluminal pressure in the resting state at this point was almost equal to atmospheric pressure. Manometric testing showed that no swallowing pressure was produced in the reconstructed gullet. So bolus propulsion at the pharyngeal stage occurs mainly by gravity. They also found a 25 mm luminal diameter at the mucocutaneous junction and recommended an 11 cm suture line to minimize stenosis.

In regards to voice, Deschler et al in 1998 analyzed tracheoesophageal speech after pectoralis major flap reconstruction. They compared 6 patients with pectoralis reconstruction after laryngectomy with partial or total pharyngectomy versus 6 patients who underwent laryngectomy with standard pharyngeal closure. All patients underwent full course XRT, and all underwent successful voice restoration with the Blom-singer prosthesis. All patients in the PM group had used the prosthesis for at least 6 months. There were no statistically significant differences for various acoustic parameters. However, perceptual analysis by trained and naïve listeners revealed that control patients had significantly better voice for most tested parameters.

The advantages of the pectoralis flap are its ease of harvest, reliability, low donor site morbidity, and the ability to perform this reconstruction without the need for microvascular techniques. The bulk provided by the muscle is often useful in providing carotid artery coverage after neck dissection, and it tolerates radiotherapy well.

Disadvantages include the potential for excess bulk, potential for fistula and stricture, and the relatively worse results with respect to neopharyngeal and tracheoesophageal speech. Despite these disadvantages, the pectoralis flap is useful and allows the hypopharynx to be reconstructed in a single stage. It remains a reliable technique for partial pharyngeal defects that involve the lateral and/or anterior walls.

In 1960, Ong and Lee described the use of the transposed stomach to restore gastrointestinal continuity after circumferential pharyngectomy. This method was increasingly used after Orringer and Sloan described blunt mediastinal esophagectomy with gastric transposition and anastamosis in the neck in 1978. Today, this gastric pull-up operation is a preferred technique when significant tumor extends into the proximal esophagus. In these cases, skip lesions are often present and oncologically sound operations include total esophagectomy. Mobilization of the stomach and duodenum and passage through the chest allow primary anastamosis in the neck.

Spiro et al in 1991 at Memorial Sloan Kettering reviewed 120 patients who had gastric transposition from 1973 to 1990. Half of these were for pharyngeal tumors. There was 11% operative mortality. Fifty-five percent had intraoperative or perioperative complications. Thirteen percent had anastamotic leaks, and there were 3 instances of stomach necrosis. The time to oral intake depended on the post-operative course. This translates to a median of 8 days when recovery was uneventful and 11 days when there were complications. Assessment of oral alimentation was possible in 90 patients. Twenty-two percent had ?significant problems.? They conclude that gastric pull-up is reliable, but advocate careful patient selection to minimize morbidity.

While rehabilitation of swallowing is relatively rapid and stenosis rare, speech tends to be reduced in volume and quality. Researchers have shown that tracheogastric puncture is a safe and useful procedure for motivated patients. The speech produced is fluent and intelligible, but inferior in quality when compared to those patients who have undergone a standard TEP. Speech production after gastric repair is difficult because the large flaccid stomach fails to develop a true vibrating segment. Voice therefore tends to be weak and whispery with an additional gurgling quality from gastric contents that is particularly noticeable after meals. In some instances the quality of voice can be improved by applying digital pressure above the tracheostoma to create a more effective vibrating segment.

Theoretically, because there is only one suture line, less opportunity exists for wound break down. There are no abdominal anastamoses. In addition, the suture line is high in the neck at the base of tongue where anastamotic stricture is uncommon. In fact, the gastric pull-up has the lowest rate of stricture of all contemporary flaps, at approximately 10%. There is excellent blood supply and a one-stage reconstruction is possible, even in irradiated patients. There is also easy removal of intrathoracic disease extension.

The primary disadvantage is the surgical invasion of abdominal, thoracic and head and neck cavities resulting in a higher perioperative morbidity and mortality. Mortality occurs in 10-15% of cases. One half have major abdominal, thoracic, or medical complications. The gastric pull-up disrupts the normal gastroesophageal sphincter. Fifteen to twenty percent of patients often have problems with gastric reflux in addition to the dumping syndrome. Also, when the superior extent of the pharyngeal resection extends into the oro or nasopharynx, the gastric pull-up is compromised from the tension on the suture line and ischemia of the stomach, as more mobilization is required. Gastric pull-up is contraindicated in patients who have had prior gastric surgery. So, the gastric pull-up is the procedure of choice for lesions with thoracic extension or the total pharyngoesophageal defect, but, because of increased morbidity and mortality, it probably should not be used for more cephalad lesions.

Free jejunal autografts were the first microvascular tissue to be transferred to the head and neck. In 1906, Alexis Carrel reported the first successful autotransplantation of a segment of intestine into the neck in a dog. After revascularization, the intestinal segment was noted to resume peristalsis. In 1959, Seidenberg developed an experimental model in dogs for autotransplantation of a free jejunal autograft to replace the pharyngoesophagus. He and his colleagues are credited with being the first to perform this operation in a human who underwent a pharyngoesophagectomy for recurrent squamous cell carcinoma of the cervical esophagus. The patient did well until his fifth post-operative day, when he died from a CVA. But at autopsy, his revascularized jejunum was viable. In 1961, Roberts and Douglas reported 2 cases of jejunal autotransplantation for pharyngoesophageal replacement. Post-operatively, both patients began oral feedings in one week. In the late 1960s and 1970s, microvascular methods continued to be refined, and in the late 1970?s large series of free jejunal flaps for head and neck reconstruction began to appear in the literature on a regular basis.

The jejunal free flap would seem to be an ideal choice for pharyngeal reconstruction since it is another mucosa-lined conduit from the alimentary tract, which closely approximates the caliber of the pharynx. In this instance, a hollow muscular tube, the pharynx, is replaced by another hollow muscular tube.

A detailed description of operative technique is beyond the scope of this presentation, but we?ll take a brief look. This reconstructive technique is performed by 2 teams that can work simultaneously. The jejunum is harvested with its mesenteric arcade.
The jejunum is placed in an isoperistaltic direction and sutured into place. The flap is usually designed with an indicator segment, based on the same mesenteric vascular pedicle but on a different arcade from the segment used for reconstruction. This portion of jejunum is then externalized to provide an external monitor of flap viability. Post-operatively, the monitor segment is removed on the seventh day and a barium swallow is performed. If no abnormalities are noted, a clear liquid diet is started.

How do these patients do? Reece at al at MD Anderson Cancer Center in 1994 reviewed the larger English language reviews from 1982 to 1992. Free jejunal transfer (FJT) survival rates ranged from 80% to 100% with a trend towards higher success rates in more recent series. Series published after their review state a graft success rate of greater than 90%. Salvage of failed FJT with a second FJT was also successful in most instances. Failure occurred within 2 weeks of surgery in most patients. Forty percent of failures were attributed to microvascular difficulties such as thrombosis or kinking of vessels. The overall functional success was 80% or higher in most reports. Most series report a mean interval of 9-12 days for oral intake. The perioperative mortality was roughly 6 % or less for most cases. Morbidity ranged form 47% to 68%. Interestingly, a complication rate could not be determined or was not reported in one-half of these series. Although these complication rates may seem high, they are not significantly different from other techniques. Again, fistula and stricture were the two most common complications with rates of roughly 20% for both. The most frequent donor site complications were abdominal dehiscence and gastrointestinal bleeding.

Reece et al in 1995 reviewed their series of 96 free jejunal transfers in 93 patients. Their success rate was 97%. The 3 failures were repaired with repeated jejunal transfer. They report a 57% complication rate with fistula (19%) and stricture (15%) being the most common complications. The perioperative mortality was 2%. An oral diet was tolerated by 80% of patients, with 85% resuming oral alimentation within 2 weeks.

Normal swallowing is a complex sequence of synchronized biomechanical events that are well beyond the scope of this presentation. However, successful swallowing after laryngopharyngectomy with free jejunal flap reconstruction or any of the prior mentioned techniques, depends on the functional state of the remaining oral and pharyngeal anatomy. Specifically, patients with partial tongue resection or lingual deinnervation frequently suffer a loss of bolus control and reduced force of bolus delivery. This results in dysphagia, especially with solid foods. Dysphagia can also be caused by a redundant segment of jejunum. Food can become trapped in the folds of mucosa. This can be avoided by placing slight tension on the flap.

Manometric tests have shown that graft contractions do occur, but they do not propel the food bolus in a coordinated fashion.

In regards to stricture, Reece et al at MDACC favor a hand sewn distal anastomosis versus an end to end stapled anatamosis to minimize stricture risk. In addition, they found that stricture occurred on average 3.7 months post-operatively. This time delay suggests stricture may not be technically related to the anastamosis. Three-fourths of these patients were able to resume an oral diet after dilation. In addition, most authors have found that post-operative radiation therapy does not increase the rate of stricture formation. Cole et al., also at MDACC in 1995, showed that the radiation tolerance of the displaced jejunum is higher than doses accepted for the small intestine in its native location. They identified 3 of 29 patients with difficulty swallowing during their radiation therapy and only one who was gastrostomy tube dependent after therapy. Histologic studies show damage to intestinal absorptive cells and shortening of intestinal villi. This should not create symptoms, however, because absorption is no longer required of this transplanted segment. In fact post-operative radiation can improve functional results by decreasing the hypersecretion of mucus from the jejunal segment and inducing fibrosis, thus shortening the length of the grafted segment.

Malnutrition, poor surgical technique, excessive tension on the anastamoses, prior radiation therapy, and infection are factors that contribute to the formation of fistula. Most fistulas occur at the proximal anastamosis, and one-half close with conservative management. Reece et al noted that their incidence of fistula decreased with suspension of the jejunal segment from the prevertebral fascia and by adding a two layered interrupted closure.

Tracheoesophageal puncture has been used to restore speech in these patients, but their voices have a "wet" or gurgled quality. This may be due to mucus produced from the jejunum, and voice quality does improve after post-operative radiation therapy. Nonenteric methods of reconstruction may result in better voice quality and volume, because a skin paddle is less flaccid than the enteric walls of the jejunum. Menedelsohn et al compared total laryngectomy patients with total laryngopharyngectomy and jejunal free flap reconstruction. The total laryngectomy group exhibited superior scores for objective intelligibility, subjective intelligibility, and acceptability. Both surgical groups produced similar amplitude and frequency parameters during normal conversation, and patient acceptance was very high in both surgical groups.

Free jejunal transfer is a reliable one-stage procedure that does not require a thoracic dissection and is not restricted by pedicle length, or prior gastric surgery. Its donor site is located at a distance from the ablative site, which allows two teams to work simultaneously. Digestion is not disturbed by a sacrifice of a small segment of jejunum and primary anastamosis in the abdomen is fairly straightforward with minimal abdominal morbidity. The jejunum allows essentially any length of defect that may be encountered in pharyngolaryngectomy to be reconstructed. Post-operatively, early oral alimentation with a high rate of success and a low mortality rate is generally observed. The free jejunal autograft is more physiologic and carries a lower incidence of anastamotic leaks and strictures compared to other methods of pharyngoesophageal reconstruction.

Free jejunal flaps also have their disadvantages. This technique requires a surgeon with microvascular expertise. The operation is long and requires the patency of 5 anastamoses (3 enteric and 2 microvascular) for a successful outcome. It necessitates a laparotomy that increases morbidity. There are worse results with tracheoesophageal speech. Free jejunal autografts are contraindicated in patients with ascites or chronic diseases of the jejunum such as Crohn?s disease.

The radial forearm free flap for pharyngoesophageal reconstruction was first described in 1985, by Harii et al in Japan. Since that time the majority of the literature regarding this method of reconstruction has come from Anthony and Singer from UCSF. They have described this technique for reconstruction in patients who have undergone total laryngopharyngectomy or patients with a stenosis of the neopharynx after total laryngectomy to reconstruct the narrow segment.

Again, an in-depth discussion of the operative technique is beyond the scope of this presentation. The non-dominant arm is usually selected for the flap donor. A pre-operative Allen's test is performed to evaluate ulnar artery patency. The radial artery is the axial nutrient artery. The venous drainage is provided by the paired venae comitantes, which accompany the radial artery and the cephalic vein. Nine centimeters of width is recommended for circumferential reconstruction to provide a lumen diameter of 3 cm. If circumferential reconstruction is necessary, the flap is tubed with a 2 layered closure. The flap is then sutured into place in the neck. The forearm donor site is covered with a split thickness skin graft and splinted for 5 days. Barium swallow is obtained 10-14 days after surgery to exclude anastamotic leak, and oral feedings are started.

Let?s take a look at their results. In 1994, they reported on 22 patients who had undergone primary or secondary reconstruction after total laryngectomy. Thirteen patients had circumferential reconstruction and nine had patch reconstruction. There were no flap failures. Perioperative mortality was zero. Thirty-two percent had radiographically-demonstrated pharyngeal leakage. Fistula rate was 50% for patients reconstructed with a tubed flap. The majority of fistulas closed with conservative management. Only one required surgical intervention. Two patients had strictures requiring dilation. Patients resumed oral alimentation anywhere from 7-14 days post-operatively, depending on whether they had been previously radiated. At 8-month follow up, 88% of patients with an intact tongue base were tolerating a regular diet. None were tube feed dependent. Donor site morbidity was minimal. Ninety-five percent had excellent take of their forearm skin graft. Preservation of the lateral cutaneous nerve prevented any sensory deficits of the radial portion of the hand, and there were no motor deficits.

Speech results were tested for 6 patients with radial forearm free flap reconstruction versus 5 control patients who had undergone standard primary pharyngeal closure after laryngectomy. Compared with controls, radial free flap patients demonstrated similar loudness with soft and loud speech, as well as comparable fundamental frequencies. Naive listeners judged speech intelligibility in all 5 control patients to be excellent. These same listeners judged speech intelligibility to be excellent for 4 radial forearm patients and good intelligibility for the other 2. They conclude this flap is well suited to voice restoration because it is thin and pliable, yet the walls have good tone and no redundancy. The consistency is close to that of normal pharynx.

The radial forearm flap can be harvested quickly under tourniquet control with minimal blood loss. This flap is extremely reliable due to the large caliber of the radial artery and the presence of multiple veins that can be used to drain the flap. Donor site morbidity is also low. There is no laparotomy and its associated complications. Speech rehabilitation is nearly equivalent to total laryngectomy patients who have had primary pharyngeal closure.

This flap does require an additional suture line. They do have a higher fistula rate, although they say this rate has lowered with more careful technique and a 2-layered closure.

It is difficult to say which of these flaps is truly the most optimal. Certainly some are tailored more towards certain defects. Factors involved in determining which technique is most useful include operative mortality rate, number of patients successfully rehabilitated, which includes success of reconstruction, rate of alimentation, and number of days to alimentation. Other factors include fistula and stricture rates, and the quality of tracheoesophageal or neopharyngeal speech.

Reconstruction of the hypopharynx has undergone a rapid evolution in the last 25 years. Several institutions have performed retrospective reviews of their experience. Clearly, the gastric pull-up has the highest mortality. Irrespective of the technique of reconstruction selected, complications do occur. Researcher have found that reconstruction and operation-related complication rates were 50% or higher for all techniques. The overwhelming majority concludes that enteral reconstructions are superior to skin flaps in terms of restoration of function and minimizing morbidity. Most agree that the free jejunal transfer is the procedure of choice for reconstruction of laryngopharyngectomy or ?high? defects and that gastric pull-up is the procedure of choice for ?low? lesions. Those who advocate radial forearm free flap reconstruction stress their superior voice rehabilitation results. Other factors vital for successful rehabilitation that are not often documented include tongue function and intact sensation in the oropharynx.

In summary, no technique in use today for reconstruction is applicable to all patients. The primary goal in reconstruction for patients who have undergone ablative surgery to the hypopharynx should be to restore them to a functional status in the shortest period of time with the most minimal morbidity.

Case Presentation

Bibliography