Laryngopharyngectomy and reconstruction with jejunal graftMedical editor Olav Jetlund MD
Oslo University Hospital
A selected group of patients with pharyngeal cancer who have received radiation therapy are offered potentially curative surgical treatment by laryngopharyngectomy (resection of the lower content of the pharynx and larynx). The pharynx is replaced with a vascularized graft from the small intestine.
This applies to patients with residual tumor or recurrence. Without surgery, the patient has a poor prognosis, and the condition is associated with considerable adverse symptoms.
Many patients undergoing this procedure maintain relatively good swallowing function. Most are able to drink fluids and many can eat food that passes easily through the pharynx. Some are able to eat normal food after some time.
The surgery is a collaboration between head/neck, transplantation, and gastrointestinal surgeons.
Residual tumor or recurrence
- in the hypopharynx, without invasion of the root of the tongue, vertebra, or lower content of thoracal esophagus.
- for advanced laryngeal cancer with invasion of hypopharynx.
- Tumor-free while preserving swallow and speech function.
- throat surgery
- The patient is informed and prepared for loss of normal speech and change in swallow function. All patients are given the opportunity to speak to a laryngopharyngectomee before surgery.
- The surgery is performed under general anesthesia.
- The patient lies supine with the cervical spine extended.
- Two surgical fields are prepared.
Resection of the larynx and pharynx is done parallel with resection of the intestinal graft.
Resection of larynx and pharynx
- Laparatomy through midline incision.
- A suitable jejunum segment is selected, about 50 cm from the ligament of Treitz.
- The vessels are carefully ligated. The specimen is taken out and put on ice.
- Most often, the facial artery or superior thyroid artery is used as supplying arteries. End to end anastomoses are sutured to the intestinal arteries.
- On the venous side, end to side anastomosis is usually sutured on the jugular vein.
- Macrodex and heparin are given before revascularization.
- Peristalsis resumes within a few seconds.
- The proximal intestinal end is opened and an oblique incision is made on the antimesenterial side to accomodate the size of the pharynx.
- The intestinal segment is sutured to the base of the tongue and upper pharyngeal wall after adaptation. The peristalsis should forward in the caudal direction.
- The distal end of the intestinal segment is sutured to the cervical esophagus after insertion of a nasogastric tube.
- The trachea is sutured to the skin as in a regular laryngectomy.
- Doppler evaluation of the graft.
- Antibiotic prophylaxis
- H2- blockers
- Thrombosis prophylaxis with macrodex, Fragmin® and salicylate.
- The patient is explained about stomal maintenance, moisturization, and cleaning.
- Feeding by tube can start after 24 hours.
- After 14 days, the patient may start drinking liquids.
- Voice rehabilitation starts at the ward and continues at the Bredtvedt speech therapy center.
- After a few months, a voice prosthesis is tried (Provox®).
- Almost all patients learn to speak with the voice device Servox®.
The patient will be in the hospital for ≥ 14 days.
Follow-up visits will be monthly for the first three months.
The patient will have follow-up visits for at least 3 years.