Microvascular Reconstruction of Free Jejunal Graft in Larynx-preserving Esophagectomy for Cervical Esophageal Carcinoma.

For the treatment of cervical esophageal carcinoma, laryngectomy, in addition to the esophageal carcinoma resection, has been considered to be necessary.1 Laryngectomy is performed to obtain a safe upper surgical margin; however, if the larynx is preserved in patients with high-cervical esophageal carcinomas, the duration of intubation and the risk of fatal pneumonia increase because of persistent postoperative aspiration.1,2 However, losing the ability to speak severely decreases postoperative quality of life. Danker et al3 reported that half of the interviewed patients rarely talked to their relatives or refused to go where they had to talk. Patients tend to become socially isolated and subjectively perceived poor speech quality, and depression may lead to social withdrawal.3 Surgical defects after esophagectomy are generally repaired by using a variety of methods, such as gastric pull-up, colon interposition, skin flaps, or a free jejunal graft.4 For restoration of the voice after laryngectomy, esophageal speech and electrolaryngeal methods are common, and voice prosthetics have recently been shown to provide better quality of voice.5 However, even with recent advancements in voice restoration methods, substitute speech by itself still has lower intelligibility.6,7 With advancements in chemoradiotherapy (CRT), including induction chemotherapy, and alternative perspectives on postoperative quality of life, larynx preservation has been pursued recently8–10; however, the selection of candidates and the optimal reconstructive procedure remain controversial.2 Although patients with cervical esophageal carcinoma are treated with both laryngectomy and esophagectomy, poor prognoses have been reported, and similar survival rates have been reported in patients who underwent cervical esophagectomy regardless of whether laryngectomy was performed.11,12 Therefore, if preservation of the larynx is possible without decreasing the survival rate, postoperative quality of life would be improved.13 Recently, Kadota et al2 reported that using free jejunal grafts for the reconstruction of larynx-preserving cervical esophagectomy (LPCE) enabled them to obtain acceptable results even in high-cervical esophageal carcinomas involving the hypopharynx. However, this approach has not been commonly used for high-cervical esophageal carcinomas, and we considered that microvascular reconstruction, which is an important factor for achieving successful free jejunal transfer, in LPCE is slightly different from what we experience in esophagectomy with laryngectomy. In this study, we reviewed our experience with 7 patients who underwent free jejunal transfer for LPCE and described the difficulties or pitfalls to perform microvascular reconstruction for free jejunal graft in LPCE.