Healing the gap: The evolution of esophageal substitute and quality of life in patients undergoing total pharyngolaryngoesophagectomy with reconstruction

Aim: Hypopharyngeal squamous cell carcinoma is reportedly one of the most aggressive primary cancers, and surgical resection continues to be the standard therapeutic choice. In patients with hypopharyngeal cancer involving the esophagus or synchronous hypopharyngeal and esophageal cancer, total pharyngolaryngoesophagectomy (TPLE) is indicated to control both malignancies at the same time. Reconstruction remains challenging with regard to the length of the substitute for the esophagus as well as the donor site morbidity. We reported our long-term follow-up and the outcome of the quality of life (QoL). Methods: We retrospectively reviewed the records of all patients who underwent TPLE between January 2012 and December 2020. Information was collected on sex, age, surgical indications, operative time, postoperative complication, swallowing function, hospital stay, and survival. Quality of life scores were acquired by World Health Organization Quality of Life-Brief (WHOQOL-BREF) questionnaires and completed at the outpatient clinic. Gaussian kernel-smoothing was applied to estimate the dynamic changes of QoL function. Results: A total of 40 patients undergoing oncologic pharyngolaryngoesophagectomy were enrolled in this study. There were 26 patients (65%) undergoing gastric tube reconstruction with direct anastomosis to the oropharynx (GP group), 7 patients (18%) undergoing additional free jejunal flap to bridge the gap between the gastric tube and oropharynx (GP-JF group), 4 patients (10%) undergoing additional free anterolateral thigh flap to bridge the gap and resurface the neck skin (GP-ALT group), and 3 patients (8%) undergoing colon interposition (CI group). The leakage rate in each group was 50% for GP group, 29% for GP-JF group, 50% for GAP-ALT group, and 67% for CI group. The mean operation time was 1010 ± 195 min. Although the overall leakage rate was 47.5%, only 15% of the patients needed further surgical intervention. One patient (2.5%) died with persistent leakage and pneumonia. In terms of life quality assessment, the response rate for the QoL questionnaire was 50%. We found the overall QoL deteriorated for the first year after operation, but it gradually improved and even surpassed the patient pretreatment scores by the end of the second year after operation. Conclusion: The gap caused by TPLE in patient, perioperative morbidity, and postoperative quality of life could be managed by the evolution of esophageal substitute, surgical techniques, perioperative wound care, and evaluation of the quality of life.