CIRCUMFERENTIAL PHARYNGOLARYNGECTOMY WITH TOTAL ESOPHAGECTOMY FOR LOCALLY ADVANCED CARCINOMAS

Background: Forty-nine cases of circumferential pharyngolaryngectomy w ith total esophagectomy (PLTE) done between 1982 and 1996 were studied retrospectively. These procedures were performed for advanced squamou s cell tumors of the superior esophageal sphincter (n = 23), for hypop haryngeal tumors with synchronous esophageal carcinoma (n = 15), and f or hypopharyngeal tumors extensively invading the cervical esophagus ( n = 11). Methods: Ninety-six percent of the patients had T3-4 lesions, and it was impossible to use a free jejunal graft reconstruction. Pat ients underwent primary surgery in 70% of the cases, and salvage surge ry (after failure of chemoradiotherapy) in 30%. In most patients, esop hagectomy was per formed without thoracotomy (n = 45). Resection was c urative (RO) in 70% of the cases, in spite of lymph node invasion in 9 4%. Reconstruction of the digestive tract was achieved with the stomac h in 33 patients (67%) or with the colon in 16 patients (33%). Results : Before 1989, postoperative mortality was high, was correlated with t he high frequency of palliative surgery, and resulted in unsatisfactor y survival results (overall 5-year survival rate of 7%). After 1989, a s a result of better selection of patients and appropriate training of our team, postoperative mortality decreased from 33% to 10%, R1-2 res ections decreased from 39% to 26%, and a 3-year overall survival rate of 28% was obtained for the last 25 patients, all of whom were able to eat without difficulty. These results are superior to the survival ra tes and functional results obtained with radiochemotherapy alone for s uch advanced tumors, even though the voice is preserved with radiochem otherapy alone. Conclusions: PLTE for advanced pharyngeal or cervical esophageal tumors is the best treatment currently available, but it is indicated only in very selected cases: when it is technically impossi ble to perform reconstruction with a free jejunal graft after circumfe rential pharyngolaryngectomy; as primary surgery, rather than as salva ge surgery following chemoradiotherapy; after careful preoperative mor phologic and endoscopic assessment of the extent of the tumor; and in patients able to tolerate a thoracotomy for an esophagectomy with lymp hadenectomy. Selection according to these guidelines should improve re sults.