Acta Oto-Laryngologica, 2005; 125: 642 /646

ORIGINAL ARTICLE

Ileocolic free flap reconstruction, concomitant chemotherapy and radiotherapy and assessment of speech and swallowing function during management of advanced cancer of the larynx and hypopharynx: Preliminary report

YI-SHING LEU1,2, HUNG-TAO HSIAO2,3, YUAN-CHING CHANG4, CHENG-CHIEN YANG1,5, JEHN-CHUAN LEE1, YU-JEN CHEN6 & YI-FANG CHANG7
Department of Otolaryngology */Head & Neck Surgery, Mackay Memorial Hospital, 2Mackay Medicine, Nursing and Management College, Peito, the Departments of 3Plastic and Reconstructive Surgery and 4General Surgery, Mackay Memorial Hospital, 5Department of Speech and Hearing Disorders and Sciences, National Taipei College of Nursing, and the Departments of 6Radiology Oncology and 7Hematology, Mackay Memorial Hospital, Taipei, Taiwan
1

Abstract Conclusion. The new technique of ileocolic free flap reconstruction provides a better quality of life in terms of swallowing and speech for patients who have undergone laryngopharyngectomy with concomitant chemotherapy and radiotherapy (CCRT). Objectives. To compare and contrast the swallowing and speech outcomes of patients who underwent total laryngopharyngectomy with ileocolic free flap reconstruction and to analyze the survival rate after surgery and CCRT. Material and methods. This was a follow-up study of 12 patients with advanced (stages III, IVA and IVB) laryngeal and hypopharyngeal cancer who underwent major surgery, CCRT (with one exception) and ileocolic free flap reconstruction. Results. All patients were able to tolerate single-stage combined management comprising total laryngopharyngectomy with or without radical neck dissection plus ileocolic free flap reconstruction and postoperative CCRT (with one exception), without immediate morbidity or mortality. Eleven patients were diagnosed with hypopharyngeal cancer and one with laryngeal cancer. The mean interval between surgery and CCRT was 34.1 days. The mean follow-up period was 16.5 months. Four patients died during the follow-up period as a result of local recurrence (n 0/2), distant metastasis (n 0/1) and suicide (n 0/1). One patient was alive with disease despite neck recurrence.

Keywords: Hypopharyngeal cancer, ileocolic ap, treatment

Introduction Advanced cancers of the hypopharynx and larynx pose many therapeutic problems to oncologists and surgeons, not only in terms of the survival rate and reconstruction after surgery, but also with respect to quality of life. Laryngopharyngoesophagectomy with radical neck dissection is considered the standard surgical management. With the purpose of performing a radical resection and preventing skip metastases, we enlarge the safe surgical margin and sacrifice the larynx because these tumors frequently infiltrate the trachea and neighboring structures. Various surgical and prosthetic devices have been

designed in an attempt to alleviate the depression induced by voicelessness after laryngectomy. To overcome this problem, we performed an ileocolic flap reconstruction including a tracheo-ileal shunt for voice restoration and interposition of the colon for food passage. The ileocolic valve is a competent sphincter: an increase of pressure within the cecum compresses the ileum and blocks reflux through the valve effectively. Material and methods Twelve patients with advanced laryngeal and hypopharyngeal cancers (stages III, IVA and IVB) treated

Correspondence: Yi-Shing Leu, MD, Department of Otolaryngology */Head & Neck Surgery, 92, Chung-Shan N. Rd., Sec.2, Taipei 10449, Taiwan. Tel: '886 2 2543 3535. Fax: '886 2 2543 3642. E-mail: lys@ms2.mmh.org.tw / /

(Received 5 November 2004; accepted 11 November 2004)

ISSN 0001-6489 print/ISSN 1651-2551 online # 2005 Taylor & Francis DOI: 10.1080/00016480510027457

Ileocolic flap between January 2002 and December 2003 at Mackay Memorial Hospital were analyzed (Table I). Results Patient characteristics All patients were able to tolerate surgical intervention and postoperative concomitant chemotherapy and radiotherapy (CCRT) (except Case 9) without immediate morbidity or mortality. There were no abdominal complications. The mean age at time of diagnosis was 48.2 years (range 33 /61 years). All patients were male. The distribution of clinical stage was as follows: stage III, n 0/3; stage IVA, n 0/8; stage IVB, n 0/1. Tumor classification Eleven patients were diagnosed as having hypopharyngeal cancer (pyriform sinuses, n 0/8; posterior pharyngeal walls, n 0/2; postcricoid region, n 0/1) and one as having laryngeal cancer. The pathological reports revealed carotid artery involvement in one case, microscopic vascular invasion in three, thyroid cartilage invasion in two, soft tissue invasion in one and perineural invasion in one. The upper surgical margin was involved in two cases and the lower
Table I. Patient characteristics. Case No. 1 2 3 4 5 6 7 8 9 10 11 12 Age (years) 48 47 44 51 33 50 46 46 53 44 56 61 Tumor size (cm)/cell differentiation/side of RND (LN positive/LN total) 14)/4)/3/well/lower margin involved 4.8)/3.5)/0.8/well/(/ 5)/3.5)/3/mod/upper margin involved 3)/2 )/2/mod/soft tissue involved, right (4/30), left (2/5) 3.9)/3.2)/2.4/well/right (3/13) 4.5)/4.5)/2/mod/vascular invasion, right (2/3), left (1/31) 4.1)/4 )/2.2/well/vascular and soft tissue invasion, left (5/19) 4.4)/3.2)/2/well/thyroid cartilage invasion 3.6)/3.2)/1/mod/upper margin involved, right (4/22), left (2/18) 5.5)/3 )/4.5/well/thyroid cartilage and carotid artery invasion, left (1/24) 3.5)/2.5)/1.5/mod/vascular perineural invasion, left (1/24) 5)/2.5)/2/mod/right (2/9)

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margin in one. Well and moderately differentiated squamous cell carcinomas were found in six and six patients, respectively. Three patients were diagnosed with bilateral and five with unilateral neck metastases; contralateral neck metastasis was found in Case 7 (Table I). Surgery All patients underwent a single-stage combined operation involving total laryngopharyngectomy with or without radical neck dissection and ileocolic free flap reconstruction by head and neck surgeons, general surgeons and plastic surgeons. The nasogastric tube was removed and oral feeding begun 3 /4 weeks after operation. After operation on the primary lesion, an ileocolic segment is harvested after complete isolation from the ileocolic vessels that originate from the superior mesenteric vessels (Figure 1). The autograft, including the terminal ileum and ascending colon, measured 10 /15 cm according to the resected area of the hypopharynx (Table II). The mean lengths of the ileum and ascending colon used for reconstruction were 11.8 and 11.9 cm, respectively (ranges 10/15 and 10 /14 cm, respectively). The segment is then transferred to the neck and positioned in the recipient bed. The

Stage IVA III III IVA IVA IVA IVA IVA IVA IVB III IVA

Diagnosis Hypopharyngeal cancer (PC) Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PW) Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PW) Hypopharyngeal cancer (PS) Laryngeal cancer Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PS) Hypopharyngeal cancer (PS)

Survival (months) 8; DOD (LR) 18; alive 17; alive 10; DOD (LR) 12; DOO (suicide) 13; DOD (LM, BM) 14; alive (NR) 14; alive 13; alive 12; alive 12; alive 12; alive

PS0/pyrifom sinus; PC0/postcricoid; PW 0/posterior pharyngeal wall; RND 0/radical neck dissection; LN0/lymph nodes; well 0/well differentiated; mod0/moderately differentiated; DOD0/died of disease; DOO 0/died of other cause; LR0/local recurrence; LM0/lung metastasis; BM0/brain metastasis; NR0/neck recurrence.

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Figure 1. An ileocolic segment with ileum (right ), appendix and colon (left ).

cecum is anastomosed to the pharynx proximally, the ascending colon is anastomosed to the remaining esophagus distally and the ileum is anastomosed to the residual tracheal stump (Figure 2). Radiotherapy and chemotherapy All except one patient (Case 9) received 2 months of CCRT postoperatively. External-beam radiation therapy was given as follows: 3D conformed type (first six cases) and intensity-modulated type (last six cases). The mean total dosage was 63 Gy (range 59.4 /64.8 Gy) without a reduced dosage to the intestinal flap. Our standard chemotherapy regimen (cisplatin'/5-fluorouracil) consists of two doses of concurrent radiotherapy and two doses of adjuvant chemotherapy. Four doses of salvage chemotherapy with a Taxol-based agent were given in Cases 6 and 7

Figure 2. Status after ileocolic free ap reconstruction.

(Table II). The mean interval between surgery and CCRT was 34.1 days (range 25 /69 days). As requested by the patient, CCRT was delayed for 69 days for Case 7 due to general weakness.

Table II. Management and postoperative assessment. Lengths of ileum/colon (cm) 12/14 12/10 15/12 12/10 10/10 13/14 14/14 10/10 12/14 12/12 10/12 10/11 Interval between operation and CCRT (days) 27 25 26 34 32 30 69 25 / 31 40 38

Case No. 1 2 3 4 5 6 7 8 9a 10 11 12

Operation on primary lesion TPL TPL TPL TPL'/bilateral RND TPL'/right RND TPL'/bilateral RND TPL'/left RND TPL TPL'/bilateral RND TPL'/left RND TPL'/left RND TPL'/right RND

No. of sessions of chemotherapy 4 4 4 4 2 8 8 4 / 4 4 4

Speech efficacy (%) 70 70 75 20 10 50 80 70 20 80 40 70

Swallowing function SSD SD SD SSD LD SD SSD SD SSD SD SSD SD

a Patient refused CCRT. TPL0/total pharyngolaryngectomy; RND0/radical neck dissection; SD0/solid diet; SSD0/semi-solid diet; LD0/liquid diet.

Ileocolic flap Follow-up and assessment of swallowing and speech functions The mean follow-up time was 16.5 months (range 12 /20 months). Two patients died as a result of local recurrence and one as a result of lung and brain metastases. Case 5 committed suicide for unknown reasons and Case 7 was alive with contralateral neck recurrence. All patients were able to swallow meals without aspiration, although mild regurgitation was found on barium imaging in an esophagogram. Six patients could eat a solid diet, five a semi-solid diet and one only a liquid diet. Speech evaluation was performed 6 months after operation and the mean speech efficacy was 55% (range 10 /80%). During phonation, vibration of the ileocolic valve (Bauhins valve) could be observed endoscopically (Figure 3). Discussion Advanced cancer of the hypopharynx remains one of the upper aerodigestive tract tumors with the worst prognosis (survival rate B/30%) [1,2]. Patients generally die of persistent or recurrent disease, distant metastasis or second malignancies [2]. This is not only because of tumor extension both locally and regionally, but also because of the general characteristics of patients afflicted with these diseases. When first observed, 70% of hypopharyngeal cancers are at stage III/IV, 25% reveal extension towards the cervical esophagus and 33% reveal extension towards the oropharynx [1]. The best form of treatment is still radical surgery followed by postoperative radiotherapy and chemotherapy [1]. The aims of management are to ensure a good quality of life plus improved local control and an improved survival rate. It is relatively impossible to restore all functions of the larynx simultaneously after operation [3].

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Figure 3. Vibration of the ileocolic valve (Bauhins valve) visualized by means of berlaryngoscopy.

With recent improvements in microvascular surgery, a free intestinal graft has become a reliable and widely accepted method of reconstruction in head and neck surgery [4]. The advantages of a free intestinal graft include: (i) it is a single-stage procedure; (ii) an adequate radical excision margin can be achieved without restricting the length of the defect to be reconstructed; and (iii) preservation of the distal esophagus in order to improve swallowing and speech rehabilitation [5]. Ileocolic free flap reconstruction is better than jejunal flap reconstruction for the following reasons: (i) it contains an inherent valve preventing aspiration, which often complicates other procedures; (ii) it is applicable to almost all carcinomas of the pharynx and cervical esophagus; (iii) there is anastomic compatibility, with less granulation, because the diameter of the ileum is nearly equal to that of the trachea [3]; and (iv) the ileocolic valve also functions as a vibrating organ to produce voice [5]. The basic theory of phonatory procedures without a larynx is to introduce expiratory air from the trachea into the oral cavity or esophagus to produce voice [6]. Therefore, despite several modifications, choking with aspiration still occurs frequently due to the lack of an inherent valve mechanism between the airway and food passage. The ileocolic valve (Bauhins valve), which maintains a good, intrinsic tone after transplantation, can serve as a phonatory shunt and function like a neoglottis to prevent retrograde passage through the valve [7]. Using finger occlusion of the tracheostomy hole, the air is forced from the ileum to the ileocolic valve shunt and voice is produced [3]. Despite adequate reconstruction, dysphagia or impaired swallowing function were predominant complications following laryngopharyngectomy, and the incidence was reported to range from 2% to 60% [8]. All patients showed excellent food passage without aspiration in our series and that of Succo et al. [3]. CCRT should be started 1 month after surgery to ensure better survival rates in these patients with advanced-stage cancer. In our series, CCRT was not delayed, the mean interval between surgery and CCRT being 34.1 days. Ileocolic free flap reconstruction improves the perceived levels of swallowing and speech without delaying the subsequent course of CCRT [6]. Although additional clinical experience and investigation are necessary, we believe that this method provides a better quality of life for patients with advanced-stage cancer of the hypopharnx and larynx.

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[5] Kawahara H, Shiraishi T, Yasugawa H, Okamura K, Shirakusa T. A new surgical technique for voice restoration after laryngopharyngoesophagectomy with a free ileocolic graft: preliminary report. Surgery 1992;111:569 /75. [6] McAuliffe MJ, Ward EC, Bassett L, Perkins K. Functional speech outcomes after laryngectomy and pharyngolaryngectomy. Arch Otolaryngol Head Neck Surg 2000;126:705 / 9. [7] Di Dio LJ, Carril CF. Mechanism of the ileo-ceco-colic valve in a living person with exteriorized ileo-ceco-colic papilla. Rev Bras Gastroenterol 1954;6:67 /96. [8] Ward EC, Bishop B, Frisby J, Stevens M. Swallowing outcomes following laryngectomy and pharyngectomy. Arch Otolaryngol Head Neck Surg 2002;128:181 /6.

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