Esophagogastric Preservation in the Surgical Management of Proximal Esophageal Cancer

Abstract

Definitive chemoradiotherapy is offered for most patients with isolated cervical esophageal tumor. Surgery is reserved for locally advanced diseases and salvage for failed chemoradiotherapy. Traditionally, surgery comprises total pharyngolaryngeal esophagectomy and gastric pull-up, which is associated with high morbidity and mortality rates. We hereby propose pharyngo-laryngo-cervico-esophagectomy by a transcervical approach, allowing preservation of the esophagus and stomach below, reducing operative morbidity and mortality. A retrospective review of 31 patients who underwent curative pharyngo-laryngo-cervico-esophagectomy for isolated cervical esophageal tumor at the Department of Surgery, The University of Hong Kong, Queen Mary Hospital, between January 1, 2005, and June 30, 2018, was performed. There were 26 male and 5 female patients. Median age was 64.8 years. Seventeen patients underwent definitive surgery. Fourteen patients underwent salvage surgery for failed chemoradiotherapy. Most patients presented with stage III and IV diseases (90.3%). Median length of pharyngoesophageal defect was 14.0 cm (range, 8.0-21.0 cm). Free jejunal flap was used for pharyngoesophageal reconstruction in 77.4%. Eight complications developed in 7 patients (22.6%). There was no in-hospital mortality. Clear radial and longitudinal resection margins were achieved in 96.8%. Median follow-up was 21.5 months. Locoregional recurrence rate was 32.3%. Nine patients died of disease progression (29.0%). Seven died of other causes (22.6%). Median survival was 21.5 months. Overall 2-year survival rate was 36.7%. Transcervical pharyngo-laryngo-cervico-esophagectomy should be considered in patients with isolated cervical esophageal tumors. Pharyngo-laryngo-cervico-esophagectomy allows adequate tumor resection while preserving the esophagus and stomach below. Operative morbidity and mortality outcomes were improved without compromising oncologic control.