Simultaneous reconstruction of pharyngoesophagus and phonetic shunt following laryngopharyngoesophagectomy

Abstract

Because of its many advantages, free jejunal transfer has gained wide acceptance for pharyngoesophageal reconstruction after ablative surgery. Because the jejunum is well vascularized, it facilitates good wound healing, and has a low incidence of anastomotic insufficiency, fistula formation and stricture. However, voice rehabilitation in this group of patients can be difficult. Therefore, we performed primary tracheojejunal shunt operations for voice restoration with jejunum siphons using Nozaki's method (type 3). In this procedure, after dividing a section of the jejunum into two segments, the reconstructed neopharyngoesophagus is anastomosed in a side-to-end fashion to the fabricated shunt using the other segment of the jejunum, as an "elephant nose shunt" so called because of its appearance. Voice restoration can be achieved in patients who undergo laryngopharyngoesophagectomy through these reconstructive procedures. We performed this surgery for nine hypopharyngeal cancer patients after total pharyngo-laryngo-esophagectomy. Following placement of the shunt, no special care was required. Only one patient developed a severe aspiration. No leakage was seen and the swallowing function was preserved in all patients. Four of nine patients could speak well following these procedures. A vibratory source is created in the neoesophagus, above the elephant shunt. During speech production, narrowing of the inside and vibration of the jejunal mucosa can be observed using a laryngeal fiber scope. In order to study the acoustical characteristics of shunt speech, voice analysis was performed in patients with restored phonatory function using Computerized Speech Lab Model 4300 (KAY). Irregularities of pitch periods in the voice sample were measured using Jita (the pitch period) and Jitt (relative evaluation of the pitch) for the very short term (cycle-to-cycle), and PPQ (pitch period pertubation quotient) for the short term (cycle-to-cycle with a smoothing factor of 5 periods). Irregularities of the peak-to-peak amplitude were measured using ShdB (evaluation in dB of the peak-to-peak amplitude) and Shim (relative evaluation of the peak-to-peak amplitude) for the very short term (cycle-to-cycle), and APQ (amplitude perturbation quotient) for the short term (cycle-to-cycle with a smoothing factor of 11 periods). The pertubation parameters of shunt speech are larger than normal ones not only in terms of the period but also in terms of the amplitude. These results are similar to those of laryngeal polyps, recurrent nerve palsy and esophageal speech. Recovery of phonation using Nozaki's type 3 method with the elephant nose shunt appears promising for pharyngo-laryngo-esophagectomized patients.