Chapter 58

Locally extensive but nonmetastatic cancers of the upper aerodigestive tract on occasion may require resection. Tumors of the larynx, cervical trachea, hypopharynx, cervical esophagus, and thyroid can be exenterated with a pharyngolaryngotracheoesophagectomy as primary therapy. It also can be used as salvage after failed primary therapy, treatment of locally recurrent tumor, treatment of benign complications of successful primary therapy, or long-term palliation. The enormity of these procedures is overshadowed by the likely possibility of limited survival, the potential for significant complications, and the expected negative impact on quality of life. However, in curatively resected and properly reconstructed patients, the long-lasting effects are little more than those experienced by the laryngectomy patient.

Distant metastatic disease is excluded by PET/CT and disease-specific imaging (e.g., thyroid scanning for differentiated thyroid cancers). Regional nodal metastases are frequently detected by physical examination and confirmed by cytologic evaluation of fine-needle aspiration specimens. However, cervical ultrasonography may be necessary to better examine and determine regional nodal status. Local extent of the primary tumor is critical in deciding resectability but frequently is underestimated by preoperative testing. Regardless, local invasion should be evaluated in particular to identify carotid, vertebral body, and mediastinal involvement. This may require multiple imaging modalities (e.g., angiography, MRI, fine-cut CT scanning, barium esophagram, and bone scan). The proximal and distal extents of the tumor are assessed by oropharyngoscopy, bronchoscopy, and esophagoscopy (i.e., panendoscopy). These endoscopic procedures are accompanied by appropriate biopsy of the tumor and its margins. The skin and subcutaneous tissue that overlie and are in the vicinity of the primary tumor must be examined to exclude malignant invasion or severe radiation damage, if radiation was administered previously.

The reconstruction must be planned and prospective organs of replacement and reconstruction evaluated. Vascular insufficiency secondary to smoking or accelerated atherosclerosis may necessitate angiographic assessment of these organs and tissues. Gastroscopy and colonoscopy are essential to exclude intrinsic disease if the stomach or colon is being contemplated for replacement. The tissue planned for pedicled or free flaps must be assessed and alternatives considered and evaluated. A mediastinal tracheostomy may be necessary for reconstruction if there is a significant length of tracheal involvement. This may require division of the innominate artery to avoid postoperative arterial erosion and ensuing hemorrhagic complications. Therefore, angiographic assessment of the cerebral blood supply and patency of the circle of Willis is mandatory if mediastinal tracheostomy and division of the innominate artery are planned.

As in all patients undergoing airway and esophageal surgery, cardiopulmonary assessment is essential. Comorbidities must be evaluated and managed optimally preoperatively. During this time, the nutritional status and fitness of the patient are maximized.

Preparation and Positioning

The patient is placed in the supine position. Arterial line, oxygen saturation probe, and venous catheter placements are guided by the possibility of division of the innominate artery and sacrifice of the left innominate vein. Similarly, electrocardiographic pad placement may be affected by ...

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