Key Points

• Surgery for cancer of the hypopharynx and cervical esophagus is challenging due to of the difficult resection and complex reconstruction.
• Options for reconstruction after pharyngolaryngectomy include pedicled and free enteric grafts as well as pedicled and free myocutaneous and fasciocutaneous flaps.
• Each of these reconstructive approaches is associated with differing rates of success, complications and functional outcomes.
• The reconstructive approach also depends on the size of defect needing to be bridged.
• Therefore, the method of reconstruction should be individualized and based upon the extent of resection, suitability of donor sites and surgeon preference.

Squamous cell carcinoma of the hypopharynx and cervical esophagus is often diagnosed at an advanced stage with approximately one third of patients having cancers that are non-curable at the time of diagnosis due to metastatic disease ([1],[2]). Patients often require multimodal therapy of which surgery forms a major part. Pharyngolaryngectomy entails resection of the aerodigestive tract and this procedure is associated with a significant impact on quality of life, causing debilitation in the fundamental functions of speaking and swallowing. In addition, the overall life expectancy of those who undergo surgery is also poor with approximately 35% overall survival at 5 years ([3]).

The complexity of the surgical management of these particular patients starts with the patients themselves. Often those deemed eligible for resection suffer from significant medical comorbidities which makes perioperative care even more challenging ([4]). This often includes a history of tobacco and alcohol use and poor nutritional status. Furthermore, for those undergoing surgery, neoadjuvant chemo-radiotherapy has been associated with better local control and quality of life compared with adjuvant treatments([5],[6]). However, neoadjuvant radiotherapy also has been found to be independently associated with an increased risk of postoperative complications ([7]). Furthermore, even for those treated with definitive chemo-radiotherapy, surgical resection in the setting of local recurrence is associated with a survival benefit ([8]). As such, surgery is often performed in an irradiated field.

With the goal of reconstruction being to balance surgical morbidity with an acceptable functional outcome, restoring gastrointestinal continuity is a daunting challenge for the surgeon. There are several approaches to performing the reconstruction and these form the basis of this chapter under the following headings: Pedicled enteric conduits (stomach, colon, intestine); enteric free grafts (jejunal, gastro-omental); pedicled myocutaneous flaps (pectoralis major); and myocutaneous free grafts (radial forearm, anterolateral thigh). We review the technical aspects of each of these methods and discuss their advantages, disadvantages and functional outcomes. Additionally, the surgical management of T4 lesions requiring extended resections of the airway will also be discussed.