Elias D, Cavalcanti A, Dubé P, Julieron M, Mamelle G, Kac J, Ducreux M, Bonvallot S, Nitenberg G, Lasser P
Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, France.
Ann Surg Oncol. 1998 Sep;5(6):511-6. doi: 10.1007/BF02303643.
Forty-nine cases of circumferential pharyngolaryngectomy with total esophagectomy (PLTE) done between 1982 and 1996 were studied retrospectively. These procedures were performed for advanced squamous cell tumors of the superior esophageal sphincter (n = 23), for hypopharyngeal tumors with synchronous esophageal carcinoma (n = 15), and for hypopharyngeal tumors extensively invading the cervical esophagus (n = 11).
Ninety-six percent of the patients had T3-4 lesions, and it was impossible to use a free jejunal graft reconstruction. Patients underwent primary surgery in 70% of the cases, and salvage surgery (after failure of chemoradiotherapy) in 30%. In most patients, esophagectomy was performed without thoracotomy (n = 45). Resection was curative (R0) in 70% of the cases, in spite of lymph node invasion in 94%. Reconstruction of the digestive tract was achieved with the stomach in 33 patients (67%) or with the colon in 16 patients (33%).
Before 1989, postoperative mortality was high, was correlated with the high frequency of palliative surgery, and resulted in unsatisfactory survival results (overall 5-year survival rate of 7%). After 1989, as a result of better selection of patients and appropriate training of our team, postoperative mortality decreased from 33% to 10%, R1-2 resections decreased from 39% to 26%, and a 3-year overall survival rate of 28% was obtained for the last 25 patients, all of whom were able to eat without difficulty. These results are superior to the survival rates and functional results obtained with radiochemotherapy alone for such advanced tumors, even though the voice is preserved with radiochemotherapy alone.
PLTE for advanced pharyngeal or cervical esophageal tumors is the best treatment currently available, but it is indicated only in very selected cases: when it is technically impossible to perform reconstruction with a free jejunal graft after circumferential pharyngolaryngectomy; as primary surgery, rather than as salvage surgery following chemoradiotherapy; after careful preoperative morphologic and endoscopic assessment of the extent of the tumor; and in patients able to tolerate a thoracotomy for an esophagectomy with lymphadenectomy. Selection according to these guidelines should improve results.
对1982年至1996年间进行的49例全喉咽食管切除术（PLTE）进行回顾性研究。这些手术用于治疗食管上括约肌的晚期鳞状细胞肿瘤（n = 23）、伴有同步食管癌的下咽肿瘤（n = 15）以及广泛侵犯颈段食管的下咽肿瘤（n = 11）。
96%的患者有T3 - 4期病变，无法使用游离空肠移植重建。70%的患者接受了一期手术，30%接受了挽救性手术（放化疗失败后）。大多数患者（n = 45）在无开胸的情况下进行了食管切除术。尽管94%的患者有淋巴结转移，但70%的病例切除为根治性（R0）。33例患者（67%）用胃进行消化道重建，16例患者（33%）用结肠进行重建。
1989年前，术后死亡率高，与姑息性手术的高频率相关，生存结果不理想（总体5年生存率为7%）。1989年后，由于更好地选择患者和团队的适当培训，术后死亡率从33%降至10%，R1 - 2切除率从39%降至26%，最后25例患者的3年总生存率为28%，所有患者均能顺利进食。这些结果优于单纯放化疗治疗此类晚期肿瘤的生存率和功能结果，尽管单纯放化疗可保留声音。
对于晚期下咽或颈段食管肿瘤，PLTE是目前可用的最佳治疗方法，但仅适用于非常特定的病例：当全喉咽切除术后技术上无法用游离空肠移植进行重建时；作为一期手术，而不是放化疗后的挽救性手术；在术前对肿瘤范围进行仔细的形态学和内镜评估后；以及能够耐受开胸进行食管切除并清扫淋巴结的患者。按照这些指南进行选择应能改善结果。
