------------------------------------------------------------------------------- TITLE: HYPOPHARYNX AND CERVICAL ESOPHAGUS RECONSTRUCTION SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: March 29th 1995 FACULTY: H. Seikaly, MD. FRCSC. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared for resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." ANATOMY - HYPOPHARYNX - The hypopharynx is the longest of the three segments of the pharynx. It extends form the tip of the epiglottis to the lower edge of the cricoid cartilage. It is widest superiorly and becomes progressively narrower towards the level of the cricopharyngeus muscle, where it merges with the cervical esophagus. The hypopharynx is divided into three distinct regions: 1) Pyriform sinuses The pyriform sinuses are laterally located pear-shaped funnels bound superiorly oropharynx and glossoepiglottic fold, antrolateraly by the medial aspect of the thyroid lamina, posteriorly by the Lateral pharyngeal wall, and medially by the lateral surface of the arytenoid and cricoid cartilage They open posteriorly into the pharynx and their apex usually extends inferiorly to the level of the laryngeal ventricle. 2) Posterior pharyngeal wall The posterior pharyngeal wall extend from a plane drawn through the tip of the epiglottis to a plane drawn thought the lower edge of the cricoid cartilage, which roughly corresponds to the level of the 3rd to the 6th cervical vertebrae. Superiorly it blend with the wall of oropharynx and inferiorly with the esophagus. 3) Post cricoid The post cricoid subunit is the region of the posterior surface to the arytenoid and cricoid cartilage. The hypopharynx is a myofascial skeleton covered by mucosa. The components of its walls are: 1) Mucosa The mucosa is made up of stratified squamous epithelium that contains some lymphoid nodules and secretory glands. 2) Pharyngobasilar fascia This fascial layer is highly developed in the nasopharynx and oropharynx but becomes less distinct inferiorly in the hypopharynx. 3) Muscular layer The middle and inferior constrictor muscles constitute musculature of the hypopharynx. These muscles are innervated by the laryngeal nerves (superior and recurrent) and the pharyngeal plexus (X, IX and possibly XI). a) Middle constrictor Origin: Lesser and greater cornua of the hyoid cartilage. Insertion: Pharyngeal raphe. b) Inferior constrictor Origin: Oblique line of the thyroid cartilage Insertion: Pharyngeal raphe The lower fibers of the inferior constrictors run horizontally forming the cricopharyngeus muscle. 4) Buccopharyngeal fascia This layer forms a thin covering on the external surfaces of the muscles. The muscles of the hypopharynx telescope past each other creating lateral deficiencies. These deficiencies are usually filled by buccopharyngeal fascia and the following structures: 1) Space between superior and middle constrictor. a) Glossopharyngeal nerve b) Glossopharyngeal muscle and styloid ligament c) Lingual artery before it enters the tongue 2) Space between middle and inferior constrictors. a) Thyroid membrane b) Superior laryngeal vessels and nerves - CERVICAL ESOPHAGUS - The cervical esophagus is that area of the esophagus situated superior to the sternum. The superior margin is the lower edge to the cricoid cartilage, while the inferior limit is the suprasternal notch. The length of the cervical esophagus varies depending on the individuals cervical anatomy. The esophageal wall is composed of three layers. 1) Mucosa: The mucosal layer is stratified squamous epithelium with a deeper layer of muscle called the muscularis mucosa. The muscle in the cervical esophagus are scant. 2) Submucosa: This is composed of areolar tissue containing nerves and blood vessels. 3) Muscular layer: There are inner circular and outer longitudinal muscles. The esophagus lacks serosa or a outer fibrous layer which is present in the rest of the digestive system. C) Lymphatic Drainage The hypopharynx and cervical esophagus are richly supplied by lymphatics. The superior lymphatics exit through the thyroid membrane and drain into the superior and middle jugular nodes. The inferior lymphatic exit through the hypopharynx and cervical esophagus to drain into the peritracheal and lower jugular nodes. The lower cervical esophagus also drains directly into the mediastinal nodes. - FUNCTION - The hypopharynx is a dynamic conduit between the oropharynx and the esophagus, that allow separation of the digestive and respiratory pathways preventing aspiration. The pharyngeal phase (Third Phase) of swallowing starts when the food bolus is propelled by the tongue past the anterior tonsillar pillar. Four neuromuscular events occur as the pharyngeal phase is triggered. 1) Velopharyngeal closure 2) Pharyngeal peristalsis -Propels the food through the pharynx to the cervical esophagus. 3) Laryngeal elevation and closure 4) Relaxation of the cricopharyngeus muscle Once the bolus of food enters the cervical esophagus it is propelled to the stomach by muscular contractions (fourth phase). - HISTORY OF RECONSTRUCTION - The first successful resection of the cervical esophagus was performed in 1877 by Czerny. Mikulicz reported the first successful cervical esophagus reconstruction in 1886. A variety of pharyngoesophageal reconstructive techniques have emerged between 1900 and 1995. The Cervical flaps are amongst the earliest methods of reconstruction. Wookey popularized the repair of pharyngoesophageal defects using local cervical tissues in 1942. He used laterally based cervical flaps which were partially folded back on themselves and sutured is the pharyngeal and esophageal ends to form a tube that was open laterally. The tubing of the flap was completed later and the neck defect was covered with a spilt thickness skin graft. Many modifications of this technique have been described, but the basic principle of using anterior cervical skin to resurface the neopharynx is constant. The modifications deal with different strategies for the resurfacing the neck defect. The use of skin form the anterior chest wall for reconstruction of the pharyngoesohagus regained popularity in the 1960's with description of the deltopectoral flap by Bakamjian. This remained the standard method of reconstruction until the advent of the myocutaneous flap in the late 1970's. The use of the pectoralis major myocutaneous flaps (PMMCF) in head and neck reconstruction was first described by Aryian in 1979. Theogaraj in 1980 reported a series of pharyngoesophageal reconstruction using a tubed PMMCF. A variety of abdominal viscera have been used to reconstruct the alimentary tract after resection of the hypopharynx and cervical esophagus. Ong and Lee in 1960 reported a technique of mobilizing and anastomosing the stomach to the pharynx. Keling and Vuillet were the first to independently report on a transverse colon transposition for reconstruction of the esophagus in 1911. Huguier et al in 1970 reported the first series of free jejunal grafts for reconstruction of the cervical esophagus. Many modifications have been described in an effort to decrease mortality and morbidity but the basic techniques remain the same. The use of tubed radial forearm free flap was first reported by Harii in 1985. Reports of the use of other fascioctaneous free flaps for reconstruction of the cervical esophagus and hypopharynx have surfaced since then. - RECONSTRUCTION CRITERIA - Reconstruction of a defect after resection of the hypopharynx and cervical esophagus remains one of the greatest challenges to the head and neck surgeon. The ideal reconstruction would restore normal anatomy, allow for normal deglutition without aspiration, allow for development of speech and for breathing without a tracheotomy. It is obvious that with our present skill and technology this type of reconstruction cannot be achieved. Patients with advanced cancer of hypopharynx and cervical esophagus have a very poor prognosis. Survival of these patients is approx. 50% at 1 year 20-30% at 5 years. Consequently, surgery for these patients should be considered primarily palliative, and the optimal reconstruction should preserve the quality of life for the duration of survival. The optimal reconstruction should therefore have the following characteristic: 1) Single stage reconstruction. 2) Low mortality. 3) Low mobility. 4) Short hospitalization. 5) Short interval to successful oral alimentation 6) High rate of speech development.. 7) Tolerate postoperative radiation. (~ 6000cGy) - RECONSTRUCTIVE OPTIONS - 1) Local tissues a) Primary closure b) Laryngeal flaps 2) Skin grafts 3) Cutaneous flaps a) Cervical b) Deltopectoral 4) Myocutaneous flaps a) Pectoralis major b) Latissimus dorsi c) Trapezius 5) Visceral transposition a) Gastric "pull-up" b) Jejunal autograft (free flaps) 6) Fasciocutaneous free flaps (FCF) a) Radial forearm b) Lateral thigh c) Scapula d) Other - TECHNIQUES - 1) Laryngeal flaps The standard pharyngolaryngectomy is performed sparing the uninvolved hemilarynx. The superior thyroid and superior laryngeal vessels are preserved on the flap side. Laryngeal cartilages are then removed through a subperichondrial dissection resulting in a pliable laryngeal flap. The flap is then rotated and used as a patch to close the adjacent hypopharyngeal defect. 2) Cervical skin flaps These flaps were the first attempts at reconstruction of circumferential defects of the hypopharynx and cervical esophagus. These techniques are multi-staged requiring the creation of a pharyngostoma and esophagostoma. A neopharynx is then fashioned from the anterior cervical skin and the resulting defect is covered with split thickness skin grafts, local or regional flaps. 3) Tubed deltopectoral flaps This technique is also multi-staged. The DP flap is initially elevated and anastomosed end-to-end to the pharynx and end-to- side with the esophagus. The second stage involves the conversion of the distal anastomosis to an end to end and replacement of the remaining DP flap onto the chest. 4) Myocutaneous flaps The pectoralis major flap is most frequently used flap in this technique, but the Latissimus dorsi and trapezius flaps have also been used. This is a one stage reconstruction with the flap used as a patch for partial or tubed for circumferential defects. Modification of this technique include the use of a skin grafted muscle to decrease the bulk of the flap, and the use of myofascial flaps. 5) Visceral transposition The most frequently used forms of visceral transposition are the gastric "pull-up" and jejunal autograft. a) Gastric "pull-up" This is a single stage procedure that requires total resection of the esophagus. The stomach is transposed into the thorax and neck pedicled on the right gastric and gastroepiploic vessels. This technique allows the stomach to be transposed as high as the nasopharynx in most patients. The stomach is then anastomosed to the remaining pharynx and base of tongue. Vagotomy and pyloroplasty are optional. b) Jejunal autograft This is also a single stage reconstruction, but it requires microsurgical expertise. A segment of jejunum is isolated on its mesenteric artery and vein. The segment is transposed to the neck and positioned such that peristalsis progress towards the esophagus. The mesenteric vessels are anastomosed to cervical vessels and the jejunum is anastomosed to oropharynx and esophagus. 6) Revascularized fasciocutaneous flaps These techniques are also single stage and require microsurgical skills, The flaps can be tubed for circumferential defects or used as a patch for subtotal defects. - LITERATURE REVIEW - A review of the literature was performed to compare the various methods of reconstruction for the above mentioned criteria. The comparative mortality , rate of stenosis, rate of fistula, and the rate of successful deglutition of the various methods is summarized in table 1. The interval to swallowing and length of hospital stay are shown in table 2. The tolerance to radiation by the various methods of reconstruction is shown in table 3. All the methods of reconstruction appear to enjoy a significant degree of success (79% - 88%), but these are determinant figures that do not reflect the influence of operative mortality and the possible delayed occurrence of strictures. There is significant increase in mortality and serious morbidity in patients undergoing visceral transposition. The skin, myocutaneous, and free fasciocutaneous flaps patients had less mortality and morbidity, but a higher rate of stenosis and fistula formation. Single stage reconstructions are characterized by rapid alimentation (7-12 days). The myocutaneus flap patients had a longer interval to alimentation ( 20-60 days) due to the high rate of significant fistulae which at times required a second procedure. Skin and muscle flaps tolerate radiation best, while the stomach tolerates it the poorest. The development of adequate speech with the aid of a prosthesis after reconstruction is best achieved with the FCF followed by the cutaneous and myocutaneous flaps. The development of speech with the visceral transpositions is generally poor but is better with the gastric pull-up. ---------------- - TABLE 1 - ---------------- Reconstruction Years Number Pt. Mortality(%) Fistula(%) stenosis(%) Success(%) Cervical flaps 42-84 214 6.5 38 38 86 DP Flaps 69-92 228 2 37 50 79 MCF (P) 80-92 203 1 37 18 88 MCF (T) 82-89 107 7 31 21 81 Gast. pull-up 60-90 402 12 16 10 81 Jejunum 70-94 528 5 19 25 87 FCF 85-95 59 0 42 8 83 ---------------- - TABLE 2 - ---------------- Reconstruction Hospital stay (weeks) Swallow interval (days) MCF 4-12 20-60 Gastric 2-4 7-12 Jejunum 2-4 7-12 FCF 2-4 7-12 --------------- -TABLE 3 - --------------- Reconstruction Radiation tolerance (cGy) Skin and muscle 7000+ Stomach 4000-5000 Jejunum 6000-6500 - DEFECT FACTORS - The important defect factors are 1) Size: the size of the defect can be classified as follows: a) Minor: defect less than 30% of the circumference of the pharynx or resection of maximum of 2 cm of the pharyngeal wall b) Major: defect that is greater than 30% but less than 70% of the pharyngeal circumference or a resection that is greater than 2 cm but at least a 2 cm stripe of pharyngeal mucosa is left c) Circumferential: defect greater than 70% of the pharyngeal circumference or a resection were less than a 2 cm stripe of mucosa is left 2) Presence of the larynx: This can rarely be performed due to oncologic or functional reasons 3) Inferior extent of the tumor - RECONSTRUCTION - Reconstruction of the pharyngeal defects remain one of the greatest challenges of the head and neck surgeon. The best reconstructive option depend on multiple factors which include the patients general health, defect factors, and specific reconstructive technique factors. Certain guidelines, however, may be followed and are listed below. A) Minor defects 1) Primary closure 2) STSG 3) Laryngeal flap B) Major defects 1) FCF 2) MCF 3) Laryngeal flap C) Circumferential defects I) Caudal lesion (disease spread to the esophagus such that the distal resection margin is within the mediastinum) 1) gastric pull-up 2) Colon II) Cephalic lesion (distal resection margin is within the neck) 1) FCF 2) Jejunum graft 3) MCF ------------------------------------------------------------------------- BIBLIOGRAPHY 1. Anthony JP, et al : Pharyngoesophageal reconstruction using tubed free radial forearm flap. clinics Plast Surg 21: 137, 1994. 2. Baek SM: Two new cutaneous flaps: the medial and lateral thigh flaps. Plast Reconstr Surg 71(3):354, 1983. PRIVATE 3. Baek S, Lawson W, Biller HF: Reconstruction of hypopharynx and cervical esophagus with pectoralis major island myocutaneous flap. Ann Plast Surg 7:18, 1981. 4. Bains MS, Spiro RH: Pharyngolaryngectomy, total extrathoracic esophagectomy and gastric transposition. Surg Gynecol Obstet 149:693, 1979. 5. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap Plast Reconstr Surg 36:173, 1965. 6. Bakamjian VY, Ling MD, Rigg BR: Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg 24:173, 1971. 7. Barazan L, Comoretto R: Hemipharyngectomy and hemilaryngectomy for pyriform sinus cancer: reconstruction with the remaining larynx and hypopharynx and with tracheostomy. Laryngoscope 103: 82, 1993. 8. Bryce DP: Conventional pharyngolaryngectomy in the surgical management of hypopharyngeal cancer. Can Otolaryngol 1:231, 1972. 9. Carlson GW, et al: Total reconstruction of the hypopharynx and cervical esophagus: a 20 year experience. Ann Plast Surg 29:408, 1992. 10. Coleman JJ, Reconstruction of the pharynx after resection for cancer: A comparison of methods. Ann Surg 209:554, 1989. 11. Cook DW, et al: Laryngeal flap for hypopharynx reconstruction. Head & Necvk 13: 318, 1991. 12. Cusumano RJ, et al: Pectoralis myocutaneous flap for replacement of cervical esophagus. Head & Neck 11: 450, 1989. 13. Czerny F: New operations. Zentralbl Chir 4:433, 1877. 14. Deane L, et al: Free jejunal transfer for the reconstruction of pharyngeal and cervical esophageal defects. Ann Plast Surg 19:499, 1987. 15. De Vries EJ, et al : Hypopharyngeal reconstruction: A comparison of two alternatives. Laryngoscope 99: 614, 1989. 16. Dennis D, Kashima H: Introduction of the Janus flap. Arch Otolaryngol 107:431:1981. 17. DeSanto LW, Carpenter RJ: Reconstruction of the pharynx and upper esophagus after resection of cancer. Head & Neck Surg 2:369, 1980. 18. Devineni VR, et al: Tolerance of gastric mucosal flaps to postoperative irradiation. Laryngoscope 101: 462, 1991. 19. Endo T, Nakayama Y: Pharyngoesophageal reconstruction with a tensor fasciae latae free flap. Plast Reconstr Surg 95:400, 1995. 20. Fabian RL: Reconstruction of the laryngopharynx and cervical esophagus. Laryngoscope 94: 1334, 1984 21. Ferguson JL, DeSanto LW : Total Pharygolaryngectomy and cervical esophagectomy with jejunal autotransplant reconstruction: Complication and results. Laryngoscope 98: 911, 1988. 22. Flynn MB, et al : Reconstruction with free bowel autografts after Pharyngoesophageal or Laryngopharyngoesophageal resection. Am J Surg 158: 333, 1989. 23. Frederickson JM, Strahan RW: Cervical esophagus reconstruction for heavily irradiated patients. Arch Otolaryngol 90:164, 1969. 24. Frederickson JM et al: Gastric pull-up vs deltopectoral flap for reconstruction of the cervical esophagus. Arch Otolaryngol 107:613, 1981. 25. Gluckman JL, McDonough J, Donegan JO: The role of the free jejunal graft in reconstruction of the pharynx and cervical esophagus. Head Neck Surg 4:360, 1982. 26. Griffiths JD, Shaw HJ: Cancer of the laryngopharynx and cervical esophagus. Arch Otolaryngol 97:340, 1973. 27. Gullane P, et al : Pharyngeal reconstruction: Current Controversies. J. Otolaryngol. 16: 169, 1987. 28. Harii K, et al : Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 75: 463, 1985. 29. Harrison DFN: The use of colonic transplants and revascularized jejunal autografts for primary repair after pharyngolaryngoesophagectomy. Proc R Soc Med 57:30, 1964. 30. Harrison DFN: Rehabilitation problems after pharyngogastric anastomosis. Arch Otolaryngol 104:244, 1978. 31. Harrison DFN: Surgical management of hypopharyngeal cancer. Arch Otolaryngol 105:149, 1979. 32. Hester T et al. Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer. Am J Surg 140:487, 1980. 33. Huguier M et al: Results of 117 esophageal replacements. Surg Gynecol Obstet 130:1054, 1970. 34. Kelly K, et al: pharyngoesophageal reconstruction using the radial forearm fasciocutaneous free flap: Preliminary results. Otolarnygol Head Neck Surg. 111: 16, 1994. 35. Koshima I, et al: Extended latissimus dorsi musculocutaneous flaps for extremely wide cervical skin defects involving the cervical esophagus. Ann Plast Surg 29: 149, 1992. 36. Lam KH, et al: avoiding stenosis in the tubed greater pectoral flap in pharyngeal repair. Arch Otolaryngol 113: 428, 1987. 37. Leonard JR, Maran AGD: Reconstruction of the cervical esophagus via gastric anastomosis. Laryngoscope 80:849, 1970. 38. LeQuesne LP, Ranger D: Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br J Surg 53:105, 1966. 39. Lewis RS: Pharyngeal reconstruction after pharyngolaryngectomy. J Laryngol Otol 79:771, 1965. 40. Maddox WA, et al: Total Pharyngeal reconstruction using a pectoralis major myocutaneuos tunnel. Arch Surg 123: 391, 1988. 41. McCaffrey TV, Fisher J: Effect of radiotherapy on the outcome of pharyngeal reconstruction using free jejunal transfer. Ann Otol Rhinol Laryngol 96: 22, !987. 42. Meyers WC et al: Postoperative function of "free" jejunal transplants for replacement of the cervical esophagus. Ann Surg 192:439, 1980. 43. Missotten FE: Historical review of pharyngo-oesophageal reconstruction after resection for carcinoma of the pharynx and cervical oesophagus. Clin. Otolaryngol. 8: 345, 1983. 44. Montgomery WW: Reconstruction of the cervical esophagus. Arch Otolaryngol 77:609, 1963. 45. Murakami Y et al: Esophageal reconstruction with a skin- grafted pectoralis major muscle flap. Arch Otolaryngol 108:719, 1982. 46. Mustard RA: The use of the Wookey operation for carcinoma of the hypopharynx and cervical esophagus. Surg Gynecol Obstet 111:577, 1960. 47. Nakamura T, Inokuchi K, Sugimachi K: Use of revascularized jejunal as a free graft for cervical esophagus, Jpn J Surg 5:92, 1975. 48. Nassif TM et al: The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg 69(4):591, 1982. 49. Neifeld JP, et al: Tubed pectoralis major musculocutaneous flaps for cervical esophagus replacement. Ann Plast Surg 11: 26, 1983. 50. Nieto CS, et al: Reconstruction of the posterior wall of the pharynx using a myocutaneous platysma flap. Br J Plast Surg 36: 36, 1983. 51. Omura K, et al : Reconstruction with free jejunal autograft after pharyngolaryngoesophagectomy. Ann Thorac Surg 57: 112, 1994. 52. Ong GB, Lee TC: Pharyngogastric anastomosis after esophagopharyngectomy for carcinoma of the hypopharynx and cervical esophagus. Br J Surg 48:193, 1960. 53. Pardhan SA, Rajpal RM : gastric pull-up for cancers of the hypopharynx and cervical esophagus: Our experience. J Surg oncol 26: 149, 1984. 54. Parks JS, Sako K, Marchetta FC: Reconstructive experience with the medially based deltopectoral flap. Am J Surg 128:548, 1974. 55. Perry A, et al: Surgiacl voice restoration with the Blom- Singer prosthesis following laryngopharyngoesophagectomy and pharyngogastric anastomosis. Ann Otol Rhinol Laryngol 100: 142, 1991. 56. Reece GP, et al: Reconstruction of the pharynx and cervical esophagus using free jejunal transfer. Clin Plast Surg 21: 125, 1994. 57. Robertson M, Robinson JM: Immediate pharyngoesophageal reconstruction. Arch Otolaryngol 110: 386, 1984. 58. Robertson M, Robinson JM: Pharyngoesophageal reconstruction: is skin-lined pharynx necessary? Arch Otolaryngol 111: 375, 1985. 59. Sambataro G, et al: Reconstruction of the hypopharynx following extensive loss of mucosa. Laryngoscope 94: 671, 1984. 60. Schechter GL, et al : Combined treatment of advanced cancer of the laryngopharynx and cervical esophagus. Laryngoscope 92: 11, 1982. 61. Schechter GL, et al : Functional evaluation of Pharyngoesophageal reconstructive Techniques. Arch otolaryngol 113:40, 1987. 62. Schuller DE: Reconstructive options for pharyngeal and/or cervical esophageal defects. Arch Otolaryngol 111: 193, 1985. 63. Schusterman MA, et al: Reconstruction of the cervical esophagus: Free jejunal transfer vs gastric pull-up. Plast Reconstr Surg 85:16, 1990. 64. Seidenberg B et al: Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 142:162, 1959. 65. Shah JP, et al: Selecting variants in pharyngeal reconstruction. Ann Otol Rhinol Laryngol 93: 318, 1984. 66. Sherlock EC, Maddox WA: The versatile deltopectoral skin flap in reconstruction about the head and neck. Am J Surg 118:744, 1969. 67. Shindo M, et al: The pectoralis major myofascial flap for intraoral and pharyngeal reconstruction. Arch Otolaryngol 118: 707, 1992. 68. Silver CF: Reconstruction after pharyngolaryngectomy- esophagectomy. Am J Surg 132:428, 1976. 69. Silver CF, Som ML: Reconstruction of the cervical esophagus after total pharyngolaryngectomy: a modified Wookey operation. Ann Surg 165:239, 1967. 70. Slaney G, Dalton FA: Problems of viscus replacement following pharyngolaryngectomy. J Laryngol Otol 87:539, 1973. 71. Stell PM: Esophageal replacement by transposed stomach. Arch Otolaryngol 91:166, 1970. 72. Stell PM, Maisels DO, Brown GA: Immediate pharyngeal repair after pharyngolaryngectomy using the medially based chest flap. J Laryngol Otol 84:1113, 1970. 73. Surkin MI, Lawson W, Biller HF: Analysis of the methods of pharyngoesophageal reconstruction. Head Neck Surg 6(5),953, 1984. 74. Takato T, et al: Oral and pharyngeal reconstruction using the free forearm flap. Arch Otolaryngol. 113: 873, 1987. 75. Theogaraj SD et al: The pectoralis major myocutaneous island flap in single-stage reconstruction of the pharyngoesophageal region. Plast Reconstr Surg 65:267, 1980. 76. Ti-Sheng C, Oi-Ling H, Wang-Wei: Reconstruction of esophageal defects with microsurgically revascularized jejunal segments: a report of 13 cases. J Microsurg 2:83, 1980. 77. Urkin ML, et al: A modified design of the buried forearm free flap for use in oral cavity and pharyngeal reconstruction. Arch Otolaryngol. 120: 1233, 1994. 78. Withers EH et al: Immediate reconstruction of the pharynx and cervical esophagus with the pectoralis major myocutaneous flap following laryngopharyngectomy. Plast Reconstr Surg 68:898, 1981. 79. Wookey H: The surgical treatment of carcinoma of the pharynx and upper esophagus. Surg Gynecol Obstet 75:449, 1941. 80. Yamamoto K, et al: Entire pharyngoesophageal reconstruction with latissimus dorsi myocutaneous island flap. Head & Neck 7: 461, 1985. 81. Yang G, Chen B, Gao Y: Forearm free skin flap transplantation. Natl Med J China 61:139, 1981. --------------------------------END---------------------------------