This study on a series of 70 operations in 63 patients with head and neck cancer requiring a total laryngopharyngectomy with circumferential pharyngeal reconstruction with either jejunum interposition or gastric pull-up shows that perioperative morbidity of both procedures is high. However, the overall success rate of these reconstructions and long-term functional outcome is good in those patients surviving their disease.
Reconstructions with a gastric pull-up seem to have a lower success rate (74 vs. 84%), higher perioperative mortality (16 vs. 4%) and more overall early complications (89 vs. 63%) than jejunum interposition in our institution. However, these results are biased because a gastric pull-up is mostly used for inferiorly located defects that cannot be reconstructed with jejunum interposition. This is in line with the most literature, where a free transfer (i.e. jejunum, colon, tubed radial forearm flap, anterolateral thigh flap) [6–8, 13] is preferred in hypopharyngeal defects, and a gastric pull-up is the treatment modality of first choice in esophageal cancer [5, 8, 10].
To gain an extended overview of the postoperative morbidity of this difficult to treat group of patients, we have described various complications including those not directly related to the surgical procedure itself, making it difficult to compare these numbers to other studies. Most studies only describe wound complications in 27–50% of the patients [5, 9], which is comparable with 40% in our overall study population, when only considering the wound complications. Our in-hospital mortality rates of 4% for jejunum interpositions and 16% for gastric pull-up procedures are consistent with other reports [5–7, 9, 10, 14, 15].
Pharyngocutaneous fistulas are the most frequently occurring complications associated with these reconstructions in the early postoperative period. The overall fistula rate of 40% (of which 39% of the patients needed surgical intervention) in this study compares poorly to a previous report from our institute and other studies [6, 10, 14]. A number of reasons make a comparison of reported fistula rates in different studies difficult. A clear distinction between operations performed for primary versus recurrent tumors or functional (revision) operations is rarely made. This is an important differentiation to make as was shown by a study by Eckardt et al.  which included patients operated for both malignant and functional indications (i.e. trauma, congenital defects). Moreover, the indication for surgery has shifted during the past two decades towards more complex patients. The treatment strategies have evolved into organ preservation protocols and consequently, a considerable number of patients were initially treated with (chemo-)radiation. This resulted in a secondary role for surgery in 29% of the cases when previous therapy (i.e. radiotherapy or chemoradiation) had failed. In addition, 55% of the patients were classified as ASA III, preventing most of them to be suitable candidates for chemoradiation in the first place. The high rate of pretreated patients together with the significant co-morbidity (96% ASA II/III) will have largely attributed to the high complication rates. However, due to the large diversity within our patient population (e.g. medical history, pretreatment modalities, disease stage), much larger groups of patients would be required to analyze the contribution of each of these components to the complication rates.
Few studies address long-term complications and morbidity of total laryngopharyngectomy [5, 9]. Twenty-four percent long-term complications for jejunum interpositions and up to 50% for gastric pull-up, found in our present study, is not insignificant. The majority of long-term complications, requiring surgical intervention in 81% of cases, consisted of strictures of the neopharynx or of the tracheostoma. The reason for the late developments of these strictures is unclear.
It has been suggested that the trans-esophageal puncture may play a role by compromising the blood flow and progressive fibrosis when performed too proximal to the anastomosis . Theoretically, the jejunum interposition has several advantages. It is likely that mucous secretion in the jejunum interposition will favor the swallowing function. Moreover, a more robust junction will be reached with a mucous-to-mucous anastomosis as compared to a mucous-to-skin anastomosis. Finally, no vertical anastomosis is required when a circular graft is used. However, we have previously reported pouch formation of the jejunum interposition resulting in dysphagia complaints , and Murray et al.  have suggested that alternative reconstruction methods (tubed radial forearm flap, anterolateral thigh flap) provide better long-term results. Nevertheless, a retrospective study by Yu et al. , comparing the functional outcomes of the jejunum interposition with the anterolateral thigh flap, showed similar complication rates. In conclusion, as long as prospective, randomized controlled trails have not been performed, the optimal reconstructive method for these large circular defects will remain subject to debate.
One of the greatest impacts of total laryngopharyngectomy is the loss of the natural voice. There are numerous means of speech rehabilitation of which the voice prosthesis is currently the most commonly used in our institution. Voice rehabilitation is usually started 10 days postoperatively. The use of a Provox® speech button (41%) or an electrolarynx (52%) resulted in a total of 95% of the patients being able to communicate by means of speech. This possibility of direct communication is essential for a sufficient quality of life, which is reflected in satisfying global functional scores (mean 69–100). However, despite the communication capability, significant speech problems were reported (mean 48/100). This most likely reflects the practical and psychological difficulties resulting from the obligatory use of an electrolarynx instead of the natural voice. In our institute, most tracheoesophageal punctures are performed during a secondary procedure, approximately 6 weeks after the first operation. Boscolo-Rizzo et al.  found no difference in complication rate between initial or secondary placement of the voice prosthesis. However, we feel that each effect that could provoke wound complications should be avoided. To our knowledge, these are the first results that fully confirm the experience-based presumption of the wide extent of the postoperative morbidity. Complete oral intake, defined as the moment when enteral supplementation is no longer required, was achieved in 97% of patients, an excellent outcome as compared to the reported 65–81% in the literature [7, 10, 21, 22]. However, despite the lack of need for a feeding tube, in many cases patients are restricted to a soft diet, which could explain the moderate problems in social eating (mean 29/100). Furthermore, late stricture formation was seen in 17% of the patients, which could explain the mild swallowing problems (mean 21/100). Swallowing rehabilitation started between 3 and 80 days postoperatively with a mean of 18 days. Complete oral intake was on average accomplished after 2 months. These data are rarely reported in the literature, but Oniscu et al.  reported satisfactory swallowing of 78% after 6 months and 81% after 12 months, suggesting that a rehabilitation period of 2 months should on average be expected. An interesting alternative reconstruction technique was introduced by Schilling et al.  who described the use of a fundus rotation gastroplasty resulting in a low complication rate and moderate dysphagia during the first 6 months after surgery which resolved within 1 year. Patients undergoing total laryngopharyngectomy are generally patients with advanced disease, roughly 75% having stages III or IV disease. Reported 5-year survival rates vary between 11 and 47% [5, 7, 14, 21, 22]. In this study, the 5-year survival rate was 25%. Adding the high postoperative complication rate and lengthy rehabilitation period, especially in the salvage setting, it can in some instances be questionable if surgery should at all be offered if there is no (further) alternative treatment available.
However, analysis of the global health score and functional scores of the surviving patients reveal strikingly satisfactory results. Minimal pain was experienced, which is an important factor of gaining an acceptable quality of life. As demonstrated in previous quality of life studies of partial and total laryngectomy  and confirmed by our data, significant deterioration in smell and taste functioning does not result in a loss of appetite, contrary to what might be expected. Despite the use of voice prostheses, speech problems are still among the most important complaints during the follow-up of these procedures . No emotional regression was reported. However, some patients did describe a decrease in interest and pleasure regarding sexual activities. With regard to the symptoms, sticky saliva is the most prominently and generally described complaint, followed by fatigue, dry mouth and coughing. Although the assessment of the quality of life was performed in a relatively small and selective group of surviving patients, we consider the results a relevant indication, because they are similar to studies on the quality of life after a total laryngopharyngectomy [7, 24]. However, to fully appreciate the quality of life in this selective group of patients, a prospective study in a larger population is necessary. This would most likely require a multicenter study to include an adequate number of patients.