الفهرس 
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Abstract
Unlike other malignant tumors in the head and neck, hypopharyngeal cancer has a very bad prognosis, regardless of treatment options used. This is due to delayed symptoms, tendency to spread under the mucous membranes, the lack of anatomical barriers of hypopharyngeal wall and early metastases to regional lymph nodes of the neck at time of presentation, as well as high chance of distant metastasis.
Hypopharyngeal cancer treatment depends on the early diagnosis, age, stage of the disease and general health of the patient. In most cases, hypopharyngeal cancers require an extended radical resection consisting of total laryngectomy combined with partial or total pharyngeal resection. In those extended resections, a reconstructive procedure is required.
The jejunal free flap (JFF) and radial forearm free flap (RFFF) are probably the methods of choice. However, apart from donor site morbidity and reported total flap loss, the main disadvantages of microvascular surgery are their costs, prolonged surgical time, the need for two surgical team and microvascular experience.
The aim of this study is to assess the success and complications of pectoralis major myocutaneous flap (PMMCF) sutured directly to the prevertebral fascia for reconstruction of hypopharyngeal defect following total hypopharyngolaryngectomy.
This study is a prospective case series that was done in the department of Ear, Nose and throat (ENT) of Assiut university hospital, from June 2011 to January 2016 after the approval of the ethical committee on 17/5/2011. It included ten patients, seven were females and three were males with an age that ranged from 20 to 59 years proved to have hypopharyngeal squamous cell carcinoma. All the patients were subjected to clinical, radiological, laboratory and endoscopic evaluation.
All the patients were subjected to tumor resection in the form of total hypopharyngolaryngectomy, total thyroidectomy and partial oesophagecctomy with or without radical neck dissections. Reconstruction with the left pectoralis major myocutaneous flap (PMMCF) was done.
The main outcome measures included: durations of tube feeding and hospital stay, character of diet and speech, persistent fistula and tumor recurrence.
Preoperatively, all the patients presented with progressive dysphagia and weight loss. Nine patients were in stage IVA and only one patient was in stage III by the TNM staging system. Preoperative evidence of lymph node metastasis (clinical and radiological) was found in three patients (bilateral in one of them). One patient had a previous failure of a chemoradiotherapy course for hypopharyngeal cancer.
Operatively, resection was done without reported morbidity or mortality. In one patient it was necessary to resect much of the tracheal wall than usual to obtain adequate safety margin. Primary radical neck dissection was done in three patients with clinically palpable lymph node (bilateral in one of them, in whom a lymph node was found fixed to the right carotid artery). Secondary left sided radical neck dissection was done in the 9th postoperative month in another patient who developed an enlarging left sided lymph node during the follow up period. The lymph nodes affected were levels II and III. The left PMMCF was successfully elevated by the ablation team after completion of the resection in seven cases and by another team in three cases. The donor site was closed primarily without the need for skin grafting.
Postoperatively, in seven out of ten patients the average duration of hospital stay and nasogastric tube feeding were, 23 days and 32 days respectively. Some of the patients were sent home with the nasogastric tube. The hospital stay and nasogastric tube feeding were prolonged in two patients because of pharyngocutaneous and pharyngotracheal fistula. In one of them, surgical closure with local flaps was done successfully. She regained oral feeding after two weeks of fistula closure. In the other one, persistent pharyngocutaneous fistula was reported because of incomplete surgical resection of a metastatic lymph node fixed to the right carotid artery. She was diverted to feeding gastrostomy and died during the course of postoperative chemoradiotherapy. Cervical wound dehiscence was reported in one patient and he died because of carotid blow out in 12th postoperative day although the PMMCF was observed to be viable.
Functionally, eight patients were able to have oral feeding. Swallowing was described to be good (normal diet) by six patients, adequate (soft diet) by a patient and poor (liquid diet only) by another one. All the patients had no satisfactory speech results.
At the donor site, chest wound dehiscence was reported once, in the patient who had failed chemoradiotherapy course for hypopharyngeal cancer. Also a seroma that was reported in another one and it was treated conservatively. Local recurrence of the tumor was reported in two patients, at the lateral oropharyngeal wall in one of them and in the other one, at the esophageal stump. Postoperative radiotherapy was applied for six patients and chemoradiotherapy for three patients. No neopharyngeal stricture could be detected in all patients in the follow up period.
In this study, using the PMMCF sutured directly to the prevertebral fascia is an easy surgical technique, with acceptable functional results, postoperative hospitalization and local complications.