Case

A 77-year-old woman was diagnosed with a localized squamous cell carcinoma (SCC) inferior to the cricopharyngeus. She was considered unfit for chemotherapy and was treated with definitive radiotherapy alone (56gy in 28 fractions). Surveillance endoscopy at three months was normal but at six months there was evidence of recurrent disease with a 2cm nodule below the cricipharyngeus region, confirmed as SCC on pathology. The rest of the oesophagus was normal. FDG PET/CT revealed a localized avid lesion as the only pathology. Panendoscopy and rigid bronchoscopy demonstrated extrinsic protrusion into the membranous tracheal wall with intact mucosa and no other mucosal abnormality.

The patient wished to avoid permanent tracheostomy. She accepted the option of a cervical oesophagectomy with jejunal interposition if it was evident a normal margin from the cancer could be achieved. At operation the cancer did not involve the trachea. The thyroid isthmus was divided and the individual thyroid lobes mobilized and laterally pedicled on their blood supply. The recurrent laryngeal nerves on each side were preserved, kept moist, and continually monitored using a NIM (Nerve Integrity Monitor).Complete access to the cervical oesophagus was obtained by tracheal transection between the first and second rings opening the trachea like a sliding double door (Figure 1). Proximal resection was through the level of the inferior constrictor 1cm beyond the tumour with a similar margin distally through the oesophagus. Frozen section reported no evidence of carcinoma at either margin. A left level II – IV neck dissection was performed. A jejunal segment was harvested via laparotomy and a feeding jejunostomy constructed. The jejunum was revasularized with microvascular anastomosis to the facial artery and internal jugular vein. Anastomosis to the lower pharynx and the oesophagus was performed with interrupted absorbable sutures (Figure 2). The trachea was closed with interrupted sutures, and tracheostomy created between the 4^th and 5^th tracheal rings (Figure 3).

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   Figure 1:

   Tracheal transection. Arrows indicating the recurrent laryngeal nerves.
   
   
   

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   Figure 2:

   Jejunal interposition. Arrows indicating microvascular anastomosis to the facial artery and internal jugular vein.
   
   
   

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   Figure 3:

   Tracheal closure with interrupted sutures as indicated by arrow.