When cervical esophageal cancer or hypopharyngeal cancer invades the cervical esophagus, there are many methods to repair the hypopharyngeal esophagus, and the common means include: gastric substitution of esophagus, free jejunum, colon substitution of esophagus, free flap or tipped flap, etc., among which gastric substitution of esophagus is the most widely used clinically. Traditionally, gastric substitution of esophagus is performed by two simultaneous cervical and abdominal groups, usually by head and neck surgery in cooperation with thoracic surgery or general surgery in general hospitals in China. The head and neck surgical group completes the cervical lymph node dissection and resection of the primary focus, and when the abdominal group is free and disconnected from the lower end of the esophagus, the esophagus is lifted off through a gauze band; then the gastric body is lifted up to the neck through a traction line. This classical gastric substitution of the esophagus leaves three wound incisions, namely an open incision in the abdominal cavity, an extraction incision in the thoracic esophageal bed and a neck incision. In order to minimize the damage of this traditional surgery, especially to reduce the blindness of esophageal extraction, we newly completed 3 lumpectomy-assisted hypopharyngeal cancer combined with thoracic segment esophageal cancer patients, which was done jointly by the abdominal group and the head and neck group, with the lumpectomy-assisted tubular gastroplasty done by President Jixiang Wu in the abdominal group, and the complete resection of the esophagus under direct view of the laparoscope from the thoracic entrance after resection of metastases and primary foci in the head and neck group esophagus, eliminating the risks associated with blind esophageal extraction, and achieving good clinical outcomes. 1. The patient, a middle-aged male, was a patient with locally advanced hypopharyngeal cancer. Under general anesthesia, cervical lymph node dissection on the affected side + lateral hypopharyngectomy on the affected side + subabdominal assisted esophageal extraction and tubular gastroplasty + tracheotomy were performed. The laryngeal function was preserved during the operation, and the operation was smooth, lasting 3 hours with 200 ml of bleeding. 5 weeks after the operation, the tube was blocked, the bilateral vocal cord movement was normal, and the vocal function was good. highly differentiated squamous epithelial cell carcinoma was reported, and radiotherapy and chemotherapy were given to the oncology department 7 weeks after the operation. 2. Surgical procedure. The head and neck surgery group and the laparotomy group operated simultaneously, and the head and neck surgery group first completed the left cervical lymph node dissection and total resection of the left hypopharynx, while the laparotomy group completed the freeing of the stomach body and lower esophagus under laparoscopy. The laparotomy group first punctured four sites, including the umbilicus, filled with carbon dioxide, established the operation hole, and placed the laparoscope, trocar needle and liver pulling hook. Then the large and small omentum was freed with ultrasonic knife combined with electrocoagulation forceps, and the short gastric artery and left gastric artery were separated and cut one by one. Then the suspensory abdominal laparoscopic technique was switched to a 3-cm incision along the midline of the abdomen, and the abdominal suspensory pulling hook was placed. The esophagus was disconnected at the cardia and the free stomach was lifted out of the body, and the lumpectomy suture was made into a tubular stomach. After completion of resection of metastases and primary foci in the head and neck group, the esophageal muscle layer and the esophageal bed were separated via the entrance of the thorax with the assistance of laparoscopy, and the vessels distributed in the esophageal segments were coagulated by ultrasonic knife under endoscopy, and the bilateral laryngeal recurrent nerves were preserved, and care was taken to avoid damaging the thoracic duct, which was separated all the way to the lateral lumen of the abdominal cavity and connected with the lumen after separation in the abdominal group. The completely freed esophagus was lifted from the thoracic cavity to the thoracic inlet under direct endoscopic view, and the tubular gastric body was moved up to the neck through the gauze bag, and the cervical segment of the stomach was anastomosed under tension-free, and the cervical tracheotomy was performed. The abdomen and neck were hemostatic, and drainage was placed separately, with the neck drainage connected to a negative pressure bottle and the abdomen connected to a drainage bag. Finally, the cervical and abdominal incisions were closed layer by layer. The operation lasted for 3 hours and the patient lost 200 ml of blood. The patient went down to the floor the day after the operation. The tube was blocked 5 weeks after surgery and normal breathing occurred. He was transferred to the oncology department for further treatment 2 months after surgery. 3, Discussion. Classical gastric substitution of esophagus takes traditional neck incision and open abdominal incision, which are performed simultaneously by head and neck group and abdominal group in the neck and abdomen, respectively, due to many incisions and trauma, and the patient’s postoperative recovery is slow. In the traditional cervical esophageal extraction, the abdominal group separates the esophagus around the esophageal fissure, and the head and neck group releases the cervical segment of the esophagus at the root of the neck. -Extraction. As the blood supply to the esophageal bed is stage-distributed, the supply vessels of the esophagus break during extraction and bleed easily, so a piece of gauze is usually followed at the lower end of the extraction line to stop the bleeding by gauze compression; in fact, there are important structures around the esophageal bed such as the thoracic duct, pleura and the laryngeal nerve, and blind extraction may also increase these injuries. 208 patients, 11.1% had pneumonia, 9.1% had anastomotic fistula, 7.2% had thoracic exudate, 3.9% had post-traumatic infection, 3.4% had anastomotic stricture, 1.9% had cardiac failure, 1.9% had celiac disease, 1.4% had pleural hemorrhage, 1.0% had abdominal hemorrhage, and 1.0% had laceration of the laparotomy. From these statistics, it is clear that the incidence of complications of gastric substitution of the esophagus during esophageal extraction is very high. A careful analysis of these complications, such as pneumonia and heart failure, is related to the large gastric body squeezing the chest cavity and acid reflux, which have been decreasing since the introduction of the tubular stomach. In this case, the surgical gastric substitution of the esophagus was performed with a tubular gastric fabrication for supination. Because of the difficulty in completing the production of the tubular stomach laparoscopically, the strategy adopted by this group laparoscopically was a combination of two laparoscopic techniques, i.e., the dissociation of the gastric body and the peri-esophageal cleft was completed first with the gas injection endoscope; then the operation was changed to a suspension system, and the gastric body was moved outward using a minimally invasive incision, and the tubular stomach was shaped in vitro, then the tubular stomach was retracted into the abdominal cavity, and the subsequent operation was completed under the suspension endoscope. The biggest advantage of this is that the patient’s abdominal incision is reduced and the postoperative recovery is fast. Another major improvement in this case was the use of lumpectomy for separation of the esophageal bed. The disadvantages of this approach include: if there is a tumor in the esophagus, this operation may result in esophageal rupture and tumor implantation and metastasis; direct extraction of the esophageal supply vessels and disconnection, resulting in bleeding; damage to important structures around the esophagus, such as the thoracic duct, the recurrent laryngeal nerve, and the mediastinal pleura. The probability of celiac fistula, celiac chest, pneumothorax, hemopneumothorax and other injuries increases after surgery. In this case, the lumpectomy was used to separate the esophageal muscles and surrounding structures, and the whole operation was performed under direct vision, which could show the recurrent laryngeal nerve, thoracic duct, pleura, large mediastinal vessels and abnormal enlarged lymph nodes. These important structures can be protected endoscopically, while significant lymph nodes can be removed. The general trend of the whole surgical development is minimally invasive and functional protection. Endoscopic technology has brought revolutionary changes in surgery, and open surgical treatment of many traditional diseases has gradually given way to endoscopic surgery, and head and neck tumor surgery is no exception. This patient’s double primary carcinoma successfully preserved laryngeal function with short operation time and less bleeding. To summarize the experience of his better initial clinical results, there are two main points: firstly, with the help of multidisciplinary collaboration, the technical advantages of each discipline are brought into play to minimize surgical trauma. With the mature laparoscopic technology experience in general surgery, the production of tubular stomach was completed through the alternate use of gas injection laparoscope and suspension laparoscope, which changed the large trauma caused by the traditional open laparoscopic incision; secondly, the laparoscopic technology was used to change the traditional esophageal dissection, and the “blind” operation was replaced by the laparoscopic separation of the esophagus under direct vision throughout the operation, which reduced the trauma caused by the “blind” operation. This reduces the risks associated with “blind” operation and also reduces the complications of surgery. According to the literature available to us, there are no reports of laparoscopic total transjugular esophageal detachment and laparoscopic assisted tubular gastric production in hypopharyngeal cervical esophageal cancer, in which this technique better illustrates the minimally invasive effect of endoscopic surgery.
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