Il lembo libero ileocolico nella chirurgia oncologica cervicale avanzata

Tumours of the hypopharynx and cervical esophagus are a relatively rare pathology, but are very severe and have important diagnostic-therapeutic implications. Excision and reconstructive surgery are equally important since good morphological-functional outcome and an acceptable residual quality of life are dependent on their success. The lack of symptomatology and the difficulties in making an early diagnosis mean that tumours of the hypopharynx are generally diagnosed in the IIIrd and IVth stages. Moreover, functionally speaking, this pathology involves a critical part of the body, with serious consequences for quality of life. Hence the optimum therapeutic strategy to adopt becomes a very delicate question. Elective treatment is often (cervical or total) pharyngolaryngoesophagectomy, immediately followed by appropriate reconstruction, in order to regain an acceptable quality of life in as short a time as possible. Over the years numerous attempts have been made to re-establish communication between the respiratory and digestive tracts in order to recover the voice function. However, none of the various surgical solutions adopted has been able to recreate a physiological mechanism to protect the airways (myocutaneous flaps, gastric transposition, autotransplantation of the jejunum, antibrachial free flaps). This article illustrates a new one-stage technique for reconstructing the upper respiratory-digestive tract, based on microvascular transfer of the ileocolic segment to the neck, following pharyngolaryngoesophagectomy or extensive, total pharyngolaryngectomy. Continuity of the alimentary canal is re-established using the cecum and ascending colon, while the final ileal loop is joined by anastomosis to the cervical trachea, using the ileocecal valve to protect the airways during deglutition and for phonation. In the period March 1998 through February 1999, seven patients were admitted to reconstruction by free ileocolic flap. At the present time, clinical application of the free ileocolic flap, be it integral or tubulized, represents one of the most interesting options in reconstructive surgery, after total or more or less extensive pharyngolaryngectomy, since in a single operation excision can be followed by intervention to restore both deglutition and sufficiently intelligible phonation.