# Evaluation of Remnant Esophageal Perfusion Using Indocyanine Green Fluorescence Imaging during Ivor Lewis Esophagectomy after Total Pharyngolaryngectomy: A Case Report

## TL;DR

A case report shows how ICG fluorescence imaging helped safely perform esophagectomy after throat surgery by checking blood flow in the remaining esophagus.

## Contribution

Demonstrates the safe use of ICG fluorescence imaging to assess remnant esophageal perfusion during Ivor Lewis esophagectomy after TPL.

## Key findings

- ICG fluorescence imaging confirmed sufficient blood supply in the remnant esophagus, enabling a safe anastomosis.
- The patient had an uneventful postoperative recovery and remains disease-free two years later.
- Ivor Lewis esophagectomy is feasible after TPL with proper intraoperative perfusion evaluation.

## Abstract

Head and neck cancer frequently coexists with synchronous or metachronous esophageal cancer, owing to shared carcinogenic exposures such as alcohol and tobacco use. In patients undergoing esophagectomy after total pharyngolaryngectomy (TPL), surgical reconstruction poses significant challenges due to dense adhesions and altered cervical anatomy. The McKeown procedure requires cervical manipulation, demanding careful preservation of the tracheal stoma and free jejunal graft blood supply. In contrast, the Ivor Lewis procedure eliminates the need for cervical maneuver but necessitates an intrathoracic anastomosis between the gastric conduit and the remnant esophagus. This raises concerns regarding potential ischemia of the remnant esophagus, particularly after prior TPL, in which proximal blood supply may be compromised. We report a case of successful robot-assisted Ivor Lewis esophagectomy after TPL, in which intraoperative indocyanine green (ICG) fluorescence imaging was used to confirm sufficient blood supply in the remnant esophagus and to ensure a safe anastomosis.

A 73-year-old man with a history of TPL for hypopharyngeal cancer, endoscopic submucosal dissection for gastric and esophageal cancer, and colon resection for descending colon cancer was diagnosed with a new esophageal squamous cell carcinoma during routine surveillance endoscopy. Contrast-enhanced CT revealed no lymph node or distant metastasis (cT1bN0M0, Stage I). Considering his prior TPL and the absence of cervical lymph node involvement, a robot-assisted Ivor Lewis esophagectomy with intrathoracic gastric conduit reconstruction was planned without cervical manipulation. Intraoperative ICG fluorescence imaging demonstrated adequate perfusion of the remnant esophagus (about 45 mm), confirming its viability and allowing safe esophagogastric anastomosis. The postoperative course was uneventful, and the patient was discharged on POD 12. Histopathological examination revealed moderately differentiated squamous cell carcinoma invading the lamina propria mucosa (pT1aN0M0, Stage IA). The patient remains disease-free 2 years postoperatively.

Ivor Lewis esophagectomy can be safely performed after TPL when careful intraoperative evaluation of remnant esophageal perfusion is undertaken. ICG fluorescence imaging provides a simple and reliable method for assessing blood supply, helping to prevent ischemic complications. This technique may expand the surgical options for patients requiring esophagectomy following TPL.