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

Sep 23, 2026

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Head and neck cancer frequently coexists with esophageal cancer, and patients undergoing esophagectomy after total pharyngolaryngectomy (TPL) face high surgical risk due to dense adhesions and altered cervical anatomy. This case report describes a successful robot-assisted Ivor Lewis esophagectomy after TPL using intraoperative indocyanine green (ICG) fluorescence imaging to confirm adequate remnant esophageal perfusion and enable a safe intrathoracic anastomosis. The patient had an uneventful postoperative course and remained disease-free for two years.

LanguageEnglish

CategoryHealthcare

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Pages7

Reading Time18 min

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Abstract

Introduction

Case Presentation

Conclusions

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SURGICAL CASE REPORTS Surg Case Rep 2026; 12: 25-0737 Case Report Evaluation of Remnant Esophageal Perfusion Using Indocyanine Green Fluorescence Imaging during Ivor Lewis Esophagectomy after Total Pharyngolaryngectomy: A Case Report Shirou Kuwabara , Kazuaki Kobayashi, Natsuru Sudo, Masanori Nobuhiro, Gen Tomizawa, Yoh Kajiyama, Kohei Sato, and Jun Yamamoto ABSTRACT INTRODUCTION: Head and neck cancer frequently coexists with synchronous or metachronous esophageal cancer, owing to shared carcinogenic exposures such as alcohol and tobacco use. Inpatients 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. CASE PRESENTATION: A 73-year-old man with a history ofTPL 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. CONCLUSIONS: 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 Department of Digestive Surgery, Niigata City General Hospital, Niigata, Niigata, Japan Corresponding author: Shirou Kuwabara. Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, Niigata 950-1197, Japan E-mail: [shirouk@hosp.niigata.niigata.jp](shirouk@hosp.niigata.niigata.jp) Received: November 27, 2025; Accepted: January 22, 2026 DOI: 10.70352/scrj.cr.25-0737 Supplementary materials are available online. © 2026 The Author(s) . Published by Japan Surgical Society This article is licensed under a Creative Commons Attribution 4.0 International License. Kuwabara S. et al. complications. This technique may expand the surgical options for patients requiring esophagectomy following TPL. KEYWORDS: esophageal cancer, total pharyngolaryngectomy, indocyanine green fluorescence imaging, Ivor Lewis esophagectomy Abbreviations ESD endoscopic submucosal dissection ICG indocyanine green ITA inferior thyroid artery TPL total pharyngolaryngectomy INTRODUCTION Head and neck cancer and esophageal cancer share common carcinogenic risk factors, most notably tobacco use and alcohol consump

FAQs

Why is remnant esophageal perfusion a concern after total pharyngolaryngectomy (TPL)?

After TPL, proximal blood supply to the remnant esophagus may be compromised, raising the risk of ischemia during intrathoracic reconstruction.

How did the team assess remnant esophageal blood supply during surgery?

Intraoperative indocyanine green (ICG) fluorescence imaging was used to demonstrate adequate perfusion of the remnant esophagus.

What were the postoperative and longer-term outcomes?

The patient’s postoperative course was uneventful, with discharge on POD 12, and the patient remained disease-free for two years.

Sep 23, 2026

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