Pharyngoesophageal Reconstruction

Early reconstruction of circumferential pharyngoesophageal defects represented one of the most challenging dilemmas for the reconstructive head and neck surgeon. The inability to reestablish continuity of the cervical esophagus resulted in a chronic pharyngocutaneous fistula often leading to infection and a poor outcome. Early attempts to remedy this problem led Czerny8 Mikulicz,9 and Trotter10 to use cervical skin flaps in a staged reconstruction. This approach proved unreliable, requiring multiple stages and prolonged hospitalization; it was commonly associated with a high rate of morbidity as a result of flap necrosis and eventual wound breakdown. Nearly a half-century later, Wookey reintroduced this technique, redesigning the cervical flaps with a wide pedicle, which resulted in a more reliable two-stage reconstruction. Although this was an improvement, a review of 148 patients reconstructed in this fashion, demonstrated that these patients required prolonged hospitalization ranging from 6 to 16 weeks, and 94% sustained some form of postoperative complication related to the reconstruction.11 Complications, including stenosis, fistula, or flap necrosis, required an average of three corrective procedures prior to successful resumption of deglutition. The limitations associated with random pattern skin flaps led to the application of the deltopectoral and, soon thereafter, the pectoralis major myocutaneous flap.

The deltopectoral flap offered reconstructive surgeons a source of reliable, well-vascularized tissue from a regional site, which was particularly useful in irradiated patients. Although this technique was an improvement over prior reconstructive methods, there were disadvantages of a staged procedure with the mandatory creation of a pharyngostome, as well as an unac-ceptably high complication rate (56%).11 The drive to reconstruct the pharyngoesophagus primarily, influenced Withers et al.12 and Baek et al.13 to report on the use of a tubed pectoralis major flap as a method of "immediate" reconstruction of circumferential defects of the pharynx and cervical esophagus. The pectoralis major flap offered the advantage of introducing nonirradiated muscle to the reconstruction site. However, the bulky nature of the flap lacked the necessary pliability to comfortably create a circumferencial skin tube and thereby hindered the reconstruction in many patients. As a result, most tube-shaped pectoralis major pharyngoesophageal reconstructions required the formation of a controlled fistula, either at the time of primary reconstruction or as a result of an often inevitable postoperative wound dehiscence.

In an effort to address the problems associated with delayed reconstruction, and the requirement for thin, pliable tissue, a variety of pedicled visceral flaps were introduced.14-16 The theoretical advantages of the gastric pull-up include a single anastomosis and hence less potential for anastomotic failure, a source of thin, pliable, nonirradiated tissue, and the opportunity for immediate reconstruction. Unfortunately, these advantages did not translate into a reliable method of reconstruction. Surkin et al.11 found mortality to range from 10% to 15%, and 50% of patients sustained major abdominal, medical, or thoracic complications. Although anastomotic stenosis is uncommon, patients often suffer from an uncontrolled regurgitation of gastric contents, or a "dumping syndrome," as a result of the atonic gastric segment. Although the gastric pull-up still plays a role in contemporary reconstruction of the thoracic esophagus, its routine use in cervicoesophageal reconstruction has been limited because of the unacceptably high complication rate and the introduction of less morbid and more reliable alternatives.

Microvascular free tissue transfer has been widely applied in contemporary head and neck reconstruction, and its impact on the primary reconstruction of the pharyngoesophagus has been profound. The drive to circumvent the morbidity associated with delayed reconstruction led to the application of free tissue transfer for pharyngoesophageal reconstruction. Seidenberg et al.1 first introduced free jejunal transfer in 1959, but this technique lay dormant for many years until 1975, when free jejunal reconstruction became increasingly popular as reported in the head and neck literature. Since then, a host of donor sites have been described for the reconstitution of circumferential defects, including visceral flaps such as the tubed gastro-omental free flap17 and free colon segments, as well as tubed cutaneous free flaps.18 Harii et al.19 were the first to report their success in using tube-shaped cutaneous radial forearm flaps. This approach offered an attractive alternative to the necessity for a laparotomy, with its attendant morbidity, to harvest a visceral flap.19 Several different cutaneous flaps have since been applied in a similar manner, including the lateral thigh20 and ulnar forearm flaps.21

Colonic segments have been used as free flaps based on the ileocolic, middle colic, and sigmoid arteries. Although this donor site is no longer the primary choice for reconstruction of the pharyngoesophagus, the mucosa-lined colon offers an inner lining similar to the native pharynx. Its large diameter facilitates the pharyngeal anastomosis, but it can present some difficulty at the distal esophageal anastomotic site.

Free jejunal autografts offer several advantages over the free colon transfer, including the ability to harvest large segments of jejunum with little or no functional gastrointestinal disturbance. The popularity of the free jejunal autograft in head and neck reconstruction22 stemmed from its diversity as a reconstructive tool. The mucosal tube can be split to reconstruct a defect in the posterior pharyngeal wall, or it can be used as a circumferential mucosal tube for primary reconstruction of the cervical esophagus and hypopharynx. Splitting the jejunal segment along its antemesenteric border can facilitate the resurfacing of defects that extend to the oral cavity. Furthermore, a jejunal harvest does not require preoperative bowel preparation and has less potential for postoperative complications as compared with the colon donor site. Similar to the colon, the jejunum offers the advantage of providing a mucosa-lined conduit; however, the diameter of the jejunum more closely approximates that of the pharyngoesophagus. The distant harvest site permits a two-team approach. The harvest itself is technically easy, usually requiring less than 1 hour to perform.

Tube-shaped cutaneous free flaps offer a source of thin and pliable tissue ideal for the primary reconstruction of the pharyngoesophagus. The enhanced pliability and vascularity of the radial forearm, lateral thigh, ulnar forearm,21 and lateral arm donor sites avoid the high rates of fistulization and stenosis associated with myocutanoeus and locoregional flaps.18'2320 All three donor sites permit a two-team harvest, as well as the decreased risk of donor site morbidity and the flexibility in design. The potential morbidity associated with a laparotomy has led many head and neck surgeons to use tube-shaped cutaneous free flaps as a first choice of reconstruction. The notable exception is when the inferior cervical esophageal margin is below the sternum, resulting in difficult distal exposure. In the case of a technically difficult anastomosis between a tube-shaped skin flap and the esophagus, an enteric stapling device enables a safe and reliable anastomosis, using a free jejunal autograft. The harvest of the radial forearm, lateral thigh, or lateral arm flaps may be closed primarily or with a split-thickness skin graft, resulting in limited donor site morbidity. Limitations may exist when the patient is obese and excessive subcutaneous fat prevents the tubing of the flap. Under these circumstances, a visceral free flap would be a more suitable option.

Microvascular free tissue transfer offers a reliable single-staged reconstruction of the pharyngoesophageal segment with low donor site morbidity. Tube-shaped cutaneous free flaps provide an excellent first-line tool, as they are associated with excellent functional results with respect to swallowing and speech, very low donor site morbidity, and an acceptably low complication rate.60

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