Pharynx And Cervical Esophagus

Reconstruction of circumferential defects of the pharynx and esophagus has been revolutionized through the use of free flaps. As in other defects of the head and neck, the extent and location of the defect will determine the need for free flap reconstruction. Small defects of the pharynx that spare the larynx can be closed primarily if adequate mucosa is saved. Some defects in the lateral pharyngeal wall may be closed with a pectoralis flap, but swallowing is generally compromised. Defects of the posterior pharyngeal wall usually require a radial forearm or a split jejunal flap, which are not too bulky for closure.30 When the entire circumference of the pharynx and esophagus is resected, the defect is best repaired using a gastric pull-up or free flap to prevent stricture and fistula formation. For circumferential defects below the thoracic inlet, a gastric pull-up is indicated because of the potential for a distal anastomotic leak into the mediastinum if a free flap is used. Contraindications to a gastric pull-up include severe pulmonary disease (because the procedure requires traversing the mediastinum) and hepatobiliary disease. The mortality from gastric pull-up procedures remains significant at 8 to 12%.30

An absolute indication for the use of a free flap includes circumferential defects that extend more superiorly into the nasopharynx. We prefer either the free jejunum or radial forearm flap for defects above the thoracic inlet. The free jejunal transfer has the advantage of almost unlimited length for reconstruction; because mucosal tissue is sutured to mucosal tissue, the problem of anastomotic stricture is reduced. In our department, free jejunal transfer has an overall success of 95%, with successful swallowing achieved in 88% of patients with an average interval until swallowing of 10.6 days.1 The most common complication has been fistula formation, which has occurred in 15% of patients;1 however, most of the fistulae healed spontaneously. The mortality rate after a free jejunal transfer is about 5%, which is considerably less than that for a gastric pull-up procedure.30 A consideration in using this flap is that, unlike patients who successfully undergo reconstruction with a gastric pull-up, the large lumen of the jejunal segment may not allow sufficient air for neo-esophageal speech.29 We have routinely performed a tracheoesophageal puncture (TEP) in our jejunal flaps, which has resulted in remarkably good quality of speech despite these concerns. Another consideration is the increased morbidity with laparotomy in obese or elderly patients or in patients who have undergone previous abdominal surgery. In these cases, a fasciocutaneous flap such as a radial forearm or lateral thigh flap should be considered. We prefer the tubed radial forearm flap, as < 20 cm can be harvested with minimal morbidity. Disadvantages of this flap include the presence of hair-bearing skin and a higher incidence of fistula formation than is associated with the jejunal flap, presumably due to the additional longitudinal suture line required to tube the flap. Although the radial forearm flap obviates the need for a laparotomy in medically compromised patients, the jejunal graft remains the gold standard for defects of extensive length.

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