Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

Deng, Lifei; Li, Yan; Li, Weixiong; Liu, Muyuan; Xu, Shaowei; Peng, Hanwei

doi:10.1016/j.bjorl.2020.05.009

Cited by 4 publications

(1 citation statement)

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“…The skin directed toward the lumen was thought to prevent damage of the flap from exposure to digestive fluids, as well [ 11 ]. Re-leakage after repair was seen in some cases, but all have healed by conservative treatment, conceivably owing to the volume of the PMMF to fill the tissue defect [ 8 , 11 , 13 , 14 ]. Reports have also shown that majority of the patients were able to start oral intake 10–15 days after PMMF repair, unless re-leakage was observed [ 8 , 13 , 15 ], providing us with a clinical indicator of when to start oral intake after surgery.…”

Section: Discussionmentioning

confidence: 99%

Repair using the pectoralis major musculocutaneous flap for refractory anastomotic leakage after total esophagectomy

et al. 2023

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Background The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF. Case presentation A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up. Conclusions The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.

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