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Gastro-omental free flaps in oral and oropharyngeal reconstruction:surgical anatomy, complications, outcomes
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BRITISH
British Journal of Oral and Maxillofacial Surgery (2002) 40, 32–36 © 2002 The British Association of Oral and Maxillofacial Surgeons doi: 10.1054/bjom.2001.0677, available online at http://www.idealibrary.com on
Journal of Oral and Maxillofacial Surgery
Gastro-omental free flaps in oral and oropharyngeal reconstruction: surgical anatomy, complications, outcomes J. Gallagher, A. Webb, V. Ilankovan Department of Oral and Maxillofacial Surgery, Poole Hospital, Poole, UK SUMMARY. Free gastro-omental flaps can be used to reconstruct defects in the oral cavity after ablative cancer surgery. The omentum can provide as much bulk as required. The generous gastro-omental pedicle allows mobility. The gastric mucosal lining has the advantage that it produces mucus, does not carry hair follicles and is not prone to troublesome desquamation. This paper reviews the surgical anatomy of free gastro-omental flaps and presents a series of eight cases in which these flaps were used for oral and oropharyngeal reconstruction. © 2002 The British Association of Oral and Maxillofacial Surgeons
These flaps can be with or without a section of greater omentum as required (Figs 1 & 2).
INTRODUCTION Various free flaps have been used in the oral cavity for soft tissue cover after resection of tumours. These include radial forearm flaps, superficial and deep circumflex iliac artery flaps, latissimus dorsi flaps, scapula flaps, inferior rectus abdominus flaps, free jejunal flaps and gastro-omental flaps. Gastro-omental free flaps were first described by Baudet in 1979,1 since then they have been used in many centres for reconstruction of defects of the mouth, pharynx, larynx and the soft tissues of the neck.2 Their use for reconstruction of the floor of the mouth3 and tongue4 has also been described. The requirements of an ideal free flap include provision of adequate bulk, adequate mobility with pliability and provision of a compatible epithelial or mucosal surface. The benefits of a gastro-omental free flap for reconstruction include the following. As much bulk as needed can be provided by harvested omentum. The generous pedicle of the gastro-omental flap allows mobility and pliability. The gastric mucosa produces mucus and is not prone to troublesome desquamation, and the good vascularity of the transferred omentum is also beneficial, particularly after radiotherapy.
Spleen
(L) Stomach Defect closed with PDS (R)
Omentum
Free gastroomental flap Omental arterial arcade
SURGICAL ANATOMY
Fig. 1 Diagram to illustrate the raising of a gastro-omental flap with development of the pedicle. After exposure of the greater curvature of the stomach, the right (R) and left (L) gastroepiploic arteries are identified. The omentum is then freed from its avascular attachments to the transverse colon. The surgeon decides which gastro-omental artery to use, and the other is ligated and cut. The omental vessels are ligated and cut as necessary depending on the size of flap needed. The artery supplying the pedicle (usually right gastroepiploic) is finally severed. The flap is taken from the midportion of the greater curvature to reduce the likelihood of subsequent gastric outlet obstruction.
The use of intestinal segments for reconstruction was first reported by Yudin in the former Soviet Union in 1944.5 The experimental use of free gastric flaps for the repair of pharyngo-oesophageal defects in dogs was reported by Papachristou et al. in 1979.6 This study, and all those since, have used a flap from the greater curvature of the stomach, pedicled on the right gastroepiploic vessels. 32
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Gastro-omental free flaps in oral and oropharyngeal reconstruction
The greater curve flap has several advantages over other intestinal flaps. It is large enough to permit the construction of a flap for various sizes of primary defect, and the defect on the greater curve can be closed more easily and safely than anastomoses after jejunal or colonic harvesting.6 The gastroepiploic vessels, particularly the right, are larger and longer than either colonic or jejunal vessels. The diameter of the right gastroepiploic artery in humans ranges from 1.5 to 3.0 mm. The left gastroepiploic artery has a slightly smaller diameter, from 1.2 to 2.9 mm. The pattern of branching of the omental arteries
33
is variable, but five main types have been identified.7 These patterns are important surgically if lengthening or division of the pedicle is needed. Both right and left gastroepiploic arteries provide branches to the greater curvature of the stomach and the omentum. These branches anastomose in the submucosal layer of the stomach (gastric branches) and in the omentum (epiploic branches). The gastroepiploic veins run with the arteries. The vascular pedicle of a gastro-omental free flap can be developed up to 20 cm, which allows distant vascular implantation without the need to use vein grafts. Gastric parietal cells are concentrated in the body of the stomach and there are substantially fewer parietal cells in the mucosa of the greater curvature. Panje et al. stated that: ‘this part of the stomach (greater curvature) does not contain any acid secreting cells’.8 This supposition, while desirable from the reconstructive perspective, is not supported by other authors,9 and is at variance with our results.
PATIENTS AND METHODS
Fig. 2 Intraoperative view of harvested gastro-omental flap, showing the right gastroepiploic vascular pedicle (R), the omentum (O) and the excised section of the greater curvature (G).
In an 8-month period, eight patients had reconstruction of oral and oropharyngeal defects with gastro-omental free flaps following excision of sqamous cell carcinomas. The tumour site and TNM staging for each patient are shown in Table 1. Two surgical teams simultaneously excised the tumour and harvested the flap.
Table 1 Patient, disease and treatment details including complications and outcome Case Age no. (years)
Sex
Site
Stage
Radiotherapy
Complications
Proton pump Outcome and inhibitor FIGS score
1
66
Female Anterior tongue
T2,N0,M0
Yes
Burning sensation, erosive lesions
Yes
2
53
Male
T2,N1,M0
No
Metaplasia
Yes
3
67
Male
T2,N1,M0
Yes
Bleeding ulcer mucositis
Yes
4
84
T4,N2,M0
Yes
Contact ulcer
Yes
5
42
Left retromolar fossa, tongue Male Left mandibular alveolus, floor of mouth Female Left tonsil
T3,N2,M0
Yes
Abdominal wall abscess
No
6
58
Male
Yes
Left submandibular duct obstruction
No
7
50
Male
Right retromolar T2,N1,M0 fossa, posterior tongue Left tonsil T3,N2,M0
Yes
Pharyngeal mucositis
Yes
8
54
Male
Left lateral tongue
No
None
No
Right tongue
T3,N2,M0
Died Recurrence 8/12 postop FIGS 7 Well FIGS 13 Ulcer biopsied Improved FIGS 12 Recurrence Right neck FIGS 13 Intracranial recurrence FIGS 7 Dochoplasty Well FIGS 15 Well FIGS 13 Well FIGS 15
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All patients underwent gastroscopy preoperatively, to ensure that the gastric mucosa was healthy and to exclude any second disease such as gastric adenocarcinoma. All patients passed this preoperative assessment. The stomach and omentum were approached through a midline, supra-umbilical, ‘mini laparotomy’ incision. The omentum was separated from the transverse colon, and the gastroepiploic vessels were dissected out. The gastric graft was excised from the greater curvature and the defect was closed with a continuous polydioxanone suture (PDS, Ethicon). A percutaneous gastrostomy tube was inserted into the body of the stomach under direct vision before the defect was closed. The mini laparotomy wound was closed in layers with PDS. The skin was closed with steel clips. The free gastro-omental flap was pedicled on the right gastroepiploic vessels, transferred to the mouth or oropharynx, and anastomosed using standard microvascular techniques with 8/0 or 9/0 nylon sutures. The flap was inserted and sutured before the arterial and venous microanastomoses were done. The recipient vessels used depended on their suitability and diameter. The following arteries and veins were used: superior thyroid artery, facial artery (right and left), maxillary artery, internal jugular vein, common facial vein and superior thyroid vein. All the arteries were anastomosed end-to-end as were the veins, with the exception of the internal jugular vein which was anastomosed end-to-side. This anastomosis was used on two occasions. Feeding was started through the percutaneous gastrostomy tube when bowel sounds had returned. As the patient recovered, swallowing was assessed clinically and with a single contrast swallow if necessary. If swallowing was satisfactory, oral feeding was introduced gradually with the help of a dietician. Patients were able to leave hospital within 10–14 days postoperatively.
They were then followed up in the combined Head and Neck Oncology Clinic. From the records in the Head and Neck Clinic it was possible to assess outcome using a scale to assess speech, swallowing and chewing, i.e. the Functional Intraoral Glasgow Scale (FIGS – see Table 2). This was first described by Finlay et al. in 1992 and provides a simple reproducible assessment of outcome.10
RESULTS Table 1 gives details of the patients’ age, sex, tumour site and stage, complications and outcome. There were six men and two women. Their ages ranged from 42 to 84 years, mean 59. None of them were given radiotherapy preoperatively but five had external beam radiotherapy postoperatively. The follow-up was between 6 and 18 months. No flaps failed. Only two of the eight patients, both of whom had recurrent disease, required prolonged feeding through the gastrostomy tube. The complications can be divided into those arising at the donor site and those arising at the recipient site. There was only one donor site complication: an abdominal wall abscess in case 5. This necessitated exploration and drainage under general anaesthesia 2 weeks after the reconstructive operation. Ulceration was the commonest recipient site complication. In case 3 an ulcer on the graft bled (Fig. 3). This was treated successfully by excision and primary repair. Other recipient site complications included burning sensations, erosive lesions, metaplasia (Fig. 4) and pharyngeal mucositis. These complications all responded well to lansoprazole therapy. On longer-term follow-up most patients had healthy flaps and oral mucosa (Fig. 5).
Table 2 Functional Intraoral Glasgow Scale (FIGS) How to score yourself I can chew Any food, no difficulty Solid food with difficulty Semisolid food, no difficulty Semisolids with difficulty Cannot chew at all I can swallow Any food, no difficulty Solid food, with difficulty Semisolid food only Liquids only Cannot swallow at all My speech Clearly understood always Requires repetition sometimes Requires repetition many times Understood by relatives only Unintelligible
Score 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1
Fig. 3 Bleeding gastric ulcer (case 3).
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The ulceration resolved with treatment by lansoprazole. Case 5 had difficulty with chewing, swallowing and speech but these may have been the result of an intracranial recurrence of her disease. Case 6 required a dochoplasty to relieve obstruction of the opposite submandibular duct, but did not have any specific complications related to the gastro-omental flap and remains well with a FIGS score of 15. Case 7, who had pharyngeal mucositis that resulted in an initial FIGS score of 13, remains well after successful treatment with lansoprazole. As with other cases, it is expected that his FIGS score will improve as a result of the proton pump inhibitor treatment. Case 8 who has not had any complications at all remains well with a FIGS score of 15.
DISCUSSION Fig. 4 Metaplasia (case 2) on gastro-omental flap used to reconstruct defect after excision of tumour of right side of tongue.
Fig. 5 Healthy gastro-omental flap (case 6).
Outcomes The FIGS score for case 1 was only 7, which can probably be explained by early intraoral recurrence. Case 2 remains well, the FIGS score of 13 at initial review shows minimal impairment of chewing, swallowing and speech, as a result of flap metaplasia. As this has resolved on treatment with a proton pump inhibitor, the FIGS score should improve. Case 3 had problems with a bleeding ulcer, resulting in a FIGS score of 12. This has also improved following excision and with lansoprazole treatment. Although case 4 has had a recurrence of his disease on the other side of his neck, the FIGS score was 13. This may have been the result of a superficial ulcer on the oral mucosa in contact with the gastro-omental flap.
Donor site complications can include peritonitis and intra-abdominal abscess after leakage from the donor site on the greater curvature. One study11 suggested placing sutures between the greater curvature of the stomach and the transverse colon to prevent volvulus. This complication was not encountered in our series. Gastric outlet obstruction is another potential complication if the flap is large and harvested too close to the pylorus. With regard to acid production from the gastro-omental graft, we did not measure the pH of the surface of the graft. In a previous series, a reduction in graft mucosal pH and tongue surface pH was observed on stimulation with gastrin.9 A large study would be needed to establish if there was a substantial reduction in oral pH after stimulation of free gastro-omental grafts. Panje et al.8 stated that excessive production of mucus was a disadvantage of the gastro-omental free flap. In our series this complication was not evident. Mucus production from the flap is also beneficial. The moistness of the flap seems to be advantageous for speech, mastication and for wearing dental prostheses, particularly after irradiation.12 Classic reconstruction and irradiation reduces oral salivary flow.13 There is evidence that patients with gastro-omental free flaps do not have a reduced oral salivary flow after radiotherapy.13 The omentum itself facilitates healing14 and this seems to be particularly useful after irradiation. The walls of the gastroepiploic vein were thinner than those of the cephalic vein of the radial forearm flap. However, the gastroepiploic vein walls were thicker and consequently easier to anastomose than jejunal veins. The use of the FIGS system allows simple assessment of outcome with excellent interobserver reliability. Ideally it should be used preoperatively to provide a baseline and postoperatively to assess outcome and aid rehabilitation. This system can also be used for early detection of deterioration in a patient’s condition.
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A deterioration in FIGS can be seen before any recurrence of tumour or clinical signs, such as weight loss, become evident. Another benefit of FIGS is that results from different centres can be compared.
CONCLUSION The gastro-omental flap is a useful method of reconstruction after oncological resection. The moistness of the flap surface and the vascularity of the omentum confer a definite advantage over other reconstructive techniques when radiotherapy is given postoperatively. Acid secretion, although not measured in this series, seems to be the main disadvantage of this method, but the beneficial response from the use of proton pump inhibitors is encouraging. This complication must be explained to the patient when preoperative consent is being obtained. The small number of flaps and the longer-term mortality associated with oral and oropharyngeal cancer make statistical analysis of this series unreliable. As this reconstructive technique is used in several centres, a multicentre prospective study with defined variables – possibly comparing this reconstructive method with others – should be done. REFERENCES 1. Baudet J. Reconstruction of the pharyngeal wall by free transfer of the greater omentum and stomach. Int J Microsurg 1979; 1: 53–59. 2. Guedon CE, Marmuse J-P, Gehanno P, Barry B. Use of gastro-omental free flaps in major neck defects. Am J Surg 1994; 168: 491–493. 3. Calteux N, Hamoir M, Van Den Eeckhaut J, Vanwicjck R. Reconstruction of the floor of the mouth after total glossectomy by free transfer of a gastro-omental flap. Head Neck Surg 1988; 10: 512–516. 4. Guedon C, Marmuse JP, Gehanno P et al. Transplantation of a gastro-omental free flap (GOFF) for total tongue reconstruction. About 10 cases. J Maxillofac Surg 1992; 20(suppl 1): 34. 5. Yudin SS. Surgical construction of eighty cases of artificial oesophagus. Surg Gynecol Obstet 1944; 78: 561–564.
6. Papachristou DN, Trichilis E, Fortner JG. Experimental use of free gastric flaps for the repair of pharyngoesophageal defects. Plast Reconstr Surg 1979; 64: 336–339. 7. Alday E, Goldsmith H. Surgical technique for omental lengthening based on arterial anatomy. Surg Gynecol Obstet 1971; 135: 103–107. 8. Panje WR, Little AG, Moran WJ, Ferguson MK, Scher N. Immediate free gastro-omental flap reconstruction of the mouth and throat. Ann Otol Rhinol Laryngol 1987; 96: 15–21. 9. Breton P, Braye F. Use of gastro-omental flaps in major neck defects. Am J Surg 1996; 173: 148. 10. Finlay PM, Dawson F, Robertson AG, Soutar DS. An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg 1992; 30: 14–17. 11. Upton J, Mulliken J, Hicks P, Murray J. Restoration of facial contour using free vascularized omental transfer. Plast Reconstr Surg 1980; 66: 560. 12. Braye F, Breton P, Caillot JL, Franc C, Friedel M. Le lambeau gastro-epiloique: un lambeau muquese secretant pour la reconstruction de l’oropharynx et de la cavite buccale. Ann Chir 1995; 49: 417–422. 13. Marunick MT, Seyedad RM, Jones M, Klein B. The effect of head and neck cancer treatment on whole salivary flow. J Surg Oncol 1991; 48: 81–86. 14. Beelen RHJ. The greater omentum: physiological and immunological concept. Neth J Surg 1991; 43: 145–148.
The Authors J. Gallagher FDSRCS MRCS Senior House Officer A. Webb FDSRCS FRCS Specialist Registrar V. Ilankovan FDSRCS FRCS Consultant Maxillofacial, Head and Neck Surgeon Department of Oral and Maxillofacial Surgery Poole Hospital Poole, UK Correspondence and requests for offprints to: Mr J. Gallagher, c/o Mr V. Ilankovan, Department of Oral and Maxillofacial Surgery, Poole Hospital, Longfleet Road, Poole, Dorset BH15 2JB, UK. Tel: ;44 (0) 1202 442 576; Fax: ;44 (0) 1202 442 230. E-mail: [email protected] Accepted 7 May 2001
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BRITISH
British Journal of Oral and Maxillofacial Surgery (2002) 40, 32–36 © 2002 The British Association of Oral and Maxillofacial Surgeons doi: 10.1054/bjom.2001.0677, available online at http://www.idealibrary.com on
Journal of Oral and Maxillofacial Surgery
Gastro-omental free flaps in oral and oropharyngeal reconstruction: surgical anatomy, complications, outcomes J. Gallagher, A. Webb, V. Ilankovan Department of Oral and Maxillofacial Surgery, Poole Hospital, Poole, UK SUMMARY. Free gastro-omental flaps can be used to reconstruct defects in the oral cavity after ablative cancer surgery. The omentum can provide as much bulk as required. The generous gastro-omental pedicle allows mobility. The gastric mucosal lining has the advantage that it produces mucus, does not carry hair follicles and is not prone to troublesome desquamation. This paper reviews the surgical anatomy of free gastro-omental flaps and presents a series of eight cases in which these flaps were used for oral and oropharyngeal reconstruction. © 2002 The British Association of Oral and Maxillofacial Surgeons
These flaps can be with or without a section of greater omentum as required (Figs 1 & 2).
INTRODUCTION Various free flaps have been used in the oral cavity for soft tissue cover after resection of tumours. These include radial forearm flaps, superficial and deep circumflex iliac artery flaps, latissimus dorsi flaps, scapula flaps, inferior rectus abdominus flaps, free jejunal flaps and gastro-omental flaps. Gastro-omental free flaps were first described by Baudet in 1979,1 since then they have been used in many centres for reconstruction of defects of the mouth, pharynx, larynx and the soft tissues of the neck.2 Their use for reconstruction of the floor of the mouth3 and tongue4 has also been described. The requirements of an ideal free flap include provision of adequate bulk, adequate mobility with pliability and provision of a compatible epithelial or mucosal surface. The benefits of a gastro-omental free flap for reconstruction include the following. As much bulk as needed can be provided by harvested omentum. The generous pedicle of the gastro-omental flap allows mobility and pliability. The gastric mucosa produces mucus and is not prone to troublesome desquamation, and the good vascularity of the transferred omentum is also beneficial, particularly after radiotherapy.
Spleen
(L) Stomach Defect closed with PDS (R)
Omentum
Free gastroomental flap Omental arterial arcade
SURGICAL ANATOMY
Fig. 1 Diagram to illustrate the raising of a gastro-omental flap with development of the pedicle. After exposure of the greater curvature of the stomach, the right (R) and left (L) gastroepiploic arteries are identified. The omentum is then freed from its avascular attachments to the transverse colon. The surgeon decides which gastro-omental artery to use, and the other is ligated and cut. The omental vessels are ligated and cut as necessary depending on the size of flap needed. The artery supplying the pedicle (usually right gastroepiploic) is finally severed. The flap is taken from the midportion of the greater curvature to reduce the likelihood of subsequent gastric outlet obstruction.
The use of intestinal segments for reconstruction was first reported by Yudin in the former Soviet Union in 1944.5 The experimental use of free gastric flaps for the repair of pharyngo-oesophageal defects in dogs was reported by Papachristou et al. in 1979.6 This study, and all those since, have used a flap from the greater curvature of the stomach, pedicled on the right gastroepiploic vessels. 32
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Gastro-omental free flaps in oral and oropharyngeal reconstruction
The greater curve flap has several advantages over other intestinal flaps. It is large enough to permit the construction of a flap for various sizes of primary defect, and the defect on the greater curve can be closed more easily and safely than anastomoses after jejunal or colonic harvesting.6 The gastroepiploic vessels, particularly the right, are larger and longer than either colonic or jejunal vessels. The diameter of the right gastroepiploic artery in humans ranges from 1.5 to 3.0 mm. The left gastroepiploic artery has a slightly smaller diameter, from 1.2 to 2.9 mm. The pattern of branching of the omental arteries
33
is variable, but five main types have been identified.7 These patterns are important surgically if lengthening or division of the pedicle is needed. Both right and left gastroepiploic arteries provide branches to the greater curvature of the stomach and the omentum. These branches anastomose in the submucosal layer of the stomach (gastric branches) and in the omentum (epiploic branches). The gastroepiploic veins run with the arteries. The vascular pedicle of a gastro-omental free flap can be developed up to 20 cm, which allows distant vascular implantation without the need to use vein grafts. Gastric parietal cells are concentrated in the body of the stomach and there are substantially fewer parietal cells in the mucosa of the greater curvature. Panje et al. stated that: ‘this part of the stomach (greater curvature) does not contain any acid secreting cells’.8 This supposition, while desirable from the reconstructive perspective, is not supported by other authors,9 and is at variance with our results.
PATIENTS AND METHODS
Fig. 2 Intraoperative view of harvested gastro-omental flap, showing the right gastroepiploic vascular pedicle (R), the omentum (O) and the excised section of the greater curvature (G).
In an 8-month period, eight patients had reconstruction of oral and oropharyngeal defects with gastro-omental free flaps following excision of sqamous cell carcinomas. The tumour site and TNM staging for each patient are shown in Table 1. Two surgical teams simultaneously excised the tumour and harvested the flap.
Table 1 Patient, disease and treatment details including complications and outcome Case Age no. (years)
Sex
Site
Stage
Radiotherapy
Complications
Proton pump Outcome and inhibitor FIGS score
1
66
Female Anterior tongue
T2,N0,M0
Yes
Burning sensation, erosive lesions
Yes
2
53
Male
T2,N1,M0
No
Metaplasia
Yes
3
67
Male
T2,N1,M0
Yes
Bleeding ulcer mucositis
Yes
4
84
T4,N2,M0
Yes
Contact ulcer
Yes
5
42
Left retromolar fossa, tongue Male Left mandibular alveolus, floor of mouth Female Left tonsil
T3,N2,M0
Yes
Abdominal wall abscess
No
6
58
Male
Yes
Left submandibular duct obstruction
No
7
50
Male
Right retromolar T2,N1,M0 fossa, posterior tongue Left tonsil T3,N2,M0
Yes
Pharyngeal mucositis
Yes
8
54
Male
Left lateral tongue
No
None
No
Right tongue
T3,N2,M0
Died Recurrence 8/12 postop FIGS 7 Well FIGS 13 Ulcer biopsied Improved FIGS 12 Recurrence Right neck FIGS 13 Intracranial recurrence FIGS 7 Dochoplasty Well FIGS 15 Well FIGS 13 Well FIGS 15
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All patients underwent gastroscopy preoperatively, to ensure that the gastric mucosa was healthy and to exclude any second disease such as gastric adenocarcinoma. All patients passed this preoperative assessment. The stomach and omentum were approached through a midline, supra-umbilical, ‘mini laparotomy’ incision. The omentum was separated from the transverse colon, and the gastroepiploic vessels were dissected out. The gastric graft was excised from the greater curvature and the defect was closed with a continuous polydioxanone suture (PDS, Ethicon). A percutaneous gastrostomy tube was inserted into the body of the stomach under direct vision before the defect was closed. The mini laparotomy wound was closed in layers with PDS. The skin was closed with steel clips. The free gastro-omental flap was pedicled on the right gastroepiploic vessels, transferred to the mouth or oropharynx, and anastomosed using standard microvascular techniques with 8/0 or 9/0 nylon sutures. The flap was inserted and sutured before the arterial and venous microanastomoses were done. The recipient vessels used depended on their suitability and diameter. The following arteries and veins were used: superior thyroid artery, facial artery (right and left), maxillary artery, internal jugular vein, common facial vein and superior thyroid vein. All the arteries were anastomosed end-to-end as were the veins, with the exception of the internal jugular vein which was anastomosed end-to-side. This anastomosis was used on two occasions. Feeding was started through the percutaneous gastrostomy tube when bowel sounds had returned. As the patient recovered, swallowing was assessed clinically and with a single contrast swallow if necessary. If swallowing was satisfactory, oral feeding was introduced gradually with the help of a dietician. Patients were able to leave hospital within 10–14 days postoperatively.
They were then followed up in the combined Head and Neck Oncology Clinic. From the records in the Head and Neck Clinic it was possible to assess outcome using a scale to assess speech, swallowing and chewing, i.e. the Functional Intraoral Glasgow Scale (FIGS – see Table 2). This was first described by Finlay et al. in 1992 and provides a simple reproducible assessment of outcome.10
RESULTS Table 1 gives details of the patients’ age, sex, tumour site and stage, complications and outcome. There were six men and two women. Their ages ranged from 42 to 84 years, mean 59. None of them were given radiotherapy preoperatively but five had external beam radiotherapy postoperatively. The follow-up was between 6 and 18 months. No flaps failed. Only two of the eight patients, both of whom had recurrent disease, required prolonged feeding through the gastrostomy tube. The complications can be divided into those arising at the donor site and those arising at the recipient site. There was only one donor site complication: an abdominal wall abscess in case 5. This necessitated exploration and drainage under general anaesthesia 2 weeks after the reconstructive operation. Ulceration was the commonest recipient site complication. In case 3 an ulcer on the graft bled (Fig. 3). This was treated successfully by excision and primary repair. Other recipient site complications included burning sensations, erosive lesions, metaplasia (Fig. 4) and pharyngeal mucositis. These complications all responded well to lansoprazole therapy. On longer-term follow-up most patients had healthy flaps and oral mucosa (Fig. 5).
Table 2 Functional Intraoral Glasgow Scale (FIGS) How to score yourself I can chew Any food, no difficulty Solid food with difficulty Semisolid food, no difficulty Semisolids with difficulty Cannot chew at all I can swallow Any food, no difficulty Solid food, with difficulty Semisolid food only Liquids only Cannot swallow at all My speech Clearly understood always Requires repetition sometimes Requires repetition many times Understood by relatives only Unintelligible
Score 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1
Fig. 3 Bleeding gastric ulcer (case 3).
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The ulceration resolved with treatment by lansoprazole. Case 5 had difficulty with chewing, swallowing and speech but these may have been the result of an intracranial recurrence of her disease. Case 6 required a dochoplasty to relieve obstruction of the opposite submandibular duct, but did not have any specific complications related to the gastro-omental flap and remains well with a FIGS score of 15. Case 7, who had pharyngeal mucositis that resulted in an initial FIGS score of 13, remains well after successful treatment with lansoprazole. As with other cases, it is expected that his FIGS score will improve as a result of the proton pump inhibitor treatment. Case 8 who has not had any complications at all remains well with a FIGS score of 15.
DISCUSSION Fig. 4 Metaplasia (case 2) on gastro-omental flap used to reconstruct defect after excision of tumour of right side of tongue.
Fig. 5 Healthy gastro-omental flap (case 6).
Outcomes The FIGS score for case 1 was only 7, which can probably be explained by early intraoral recurrence. Case 2 remains well, the FIGS score of 13 at initial review shows minimal impairment of chewing, swallowing and speech, as a result of flap metaplasia. As this has resolved on treatment with a proton pump inhibitor, the FIGS score should improve. Case 3 had problems with a bleeding ulcer, resulting in a FIGS score of 12. This has also improved following excision and with lansoprazole treatment. Although case 4 has had a recurrence of his disease on the other side of his neck, the FIGS score was 13. This may have been the result of a superficial ulcer on the oral mucosa in contact with the gastro-omental flap.
Donor site complications can include peritonitis and intra-abdominal abscess after leakage from the donor site on the greater curvature. One study11 suggested placing sutures between the greater curvature of the stomach and the transverse colon to prevent volvulus. This complication was not encountered in our series. Gastric outlet obstruction is another potential complication if the flap is large and harvested too close to the pylorus. With regard to acid production from the gastro-omental graft, we did not measure the pH of the surface of the graft. In a previous series, a reduction in graft mucosal pH and tongue surface pH was observed on stimulation with gastrin.9 A large study would be needed to establish if there was a substantial reduction in oral pH after stimulation of free gastro-omental grafts. Panje et al.8 stated that excessive production of mucus was a disadvantage of the gastro-omental free flap. In our series this complication was not evident. Mucus production from the flap is also beneficial. The moistness of the flap seems to be advantageous for speech, mastication and for wearing dental prostheses, particularly after irradiation.12 Classic reconstruction and irradiation reduces oral salivary flow.13 There is evidence that patients with gastro-omental free flaps do not have a reduced oral salivary flow after radiotherapy.13 The omentum itself facilitates healing14 and this seems to be particularly useful after irradiation. The walls of the gastroepiploic vein were thinner than those of the cephalic vein of the radial forearm flap. However, the gastroepiploic vein walls were thicker and consequently easier to anastomose than jejunal veins. The use of the FIGS system allows simple assessment of outcome with excellent interobserver reliability. Ideally it should be used preoperatively to provide a baseline and postoperatively to assess outcome and aid rehabilitation. This system can also be used for early detection of deterioration in a patient’s condition.
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British Journal of Oral and Maxillofacial Surgery
A deterioration in FIGS can be seen before any recurrence of tumour or clinical signs, such as weight loss, become evident. Another benefit of FIGS is that results from different centres can be compared.
CONCLUSION The gastro-omental flap is a useful method of reconstruction after oncological resection. The moistness of the flap surface and the vascularity of the omentum confer a definite advantage over other reconstructive techniques when radiotherapy is given postoperatively. Acid secretion, although not measured in this series, seems to be the main disadvantage of this method, but the beneficial response from the use of proton pump inhibitors is encouraging. This complication must be explained to the patient when preoperative consent is being obtained. The small number of flaps and the longer-term mortality associated with oral and oropharyngeal cancer make statistical analysis of this series unreliable. As this reconstructive technique is used in several centres, a multicentre prospective study with defined variables – possibly comparing this reconstructive method with others – should be done. REFERENCES 1. Baudet J. Reconstruction of the pharyngeal wall by free transfer of the greater omentum and stomach. Int J Microsurg 1979; 1: 53–59. 2. Guedon CE, Marmuse J-P, Gehanno P, Barry B. Use of gastro-omental free flaps in major neck defects. Am J Surg 1994; 168: 491–493. 3. Calteux N, Hamoir M, Van Den Eeckhaut J, Vanwicjck R. Reconstruction of the floor of the mouth after total glossectomy by free transfer of a gastro-omental flap. Head Neck Surg 1988; 10: 512–516. 4. Guedon C, Marmuse JP, Gehanno P et al. Transplantation of a gastro-omental free flap (GOFF) for total tongue reconstruction. About 10 cases. J Maxillofac Surg 1992; 20(suppl 1): 34. 5. Yudin SS. Surgical construction of eighty cases of artificial oesophagus. Surg Gynecol Obstet 1944; 78: 561–564.
6. Papachristou DN, Trichilis E, Fortner JG. Experimental use of free gastric flaps for the repair of pharyngoesophageal defects. Plast Reconstr Surg 1979; 64: 336–339. 7. Alday E, Goldsmith H. Surgical technique for omental lengthening based on arterial anatomy. Surg Gynecol Obstet 1971; 135: 103–107. 8. Panje WR, Little AG, Moran WJ, Ferguson MK, Scher N. Immediate free gastro-omental flap reconstruction of the mouth and throat. Ann Otol Rhinol Laryngol 1987; 96: 15–21. 9. Breton P, Braye F. Use of gastro-omental flaps in major neck defects. Am J Surg 1996; 173: 148. 10. Finlay PM, Dawson F, Robertson AG, Soutar DS. An evaluation of functional outcome after surgery and radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg 1992; 30: 14–17. 11. Upton J, Mulliken J, Hicks P, Murray J. Restoration of facial contour using free vascularized omental transfer. Plast Reconstr Surg 1980; 66: 560. 12. Braye F, Breton P, Caillot JL, Franc C, Friedel M. Le lambeau gastro-epiloique: un lambeau muquese secretant pour la reconstruction de l’oropharynx et de la cavite buccale. Ann Chir 1995; 49: 417–422. 13. Marunick MT, Seyedad RM, Jones M, Klein B. The effect of head and neck cancer treatment on whole salivary flow. J Surg Oncol 1991; 48: 81–86. 14. Beelen RHJ. The greater omentum: physiological and immunological concept. Neth J Surg 1991; 43: 145–148.
The Authors J. Gallagher FDSRCS MRCS Senior House Officer A. Webb FDSRCS FRCS Specialist Registrar V. Ilankovan FDSRCS FRCS Consultant Maxillofacial, Head and Neck Surgeon Department of Oral and Maxillofacial Surgery Poole Hospital Poole, UK Correspondence and requests for offprints to: Mr J. Gallagher, c/o Mr V. Ilankovan, Department of Oral and Maxillofacial Surgery, Poole Hospital, Longfleet Road, Poole, Dorset BH15 2JB, UK. Tel: ;44 (0) 1202 442 576; Fax: ;44 (0) 1202 442 230. E-mail: [email protected] Accepted 7 May 2001