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One-stage ante-thoracic reconstruction of the thoracic oesophagus using myocutaneous flaps
British Journul of Plastic Surgery (I 984) 37, 571-519 0 1984 The Trustees of British Association of Plastic Surgeons
One-stage ante-thoracic reconstruction of the thoracic oesophagus using myocutaneous flaps Y. MIYAMOTO,
T. HATTORI
and Y. NOSOH
Department of Orthopaedic Surgery (Plastic Surgery Division) University Hospital, Hiroshima, Japan
and the Department
of Surgery, Hiroshima
Summary-An ante-thoracic reconstruction of the thoracic oesophagus was performed by fashioning a skin tube from a skin flap supplied by perforators from the internal mammary vessels. This neo-oesophagus was covered with a trapezius myocutaneous flap and a rectus abdominis myocutaneous flap, in a one stage operation.
Case report A 42-year-old Japanese man presented with oesophagocardial cancer. After total resection of the lower portion of the oesophagus and the stomach, anastomosis of the lower portion of the oesophagus and the pedicled jejunum was carried out (Hattori et al., 1980; Hattori et al., 1982). Unfortunately due to excessive tension at the suture line, the jejunal segment sloughed and accordingly the oesophagus was brought out to the surface in the left cervical region and the jejunum exteriorised in the left upper abdominal wall (Fig. 1). As reconstruction of the swallowing mechanism using a gastrointestinal segment was considered to he impossible, a one-stage reconstruction of the thoracic oesophagus using myoclwtaneous flaps was undertaken 78 days after the original cancer resection.
Surgical technique The cervical oesophagocutaneous fistula was located just above the left sternoclavicular joint and the jejunostomy opening was located in the left hypochondrium. A skin tube was fashioned to link these two openings, basing the blood supply to this skin segment on perforating vessels from the internal mammary vessels. Two parallel incisions, 8 cm apart, were made from the pharyngocutaneous fistula to the lower end of the sternum, where the incisions were linked by a horizontal incision (Fig. 2). Taking care not to Fig. 1
Figure I-Pre-operative view of a 42-year-old patient 78 days after radical excision for oesophagocardial cancer. Note the oesophagocutaneous fistula in the left supraclavicular region and the jejunostomy in the left hypochondrium. The pattern and size of three myocutaneous flaps to be used in the reconstruction are shown. The thoracic flap that was actually employed for the reconstruction was extended 3 cm downwards and rectus abdominis myocutaneous flap 3 cm upwards (as shown in Fig. 2). 577
578
BRITISH
Fig. 3
Fig. 2 Figure
2--Schematic
drawing
JOURNAL
OF PLASTIC
SURGERY
Fig. 4
to show the three flaps that were used in the repair.
Figure 3-A skin tube is prepared by infolding a flap in the thoracic region. The jejunum is mobilised to the lower end of the skin tube and an end-to-end anastomosis is performed. The cervical region of the neo-oesophagus is covered with trapezius myocutaneous flap and the thoracic region with a rectus abdominis myocutaneous flap. Figure &Diagrammatic representation of the completed reconstruction.
damage the perforating vessels, a flap was elevated from the substratum of the pectoralis major muscle and both skin edges of the flap were sutured together to form a skin lined tube. A water tight closure of the pharyngostome was achieved. A portion of the skin tube was reinforced by covering it with the pectoralis major muscle. The jejunum was mobilised and elevated to the lower end of the thoracic neooesophagus reconstructed by the skin tube and anastomosis was performed an end-to-end (Fig. 3). The raw surface of the reconstructed oesophagus was covered by transposing two myocutaneous flaps: the pharyngostome in the upper region was covered with a trapezius myocutaneous flap from the left side; the antethoracic skin tube was covered with a rectus abdominis myocutaneous flap taken from the right side of the abdomen (Fig. 4). This one-stage reconstruction of the whole thoracic oesophagus was performed without using free skin grafts. The external appearance one month after surgery is shown (Fig. 5).
showed the circulation of the neo-oesophagus to be intact. A barium swallow confirmed a small leak at the junction of the lower end of the cervical oesophagus and the skin tube. However, the passage of barium was smooth and no stenosis was seen (Fig. 6). In spite of the minor leakage, oral feeding was started 21 days after operation and all this leakage ceased spontaneously on the 75th day. The patient was discharged 81 days after the reconstruction. Over the following year oral feeding was possible and there was no dysphagia. However, the patient did complain of a sensation of food passing through the neo-oesophagus and of retching due to reflux of food through the reconstructed system. He died of haemorrhage in the post-mediastinal region due to metastasis of cancer 22 months after the surgery. Discussion
There are several reports of the reconstruction of the full length of the thoracic oesophagus using a skin tube but these methods usually required multiple staged procedures using more than one body tissue particularly free skin grafts (Lexer, Post-operative course 1908; May, 1971; Keyes et al., 1982). These were the main disadvantages of One week after the operation a minor leak? unfortunately jejuno-dermato-oesophagoplasty. appeared in the cervical region. Endoscopy
ONE-STAGE
ANTE-THORACIC
RECONSTRUCTION
OF THE
THORACIC
OESOPHAGUS
579
Fig. 6 Figure &Barium swallow to show the neo-oesophagus one month after operation; Arrow (A) Anastomosis of the oesophagus and skin tube; Arrow (B) Anastomosis of skin tube and jejunum. Fig. 5 Figure
5-External
appearance
2 months
after reconstruction.
Our technique requires one axial pattern flap and two myocutaneous flaps which provide a safe one-stage reconstruction. The reconstruction is done with flaps only. Since the reconstructed oesophagus has no peristaltic function, reflux of food may appear and the patient may complain of a strange sensation in the skin tube. In this respect, the neo-oesophagus is considered to be inferior to that reconstructed by revascularised free transplantation of intestinal segments. However with the present technique, the oesophagus can be reconstructed without a laparotomy and surgery can be done faster and more safely than by microsurgical means. References Hattori, T., Hamai, Y., Hirai, T., Takiyama, W. and Ikeda, T. (1980). Clinical studies on the transabdominal resection of oesophagocardial cancer and cervical anastomosis using a by-pass method obviating thoracotomy. Japanese Journal of Suwerv. j. . . 10. 221.
Hattori, T., Takiyama, W., Hirai, T., Miyoshi, Y. and Yoshihara, T. (1982). Clinical studies on the transabdominal resection of oesophagocardial cancer and cervical anastomosis with a jejunal segment bypass obviating thoracotomy. Jupanese Journal of Surgery, 12, 329. Keyes, G. R., Tents, L. T. and Schultz, R. C. (1982). Myoepithelial construction of the thoracic oesophagus. Plastic and Reconstructive Surgery, 69, 683. Lexer, E. (1908). Oesophagoplastik. Deutsche medizinische Wochenschrift, 34, 574. May, H. (1971). Plastic and Reconstructive Surgery. 3rd Edition. Philadelphia: F. A. Davis Company.
The Authors Yoshihiro Miyamoto, MD, Associate Professor, Department of Orthopaedic Surgery (Plastic Surgery Division), Hiroshima University School of Medicine. Hiroshima, Japan. Takao Hattori, MD, Director and Professor, Department of Surgery, Research Institute for Nuclear Medicine and Biology, Hiroshima University, Hiroshima, Japan. Yoshihiro Nosoh, MD, Instructor, Department of Surgery Research Institute for Nuclear Medicine and Biology. Hiroshima University, Hiroshima, Japan. Requests for reprints to: Dr Y. Miyamoto. Suzugamine, Nishiku. Hiroshima. 733, Japan
1611,
One-stage ante-thoracic reconstruction of the thoracic oesophagus using myocutaneous flaps Y. MIYAMOTO,
T. HATTORI
and Y. NOSOH
Department of Orthopaedic Surgery (Plastic Surgery Division) University Hospital, Hiroshima, Japan
and the Department
of Surgery, Hiroshima
Summary-An ante-thoracic reconstruction of the thoracic oesophagus was performed by fashioning a skin tube from a skin flap supplied by perforators from the internal mammary vessels. This neo-oesophagus was covered with a trapezius myocutaneous flap and a rectus abdominis myocutaneous flap, in a one stage operation.
Case report A 42-year-old Japanese man presented with oesophagocardial cancer. After total resection of the lower portion of the oesophagus and the stomach, anastomosis of the lower portion of the oesophagus and the pedicled jejunum was carried out (Hattori et al., 1980; Hattori et al., 1982). Unfortunately due to excessive tension at the suture line, the jejunal segment sloughed and accordingly the oesophagus was brought out to the surface in the left cervical region and the jejunum exteriorised in the left upper abdominal wall (Fig. 1). As reconstruction of the swallowing mechanism using a gastrointestinal segment was considered to he impossible, a one-stage reconstruction of the thoracic oesophagus using myoclwtaneous flaps was undertaken 78 days after the original cancer resection.
Surgical technique The cervical oesophagocutaneous fistula was located just above the left sternoclavicular joint and the jejunostomy opening was located in the left hypochondrium. A skin tube was fashioned to link these two openings, basing the blood supply to this skin segment on perforating vessels from the internal mammary vessels. Two parallel incisions, 8 cm apart, were made from the pharyngocutaneous fistula to the lower end of the sternum, where the incisions were linked by a horizontal incision (Fig. 2). Taking care not to Fig. 1
Figure I-Pre-operative view of a 42-year-old patient 78 days after radical excision for oesophagocardial cancer. Note the oesophagocutaneous fistula in the left supraclavicular region and the jejunostomy in the left hypochondrium. The pattern and size of three myocutaneous flaps to be used in the reconstruction are shown. The thoracic flap that was actually employed for the reconstruction was extended 3 cm downwards and rectus abdominis myocutaneous flap 3 cm upwards (as shown in Fig. 2). 577
578
BRITISH
Fig. 3
Fig. 2 Figure
2--Schematic
drawing
JOURNAL
OF PLASTIC
SURGERY
Fig. 4
to show the three flaps that were used in the repair.
Figure 3-A skin tube is prepared by infolding a flap in the thoracic region. The jejunum is mobilised to the lower end of the skin tube and an end-to-end anastomosis is performed. The cervical region of the neo-oesophagus is covered with trapezius myocutaneous flap and the thoracic region with a rectus abdominis myocutaneous flap. Figure &Diagrammatic representation of the completed reconstruction.
damage the perforating vessels, a flap was elevated from the substratum of the pectoralis major muscle and both skin edges of the flap were sutured together to form a skin lined tube. A water tight closure of the pharyngostome was achieved. A portion of the skin tube was reinforced by covering it with the pectoralis major muscle. The jejunum was mobilised and elevated to the lower end of the thoracic neooesophagus reconstructed by the skin tube and anastomosis was performed an end-to-end (Fig. 3). The raw surface of the reconstructed oesophagus was covered by transposing two myocutaneous flaps: the pharyngostome in the upper region was covered with a trapezius myocutaneous flap from the left side; the antethoracic skin tube was covered with a rectus abdominis myocutaneous flap taken from the right side of the abdomen (Fig. 4). This one-stage reconstruction of the whole thoracic oesophagus was performed without using free skin grafts. The external appearance one month after surgery is shown (Fig. 5).
showed the circulation of the neo-oesophagus to be intact. A barium swallow confirmed a small leak at the junction of the lower end of the cervical oesophagus and the skin tube. However, the passage of barium was smooth and no stenosis was seen (Fig. 6). In spite of the minor leakage, oral feeding was started 21 days after operation and all this leakage ceased spontaneously on the 75th day. The patient was discharged 81 days after the reconstruction. Over the following year oral feeding was possible and there was no dysphagia. However, the patient did complain of a sensation of food passing through the neo-oesophagus and of retching due to reflux of food through the reconstructed system. He died of haemorrhage in the post-mediastinal region due to metastasis of cancer 22 months after the surgery. Discussion
There are several reports of the reconstruction of the full length of the thoracic oesophagus using a skin tube but these methods usually required multiple staged procedures using more than one body tissue particularly free skin grafts (Lexer, Post-operative course 1908; May, 1971; Keyes et al., 1982). These were the main disadvantages of One week after the operation a minor leak? unfortunately jejuno-dermato-oesophagoplasty. appeared in the cervical region. Endoscopy
ONE-STAGE
ANTE-THORACIC
RECONSTRUCTION
OF THE
THORACIC
OESOPHAGUS
579
Fig. 6 Figure &Barium swallow to show the neo-oesophagus one month after operation; Arrow (A) Anastomosis of the oesophagus and skin tube; Arrow (B) Anastomosis of skin tube and jejunum. Fig. 5 Figure
5-External
appearance
2 months
after reconstruction.
Our technique requires one axial pattern flap and two myocutaneous flaps which provide a safe one-stage reconstruction. The reconstruction is done with flaps only. Since the reconstructed oesophagus has no peristaltic function, reflux of food may appear and the patient may complain of a strange sensation in the skin tube. In this respect, the neo-oesophagus is considered to be inferior to that reconstructed by revascularised free transplantation of intestinal segments. However with the present technique, the oesophagus can be reconstructed without a laparotomy and surgery can be done faster and more safely than by microsurgical means. References Hattori, T., Hamai, Y., Hirai, T., Takiyama, W. and Ikeda, T. (1980). Clinical studies on the transabdominal resection of oesophagocardial cancer and cervical anastomosis using a by-pass method obviating thoracotomy. Japanese Journal of Suwerv. j. . . 10. 221.
Hattori, T., Takiyama, W., Hirai, T., Miyoshi, Y. and Yoshihara, T. (1982). Clinical studies on the transabdominal resection of oesophagocardial cancer and cervical anastomosis with a jejunal segment bypass obviating thoracotomy. Jupanese Journal of Surgery, 12, 329. Keyes, G. R., Tents, L. T. and Schultz, R. C. (1982). Myoepithelial construction of the thoracic oesophagus. Plastic and Reconstructive Surgery, 69, 683. Lexer, E. (1908). Oesophagoplastik. Deutsche medizinische Wochenschrift, 34, 574. May, H. (1971). Plastic and Reconstructive Surgery. 3rd Edition. Philadelphia: F. A. Davis Company.
The Authors Yoshihiro Miyamoto, MD, Associate Professor, Department of Orthopaedic Surgery (Plastic Surgery Division), Hiroshima University School of Medicine. Hiroshima, Japan. Takao Hattori, MD, Director and Professor, Department of Surgery, Research Institute for Nuclear Medicine and Biology, Hiroshima University, Hiroshima, Japan. Yoshihiro Nosoh, MD, Instructor, Department of Surgery Research Institute for Nuclear Medicine and Biology. Hiroshima University, Hiroshima, Japan. Requests for reprints to: Dr Y. Miyamoto. Suzugamine, Nishiku. Hiroshima. 733, Japan
1611,