Ann Thorac Surg 1995;60:1821-1823
© 1995 The Society of Thoracic Surgeons
How to Do It
Anastomosis Technique for High Pharyngogastrostomy
Mark J. Krasna, MD,
Stanley D. Phillips, MD,
William C. Gray, MD,
John F. Biedlingmaier, MD
Divisions of Otolaryngology and Thoracic and Cardiovascular Surgery, University of Maryland Medical School, Baltimore, Maryland
Accepted for publication July 6, 1995.
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Abstract
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Pharyngogastric anastomosis, otherwise referred to as the ``gastric pull-up'' procedure, is the most reliable method of reconstruction after laryngopharyngectomy. We currently use a method of gastric to pharyngeal anastomosis that avoids excess tension, and thus decreases the incidence of fistulas and flap failures. With the stomach fully mobilized, the ``pull-up'' is brought high into the neck using a plastic bag to facilitate delivery via the posterior mediastinum. A curved, U-shaped incision is then made in the fundus of the tongue anteriorly, allowing the posterior nasopharynx to be reached without tension.
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Introduction
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The surgical treatment of hypopharyngeal cancer is challenging due to the location of the tumor and the potential for serious postoperative complications. Since it was first described in 1960 by Ong and Lee [1], pharyngogastric anastomosis, or as it is commonly referred to, the ``gastric pull-up'' procedure, has been found to be the most reliable means to close the defect left by the resection of a hypopharyngeal mass [2]. As it is a one-stage procedure, the gastric pull-up allows for prompt healing, restoring early functional swallowing [3].
One of the most commonly encountered complications of this procedure is the formation of postoperative fistulas, due to dehiscence of the anastomosis. This can be prevented by careful preservation of the gastric vascular supply and the avoidance of tension at the site of anastomosis. We describe herein a method of gastric to pharyngeal mucosal anastomosis that allows a tight closure while providing adequate length to close even the most apical nasopharyngeal defects.
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Technique
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After the removal of the tumor mass by laryngectomy, pharyngectomy, and neck dissection, the stomach is mobilized (Fig 1A
). A two-team approach is generally used, allowing shorter overall operating time. The stomach vasculature is divided, saving only the right gastroepiploic artery. Extraserosal arcades between the right gastroepiploic artery and the short gastric arteries are preserved, allowing an excellent vascularized stomach conduit. The right and left gastric artery are divided and the esophagus is mobilized from above and below. A gastric tube is fashioned with multiple firings of the GIA-80 (4.8-mm stapler; Auto Suture, Norwalk, CT), parallel to the greater curvature. This ``elongates'' the gastric tube available. The staple line is oversewn with interrupted 3-0 silk (Ethicon, New Brunswick, NJ) ``Lembert'' seromuscular sutures.
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Fig 1. . (A) Margins of resected pharynx. The anterior margin of the tongue base is inferior to the posterior margin on the posterior pharyngeal wall. (B) The gastric flap allows the stomach to reach the posterior wall of the proximal pharynx, higher than the level achieved by gastric pull-up.
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The stomach is then passed up to the neck wound through the posterior mediastinum in a plastic sack for protection and ease of passage (Fig 1B
). After removal of the esophagus, the transected distal end of the esophagus is sewn to a 1-inch Penrose drain. The other end of the Penrose drain is sutured to the proposed anastomosis site, including the plastic bag in the stitch. The bag is lubricated with saline solution and brought up to the neck. The bag is brought out from the neck incision while the anterior surface of the bag is cut. This tends to deliver up more stomach into the incision. The stomach is next tacked with seromuscular sutures to the prevertebral fascia on both sides.
The proximal end of the stomach is then opened with a curved, U-shaped incision that creates a flap of stomach that can be secured high cranially (Fig 2). The stomach flap is sutured to the pharynx posteriorly and laterally, and then sutured at the base of the tongue or just below, anteriorly, depending on the amount of resection involved (Figs 3, 4). This closure is carried out with interrupted 3-0 Vicryl (Ethicon) sutures, and the anastomosis is tested with an infusion of saline solution. A second layer of interrupted Lembert sutures is used to imbricate the first closure layer where possible.
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Fig 2. . (A) The stomach after being pulled up into the neck. The dotted line shows the location of the U-shaped flap. (B) After creation of the flap and opening of the stomach, the flap is able to extend high onto the posterior pharyngeal wall.
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Very high lesions that require resection at the level of the eustachian tubes may not be amenable to primary closure. In this scenario, the gastric flap is sutured to the prevertebral fascia posteriorly as cranially as possible. The distal nasopharyngeal mucosa is then likewise sewn to the prevertebral fascia. This may result in a 2- to 4-cm gap, which eventually granulates over. The anterior section generally comes together more easily using the tongue or the base of the tongue.
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Comment
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Anastomotic dehiscence can occur in 5% to 20% of gastric pull-up procedures. The incidence of flap failure and wound dehiscence can be reduced by avoiding gastric ischemia and anastomotic tension. Careful preservation of the gastric blood supply will not guarantee flap survival but will at least increase the likelihood of success. Recently, Urschel [4] described a method of ``transplant delay,'' which may reduce the incidence of gastric pull-up failure. This is based on the principle of enhancing flap pedicle blood flow by occluding the left gastric arterial system.
Other surgical reconstruction techniques each have their own disadvantages. Reconstruction using a cutaneous tube is found by most surgeons to be unsatisfactory. It requires multiple stages and has frequent complications, especially if the tissue has been irradiated. Free grafts of intestine (jejunum or colon) are dependent on accurate anastomosis of small vessels and require more than one conduit anastomosis, increasing the chance of leak. This is especially difficult when long gaps need to be bypassed. Use of the tube pectoralis major myocutaneous flap has been found to have a high stricture rate [5].
The gastric pull-up procedure is thought to be inadequate for hypopharyngeal reconstruction when very high nasopharyngeal defects are left. In this situation other methods of reconstruction such as free or pedicled flaps are used. We have found that using this method of a U-shaped incision in the gastric fundus allows ample length to close even the highest of defects. We have performed this procedure on 10 patients so far, and in each case the anastomosis was adequate and did not exhibit excessive tension due to stretching.
The gastric pull-up procedure is the preferred method of hypopharyngeal reconstruction. Using the combination of U-flap technique as we have described and delivering the conduit via a plastic laser bag [6] should allow adequate closure of any defect basing a pedicle on the right gastroepiploic artery. The technique described is simple and allows a well-vascularized, tension-free anastomosis after resection of hypopharyngeal defects.
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Footnotes
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Address reprint requests to Dr Krasna, Division of Thoracic and Cardiovascular Surgery, University of Maryland Medical School, 22 S Greene St, Rm N4W87, Baltimore, MD 21201.
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References
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- Ong GB, Lee TC. Pharyngogastric anastamosis after esophageal pharyngectomy for carcinoma of the hypopharynx and cervical esophagus. Br J Surg 1960;48:193–200.[Medline]
- Ujiki GT, Pearl GJ, Poticha S, Sisson GA, Shields TW. Mortality and morbidity of gastric pull-up for replacement of the pharyngoesophagus. Arch Surg 1987;122:644–7.[Abstract/Free Full Text]
- Goldberg MD, Freeman J, Gullane PJ, Patterson GA, Todd TR, McShane D. Transhiatal esophagectomy with gastric transposition for pharyngolaryngeal malignant disease. J Thorac Cardiovasc Surg 1989;97:327–33.[Abstract]
- Urschel JD. Transplant delay will reduce anastomotic complications of gastric pull-up for isolated esophageal atresia. Med Hypoth 1993;40:379–82.[Medline]
- Schuller DF. Reconstructive options for pharyngeal and/or cervical esophageal defects. Arch Otolaryngeal 1985;111:193–7.
- Inculet RI, Finley RJ, Cooper JD. A new technique for delivering the stomach or colon to the neck following total esophagectomy. Ann Thorac Surg 1988;45:451–2.[Abstract]
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Abstract
Introduction
