Ann Thorac Surg 2001;72:267-270
© 2001 The Society of Thoracic Surgeons
Case report
Total esophageal reconstruction using a tubed parascapular free flap
Richard P. Rand, MDa,
Eric Y. Lin, MDa,
Douglas E. Wood, MDb
a Division of Plastic and Reconstructive Surgery, University of Washington Department of Surgery, Seattle, Washington, USA
b Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
Accepted for publication May 7, 2000.
Address reprint requests to Dr Rand, University of Washington Medical Center, 1959 NE Pacific St, Box 356410, Seattle, WA 98195-6410
e-mail: rrand{at}u.washington.edu
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Abstract
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A method for total esophageal reconstruction when intestinal options are no longer available is presented. The technique described utilizes the parascapular microsurgical free flap, which is tubed and interposed between the cervical esophagus and the gastric remnant in the abdomen. The technique involves a well-recognized microsurgical flap and may be added to the armamentarium for total esophageal reconstruction.
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Introduction
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Total esophageal reconstruction is most often performed using the stomach or colon [1, 2]. For partial esophageal replacement, a jejunal interposition or a free jejunal flap can be a suitable alternative conduit [3], and a combined free jejunal graft with jejunal interposition may provide for complete esophageal replacement in the absence of suitable stomach or colon. When all gastrointestinal options are exhausted, an inverted skin tube composed of either a skin flap or a myocutaneous flap represents a reconstructive option of last resort. Disadvantages of skin flaps in total esophageal reconstruction include their vulnerability to chronic and recurrent fistulas, lack of peristalsis, the need for staged procedures, and the need of a conduit constructed from two or more separate skin or myocutaneous flaps. We describe a patient with complications after esophagectomy who had limited options for total esophageal reconstruction. Total esophageal reconstruction was performed with a parascapular microsurgical flap.
A 52-year-old man presented for a total esophageal reconstruction. The patient had undergone a transhiatal esophagectomy for Barrett’s esophagus with high-grade dysplasia. This was complicated by gastric necrosis requiring a proximal hemigastrectomy with the creation of a cervical esophagostomy and feeding gastrostomy. The patient was referred with a 35-cm gap separating the esophagostomy and gastric remnant. The patient’s history was significant for Gardner’s syndrome, for which he had undergone a total colectomy with J-pouch reconstruction in the past because of colonic polyposis. This J-pouch was also unsuccessful, resulting in a permanent iliostomy. A desmoid tumor of the small-bowel mesentery further complicated the case by eliminating a jejunal interposition or free flap as options for esophageal reconstruction.
Because of the lack of any intestinal conduit for esophageal replacement, options for cutaneous and myocutaneous reconstruction were evaluated. Cutaneous options, including traditional skin tubes as well as tensor fascia lata and bilateral radial forearm microsurgical flaps, were not considered acceptable because of extensive subcutaneous lipomas located in all of these donor sites. The right posterior back was the only area where the cutaneous tissues were reasonable. Therefore, a total esophageal reconstruction was planned using an extended-length tubed parascapular microsurgical free flap from the right side of his back.
The initial operation was a vascular "delay procedure" performed around a 10- x 50-cm parascapular flap in order to enhance the distal flap circulation (Fig 1).
The patient subsequently underwent elevation and tubing of the flap. Because of scar tissue in the left neck as well as the presence of the cervical esophagostomy, the right neck was selected to provide the vascular supply for the flap, with a saphenous vein arteriovenous fistula [4] created into the external carotid artery and internal jugular vessels (Fig 2). The flap was perfused by the thoracodorsal pedicle anastomosed into the saphenous vein grafts. The flap was placed in a subcutaneous tunnel, and its distal and proximal ends were anchored adjacent to the esophagostomy and gastrostomy sites. Primary anastomosis of the flap into the intestine was not performed, in order to allow the seam in the tube to heal before exposure to salivary and gastric fluids (Fig 3). The donor site on the back was skin grafted.
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Fig 2. Skin island elevated and tubed with microsurgical anastomosis to saphenous arteriovenous fistula into right carotid and jugular systems.
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Three months later the patient returned for intestinal anastomosis. The tube had foreshortened by 5 to 6 cm at its proximal end, but it was able to be released and returned to its original length for primary anastomosis to the esophagus and stomach. After mobilization of the remnant of cervical esophagus, an anastomosis was constructed between the esophagus and the proximal skin tube at the level of the clavicle. The long-standing gastrostomy tube was removed, and a minimal abdominal dssection was performed to allow an anastomosis of the distal skin tube to the stomach at the site of the previous gastrostomy. A separate gastrostomy was created percutaneously for drainage, and a feeding jejunostomy was placed for nutritional supplementation. A fistula was intentionally left in the proximal portion of the skin tube to decompress the conduit during healing of the proximal and distal anastomoses.
Six weeks later, endoscopy through the fistula confirmed that the anastomoses were healed and widely patent. Closure of the fistula was then performed in two layers and followed after 6 more weeks by closure of a very small recurrent fistula. The patient subsequently healed completely and eats an unrestricted diet including solids such as steak (Fig 4). He initially reported no difficulty with fluids or soft foods and required no mechanical assistance for passage of these materials. When consuming coarse solids, he chewed thoroughly and applied a minimal amount of massage to complete passage. There was no delay at either anastomosis for 12 months after reconstruction, but the patient has recently developed a distal skin tube stricture thought to be secondary to acid reflux; he is now being treated by proton-pump inhibitors and dilation of his skin-tube conduit.
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Comment
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Various skin-flap choices have been described for esophageal reconstruction. Chest wall skin with or without pectoralis major muscle is the primary local option [5]. Free tissue transfers using radial forearm flap and tensor fascia lata flaps [6] have been described. Chen and colleagues [7], in a staged fashion, reconstructed the esophagus using the posterior tibial artery flap. The authors first "elevated" the skin flap into a skin tube in the subcutaneous tunnel. After the skin and mucosa edges were healed, the lower end of the tube was joined to the jejunum in the second stage. The same group of authors also described "chain flaps" using two radial forearm flaps to reconstruct the esophagus, measuring as long as 40 cm [8].
In the case presented, there was a 35-cm gap between esophagostomy and gastrostomy. Because of the lack of gastrointestinal options and limited skin-flap options, a delayed parascapular flap was designed. The parascapular flap provided the advantages of length and limited bulk for the creation of a long, single-flap conduit.
In conclusion, we describe the reconstruction of the total esophagus using a tubed parascapular free flap in a three-stage process. This provides an alternative for total esophageal reconstruction in selected cases. The use of flap delay, saphenous arteriovenous fistula, and delayed gastrointestinal anastomosis resulted in a successful outcome.
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References
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Rand R.P., Gruss J.B. The saphenous arteriovenous fistula in microsurgical head and neck reconstruction. Am J Otolaryngol 1994;15:215-218.[Medline]
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Kakegawa T., Machi J., Yamana H., et al. A new technique for esophageal reconstruction by combined skin and muscle flaps after failure in primary colonic interposition. Surg Gynecol Obstet 1987;164:576-578.[Medline]
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Chen H.C., Kuo Y.R., Hwang T.L., et al. Microvascular prefabricated free skin flaps for esophageal reconstruction in difficult patients. Ann Thorac Surg 1999;67:911-916.[Abstract/Free Full Text]
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Chen H.C., Tang Y.B., Noordhoff M.S. Posterior tibial artery flap for reconstruction of the esophagus. Plast Reconstr Surg 1991;88:980-986.[Medline]
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Chen H.C., Tang Y.B., Noordhoff M.S. Reconstruction of the entire esophagus with "chain flaps" in a patient with severe corrosive injury. Plast Reconstr Surg 1989;84:980-984.[Medline]
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Abstract
Introduction
