Ann Thorac Surg 2005;79:1406-1407
© 2005 The Society of Thoracic Surgeons
Case report
Sternocleidomastoid Myocutaneous Esophagoplasty for Benign Cervical Stricture
Deborah K. Cunningham, MD*,a,
Scott J. Stern, MDb,
Hugh F. Burnett, MDa,c
a Department of Surgery, Division of General Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
b Department of Surgery, Divisions of Division of Otolaryngology, Little Rock, Arkansas, USA
c Department of Surgery, and Division of Thoracic Surgery, Baptist Medical Center, Little Rock, Arkansas, USA
Accepted for publication October 16, 2003.
* Address reprint requests to Dr Cunningham, Surgical Oncology, University of Arkansas for Medical Sciences, 4301 W Markham, Slot 725, Little Rock, AR 72205, USA
dkcunningham{at}uams.edu
 |
Abstract
|
|---|
Benign strictures of the cervical esophagus that are resistant to dilation present a formidable challenge to the surgeon. Numerous varied techniques have been developed to restore swallowing. Reports of the sternocleidomastoid myocutaneous pedicled flap for repair of benign cervical strictures are scarce. We are reporting a case of residual lye stricture that was treated with sternocleidomastoid myocutaneous esophagoplasty in order to promote awareness of this procedure. This one-stage operation took 1 hour to complete. The patient began eating on postoperative day 4 and has not had any further symptoms.
|
Introduction
|
|---|
Benign short segment strictures of the cervical esophagus that are refractory to dilation require surgical repair. Esophageal resection and substitution, usually with a hollow viscus is the more common approach. Fraught with significant morbidity and mortality [1], these tedious and often staged operations seem disproportionate to the disease. In order to circumvent the difficulties associated with esophageal replacement for benign cervical strictures, various repairs using myocutaneous flaps have been described [2]. The sternocleidomastoid (SCM) myocutaneous flap is rarely encountered in the literature. The rich, segmental blood supply of the SCM muscle allows construction of a pedicled flap [3, 4]. This flap provides an efficient, effective alternative repair of the stenosed cervical esophagus when dilation fails [3, 4].
Our patient, now a 50-year-old woman, has a history that began with liquid lye ingestion at age 3. The caustic ingestion as a child resulted in prolonged hospitalization and tracheostomy. No feeding tube was placed; she was not expected to live. She managed to survive by initially consuming thin liquids which were gradually thickened over several months. Her tracheostomy was removed at age 8. A residual upper esophageal stricture caused daily episodes of choking or vomiting for many years. Intermittent dilations beginning at age 20 provided transient relief of dysphagia. At age 50 she had progressive dysphagia to solids then liquids develop after beginning vitamin supplements. It had been several years since her last dilation. The progressive dysphagia was initially and erroneously treated with antibiotics and steroids for a presumed diagnosis of "strep throat." She was subsequently referred to a gastroenterologist when symptoms persisted. Barium esophagram demonstrated a severe short segment stricture just below the cricopharyngeal muscle (Fig 1a). Esophagoscopy demonstrated a 4-mm lumen with very thickened, pale mucosa circumferentially. Under general anesthesia, Savoy dilators (Medovations, Milwaukee, WI) were used to successfully dilate the stricture, allowing passage of the scope. There were no abnormalities of the distal esophagus, stomach, or duodenum. After dilation, the stricture would quickly return to its previous 4 mm diameter. Surgical repair was scheduled using a pedicled myocutaneous flap based on the SCM muscle.
View larger version (140K):
[in this window]
[in a new window]
|
Fig 1. (a) Barium esophagram demonstrating a tight, short segment cervical esophageal stricture. (b) Postoperative barium esophagram demonstrating a patent cervical esophagus with no extravasation.
|
|
The operation began with the head being turned to the right and the neck being gently flexed. An oblique incision was made along the anterior margin of the left SCM muscle and curved inward at the base of the neck in a hockey-stick design. Dissection was carried down through the platysma, subcutaneous tissue, and along the medial surface of the SCM. The SCM was elevated posteriorly, taking care to identify and protect the spinal accessory nerve. Dissection continued medial to the carotid sheath to the prevertebral fascia, exposing the esophagus. Exposure of the left lateral and posterior esophagus was enhanced with rightward retraction of the trachea and thyroid gland. There was no external evidence of the location of the stricture. A Mallony dilator (Pilling, Port Washington, PA) was passed into the esophagus to facilitate palpation of the stricture. A longitudinal esophagotomy was made along the stenotic segment to healthy mucosa superiorly and inferiorly. An elliptical skin island was taken from the lateral aspect of the incision and left in continuity with the SCM (Fig 2a). The SCM was transected at the upper one-fourth. The attached skin island was rotated medially and sewn in running fashion with 4-0 Prolene (Ethicon, Somerville, NJ) to the edges of the esophagotomy, creating a skin patch (Fig 2b). The SCM was further rotated medially and tacked into place with sutures. A drain was placed, a lateral skin flap was raised, and the incision was closed. Four days later a barium esophagram showed a widely patent cervical esophagus with no leaks (Fig 1b). The patient was discharged on toleration of a soft diet on postoperative day 6. Esophagoscopy at 6 months demonstrated a well-incorporated suture line with a normal appearing skin patch. There has been no dysphagia since the surgery.
View larger version (21K):
[in this window]
[in a new window]
|
Fig 2. (a) Schematic drawing illustrating skin island taken from the lateral incision. (b) Sternocleidomastoid muscle.
|
|
|
Comment
|
|---|
When symptoms of benign disease have been present for many years despite multiple dilations, every effort should be made to preserve the native esophagus [5]. Use of local tissue is ideal for repair of short, stenosed cervical segments. The one-stage sternocleidomastoid patch esophagoplasty employs local tissue thereby avoiding complete transection of the esophagus. Coordinated peristalsis is also preserved and vagotomy is avoided [6]. The operation requires one skin incision, is relatively simple with negligible morbidity, and results in minimal functional loss of the remaining muscle [4].
Musculocutaneous flaps can be used to repair leaks or fistulas after esophageal replacement for malignant and nonmalignant disease [7]. The skin provides an adequate patch for the esophageal defect. The well vascularized muscle forms a seal around the site, obliterates dead space, and can convey antibiotics [7]. The SCM flap, unlike other musculocutaneous flaps used for repair of benign cervical strictures employs tissue from the same anatomic region and is a less traumatic operation. This flap has also been efficacious in the pediatric population after caustic ingestion when dilation fails, and after esophageal laceration from foreign body ingestion [4].
Persons with a history of caustic ingestion, as in the case of our patient, are at increased risk for the development of esophageal carcinoma [8]. It is our belief that the SCM patch esophagoplasty is an appropriate surgical option for benign caustic strictures of the cervical esophagus, along with surveillance endoscopy, and this does not preclude a more definitive procedure if malignant transformation occurs. With so few reports in the literature, it is presently unknown if the increased desquamation of the skin patch due to constant moisture leads to malignant transformation. A report of four cases revealed no evidence of re-stenosis, excoriation, or carcinoma of the skin island after more than 2 years of follow-up [4]. Although late occurring complications after SCM patch esophagoplasty needs further elucidation, it is a suitable option for one of the most difficult reconstructive problems in esophageal surgery.
|
References
|
|---|
- Geller KA, Pierce MK. Surgical management of strictures of the cervical esophagus. Ann Otol Rhino Laryngol. 1984;93:501–511
- Jurkiewicz MJ. Reconstructive surgery of the cervical esophagus. J Thorac Cardiovasc Surg. 1984;88:893–897[Abstract]
- Weerda H. Myokutaner insellappen zur Erweiterung von Hochsitzenden oesophagus-hypopharynx stenosen (in German). HNO. 1980;28:271–272[Medline]
- Frimpong-Boateng K. Sternocleidomastoid myocutaneous esophagoplasty. Eur J Cardiothor Surg. 1994;8:660–662[Abstract]
- Young MM, Deschamps C, Trastek VF, et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg. 2000;70:1651–1655[Abstract/Free Full Text]
- Othersen HB, Smith CD. Colon-patch esophagoplasty in children: an alternative to esophageal replacement. J Pediatr Surg. 1986;21:224–226
- Chen H, Tang Y, Noordhoff MS. Patch esophagoplasty with musculocutaneous flaps as treatment of complications after esophageal reconstruction. Ann Plast Surg. 1987;19:448–453[Medline]
- Moore WR. Caustic ingestions: pathophysiology, diagnosis, and treatment. Clinical Pediatrics. 1986;25:192–196
Top
Abstract
Introduction
