Ann Thorac Surg 2009;87:647-649. doi:10.1016/j.athoracsur.2008.06.045
© 2009 The Society of Thoracic Surgeons
How To Do It
Esophagectomy and Gastric Pull-Up in Patients With Previous Free Jejunal Transfer
Yoshinori Hosoya, MD, PhDa,*,
Shunji Sarukawa, MD, PhDb,
Shiro Matsumoto, MD, PhDa,
Toru Zuiki, MD, PhDa,
Masanobu Hyodo, MD, PhDa,
Koichi Abe, MD, PhDc,
Hiroshi Nishino, MD, PhDc,
Yasushi Sugawara, MD, PhDb,
Alan T. Lefor, MD, MPHa,
Yoshikazu Yasuda, MD, PhDa
a Department of Surgery, Jichi Medical University, Tochigi, Japan
b Department of Plastic and Reconstructive Surgery, Jichi Medical University, Tochigi, Japan
c Department of Otolaryngology-Head and Neck Surgery, Jichi Medical University, Tochigi, Japan
Accepted for publication June 9, 2008.
* Address correspondence to Dr Hosoya, Department of Surgery, Jichi Medical University, 3311-1 Shimotsuke, Tochigi, 329-0498 Japan (Email: hosoyo{at}jichi.ac.jp).
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Abstract
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Several options exist for reconstruction after total esophagectomy in patients with esophageal carcinoma. However, the options for a major resection after previous head and neck surgery in these patients are extremely limited. The procedure performed in 2 patients requiring esophagectomy after resection for previous head and neck malignancies is described. Both patients underwent previous chemoradiation therapy and free jejunal transfer for hypopharyngeal squamous cell carcinoma. Esophagectomy and reconstruction with a cervical gastrojejunal anastomosis combined with deltopectoral flaps were performed after the diagnosis of esophageal disease. Soft tissue defects were closed with a modified deltopectoral flap using de-epithelization. The deltopectoral flap is effective not only for cutaneous resurfacing, but also to promote delayed wound healing after radiation therapy. This report demonstrates a useful multidisciplinary approach for resection and reconstruction in patients after a previous free jejunal transfer.
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Introduction
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Patients with cancer of the head and neck also have a high incidence of esophageal cancer [1]. This phenomenon has been referred to as "field cancerization" because of the common epithelium and similar risk factors for the development of malignancies. Patients who undergo esophagectomy and then develop head and neck malignancies requiring free jejunal transfer have been reported [2]. Some patients with esophageal cancer must undergo esophagectomy and reconstruction, although they have a history of previous pharyngo-laryngo-esophagectomy with free jejunal transfer reconstruction for a prior malignancy. However, only one such case has been previously reported [3]. A technique for esophagectomy with gastric pull-up reconstruction in patients with a past history of chemoradiation and free jejunal transfer for hypopharyngeal cancer is described.
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Technique
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Patients with esophageal cancer and previous jejunal graft for reconstruction after pharyngo-laryngo-esophagectomy were candidates for this procedure. The procedure is begun by performing a right thoracotomy with lymph-node dissection when required by oncologic principles for the esophagectomy. Both tracheal arteries are preserved. Next, a laparotomy is performed with creation of a gastric tube. Through a collar incision, the proximal native esophagus and the proximal aspect of the jejunal graft are identified, preserving their vascular supply. The recipient artery of the free jejunum is the transverse cervical artery, and the recipient vein is the internal jugular vein. The lower portion of the previous jejunal graft and the remnant esophagus are then excised. The gastric tube is pulled up to the neck through the posterior mediastinum and anastomosed to the jejunal segment in an end-to-side fashion.
Figure 1
shows the resulting tissue defect after reconstruction of the gastrointestinal tract. After this, the primary skin closure is impossible because of the resulting soft tissue defect. The de-epithelialized area before development of the flap used for closure is shown in Figure 2. A deltopectoral flap is fixed to the posterior wall of the permanent tracheal stoma and patched to the anterior side of the anastomosis. The development and placement of the flap with resulting closure of the defect is shown in Figure 3.
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Fig 1. Intraoperative view of the resulting tissue defect after reconstruction with a gastrojejunostomy.
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Fig 2. Operative field before flap closure is performed. (D = de-epithelialized area; IMA2 & IMA3 = second and third branches of the internal mammary artery; J = jejunum; S = stomach; T = tracheal stoma.)
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Fig 3. Development and placement of the delto-pectoral flap used to cover the de-epithelialized area. (SG = skin graft, split thickness.)
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This procedure has been performed on 2 patients with excellent results. Both patients underwent preoperative chemotherapy followed by resection of the cervical esophagus, total laryngectomy, thyroidectomy, lymph node dissection, and reconstruction with a free jejunal graft. In 1 patient, severe stenosis occurred postoperatively, and multiple sessions of endoscopic dilation did not provide durable symptomatic relief. Considering the possibility of recurrence, a metallic stent was inserted. Five years later, granulation tissue growth in the stent and penetration of the stent through the skin necessitated esophageal resection and reconstruction. The second patient was diagnosed with superficial esophageal cancer 2 years postoperatively, and an endoscopic resection was performed. Seven endoscopic treatments were performed for multiple superficial carcinomas. Finally, invasive esophageal cancer was diagnosed, and long segment, endoscopic treatment was no longer indicated; he required esophageal resection and reconstruction.
In the first patient, the flap partially obstructed the tracheal stoma, requiring that excess tissue be excised after surgery. A minor pharyngocutaneous fistula resolved quickly, and the flap prevented aspiration. There was no recurrent tumor in the resected specimen. Although a tiny fistula was suspected after a few days in the second patient, the overall postoperative course was uneventful. Pathologically, the tumor was limited to the mucosa without lymph node metastasis. Both patients described here are now doing well with stable weight, and no evidence of tumor recurrence and 9 and 15 months of follow-up.
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Comment
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Chemoradiotherapy is effective in patients with hypopharyngeal squamous cell carcinoma to preserve laryngeal function without compromising the survival rate [4]. In patients with hypopharyngeal cancer, larynx-preserving therapy has been shown to preserve laryngeal function in approximately half of the patients at 3 to 5 years after treatment [5]. Thus, secondary esophageal cancer surgery for patients with a history of free jejunal transfer is quite difficult, not only because of anatomical changes, but also because of changes secondary to wound healing. Most patients should undergo chemoradiation treatment before surgery, as was done in both of these cases. The effect of irradiation on delayed wound healing must be considered in this setting. The development of a pharyngo-cutaneous fistula is the most common complication after free jejunal transfer for total laryngopharyngectomy [6].
We performed an esophagectomy carefully to maintain the blood flow to the jejunal graft and trachea and the retro-mediastinal stomach. After the anastomosis, we used a deltopectoral flap for delayed wound healing and to protect the tissue in the event that a pharyngocutaneous fistula developed. The delto-pectoral flap provides a large surface area of well-vascularized tissue that provides reliable coverage of the newly reconstructed area [7]. This regional flap is easily contoured to fit peri-stomal defects and defects of the surrounding cervical skin.
Dubsky and colleagues [8] reported that jejunal transfer with a pectoralis major muscle flap was carried out in a single, reconstructive procedure after salvage resection in a patient with hypopharyngeal carcinoma. Although myocutaneous flaps, such as pectoralis major and latissimus dorsi flaps, have been used previously for external coverage, they can be bulky. We believe that the pectoralis major muscle flap is not suitable for the patients described here, who underwent right thoracotomy because of their bulkiness.
Suga and colleagues [2] reported free jejunal transfer in 12 patients with a history of previous esophagectomy and gastric pull-up. After reviewing the literature we found only one case report of esophagectomy for patients with a history of free jejunal transfer [3].
Considering the high incidence of field cancerization including head and neck malignant tumors, some surgeons will encounter esophageal cancer patients after free jejunal transfer. Our experience shows that esophagectomy with gastric tube reconstruction can be performed safely, even in patients following previous free jejunal transfer and administration of chemoradiation therapy.
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References
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- Kohmura T, Hasegawa Y, Matsuura H, et al. Clinical analysis of multiple primary malignancies of the hypopharynx and esophagus Am J Otolaryngol 2001;22:107-110.[Medline]
- Suga H, Okazaki M, Sarukawa S, Takushima A, Asato H. Free jejunal transfer for patients with a history of esophagectomy and gastric pull-up Ann Plast Surg 2007;58:182-185.[Medline]
- MacMillan DP, Duarte IG, Mansour KA, Sundaresan RS. McKeown esophagogastrectomy for esophageal carcinoma after free jejunal graft Ann Thorac Surg 2002;73:1649-1651.[Abstract/Free Full Text]
- Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyriform sinus cancer: preliminary results of a European Organization for Research and Treatment of Cancer phase III trial J Natl Cancer Inst 1996;88:890-899.[Abstract/Free Full Text]
- Richard JM, Sancho-Garnier H, Pessey JJ, et al. Randomized trial of induction chemotherapy in larynx carcinoma Oral Oncol 1998;34:224-228.[Medline]
- Redaelli De Zinis LO, Ferrari L, Tomenzoli D, Premoli G, Parrinello G, Nicolai P. Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy Head Neck 1999;21:131.[Medline]
- McCarthy CM, Kraus DH, Cordeiro PG. Tracheostomal and cervical esophageal reconstruction with combined deltopectoral flap and microvascular free jejunal transfer after central neck exenteration Plast Reconstr Surg 2005;115:1304-1310.[Medline]
- Dubsky PC, Stift A, Rath T, Kornfehl J. Salvage surgery for recurrent carcinoma of the hypopharynx and reconstruction using jejunal free tissue transfer and pectoralis major muscle pedicled flap Arch Otolaryngol Head Neck Surg 2007;133:551-555.[Abstract/Free Full Text]
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Abstract
Introduction
