Repair of a large pharyngocutaneous fistula with a free jejunal patch flap after salvage laryngectomy: A case report

Preoperative chemoradiation therapy increases the risk of pharyngocutaneous fistula (PCF) after laryngectomy. In this report, we describe the use of a free jejunal patch flap and a deltopectoral flap for surgical treatment of a large PCF. A 52‐year‐old man underwent salvage laryngectomy and right neck dissection after concurrent radiotherapy for laryngeal carcinoma. On postoperative day 5, a pharyngeal fistula and neck abscess occurred with the right internal jugular vein thrombosis. We sutured the pharyngeal mucosa to the cervical skin to avoid carotid artery exposure, and we also ligated the right internal jugular vein. The PCF developed afterwards. The patient was being fed through a nasogastric tube and the fistula had increased in size. At the time of surgery, the external orifice became 5 cm × 5 cm in size. We performed the repair with a free jejunal patch flap and a deltopectoral flap. The harvested jejunum was opened along its antimesenteric border to design a sufficient free jejunal flap to cover the large PCF. A deltopectoral pedicled flap was used to reconstruct the neck skin defect to resurface the free jejunal patch flap. Both flaps survived. The patient could resume an oral diet 2 weeks after surgery. At 1 month after surgery, the skin pedicle of the deltopectoral flap was divided. There was no contracture or stricture 3 years after surgery and he maintained a regular diet. Reconstruction with a free jejunal patch flap and a deltopectoral flap may be a suitable method for repair of a large PCF. © 2014 Wiley Periodicals, Inc. Microsurgery 37:61–65, 2017.     

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.     

Reconstruction after total or subtotal glossectomy

Total or subtotal resection of the tongue for malignant lesions creates difficult reconstructive problems. Though the introduction of myocutaneous flaps revolutionized the reconstruction of the oral cavity, most patients with total and subtotal (more than 75 percent) glossectomy require laryngectomy as a concommittant or subsequent procedure to prevent persistant aspiration. Two groups of patients have been compared in this study. Group I consisted of 10 patients in whom an attempt was made to preserve voice with a total (4 patients) or subtotal (6 patients) glossectomy without laryngectomy. To decrease the chance of aspiration, the tip of the epiglottis was sutured to the posterior pharyngeal wall (epiglottopexy). This additional surgical step allowed swallowing without aspiration by blocking the glottic entrance. Group II consisted of six patients who underwent total glossectomy and laryngectomy. They had reconstruction with a pectoralis myocutaneous flap in one stage. These patients were rehabilitated without any major morbidity and they resumed an oral diet within 3 weeks after surgery. The muscle bulk of the flap and the additional protection of the airway by epiglottopexy in Group I were the keys to successful reconstruction.     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

Major head and neck reconstruction using the deltopectoral flap. A 20 year experience

Six hundred seventy-eight deltopectoral flaps were raised in 604 patients, 125 of which were delayed and 215 of which were used in previously irradiated beds. The rate of major flap necrosis was 16.9 percent and the overall rate of complications, 51.4 percent. Delay in creating the deltopectoral flap had no influence on the risk of complications and necrosis, whereas the use of the flap in a previously irradiated bed was associated with a significantly increased risk of major flap necrosis. The least flap loss occurred when the deltopectoral flap was used without tubulation for skin coverage only. Complications and flap necrosis occurred most frequently when flaps were tubulated in a reversed manner or used for lining of major portions of or for total oropharyngeal and hypopharyngeal reconstruction. The deltopectoral flap remains a useful, reliable, and versatile regional flap that can be used alone or in combination with other flaps in selected circumstances for major head and neck reconstruction.     

An effective pharyngoesophageal reconstruction with free radial forearm flaps

Summary Treatment of cancer of the cervical aerodigestive tract is challenging due in part to the difficulty in reestablishment of pharyngoesophageal continuity after resection of the involved tract. From May 1989 to August 1990, six patients underwent immediate reconstruction utilizing microvascular transfer of free radial forearm flaps following resection of pharyngoesophageal neoplasms. A small island flap connected to the radial vascular pedicle by fasciocutaneous branch was used to monitor the vascular condition of the hidden fabricated free forearm flap. Stricture is the most troublesome complication of esophageal reconstruction using a conventional free forearm flap. Two small triangular flaps were designed and inserted bilaterally in the distal anastomosis of both lateral esophageal walls to prevent circular contracture. The outer layer sutures were anchored to surrounding rigid structures to withstand shrinkage and circular contraction. The problem of stricture was solved by these procedures. This one-stage, easily monitored operation for pharyngoesophageal reconstruction is considered to be as useful as a free jejunal transfer.     

EVALUATION OF 250 FREE-FLAP RECONSTRUCTIONS AFTER RESECTION OF TUMOURS OF THE HEAD AND NECK

Background : Microvascular free-tissue transfer is now the primary method of reconstruction in many centres. The aim of this study was to evaluate the applications, complications and limitations of free-flap reconstruction in a series of patients with tumours of the head and neck. Methods : This study reviewed prospectively accessioned computerized records in a dedicated head and neck database. Patients treated between 1987 and 1995 with a minimum of a 1-year follow-up were reviewed. There were 242 patients with a mean age of 58 years (172 men and 70 women). The most common tumour sites were oral cavity (42%), oropharynx (32%) and hypopharynx (11%). Mucosal squamous carcinoma accounted for 87% of primary cancers. Results : Among the 250 free flaps, the radial forearm flap (205) and free jejunum (25) predominated. There were 21 episodes of vascular occlusion (8%), failure of 10 flaps (4%) and two patients died perioperatively (0.8%). A second free flap was used in five of 10 cases of flap failure. The fistula rate was 4.4% among 203 patients at risk for this complication, which comprised four of 178 forearm flaps and five of 25 free jejunal grafts. Four of 16 jaw reconstructions failed. Conclusions : A 96% success rate was achieved using free-tissue transfer for head and neck reconstruction. The overall complication rate was low but jaw reconstruction and free jejunal grafts posed the greatest problems because of failure of radial bone and fistulas, respectively. The radial forearm septocutaneous flap was very reliable and remains our mainstay for oral reconstruction.     

Secondary reconstruction of failed esophageal reconstruction

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.     

Intussusception of a transferred jejunal flap in cervical esophagus reconstruction

Although jejunal flaps have been used frequently for esophageal reconstruction, and the techniques for transfer, as well as subsequent modification, have been well described, a variety of complications still poses problems for both physicians and patients. The challenge exists in avoidance and management of complications. The purpose of this report is to present an unusual but severe complication involving a jejunal flap that was transferred to the neck for esophageal reconstruction. Intussusception of the jejunal flap occurred 1 year after flap transfer due to redundancy of the transferred segment. The patient was a child who had esophageal reconstruction for severe dysphagia that was due to a previous history of radiation injury. The disorder was successfully treated surgically with manual reduction of the intussuscepted segment, followed by shortening of the jejunal flap to prevent future recurrence. One should keep in mind that redundancy of the reconstructed esophagus may cause dysphagia due to kinking or, in this case, intussusception, which may result in necrosis of a segment of the transferred jejunum. One of the measures that should be taken during the initial reconstruction to prevent these serious complications is to perform the final inset of the jejunal flap after revascularization. This allows for proper assessment of jejunal length, which undergoes a significant change after restoration of the vascular supply.     

CLOSURE OF LARGE PHARYNGO-OESOPHAGEAL FISTULAS WITH FREE FLAP TRANSFER AFTER RESECTIONS FOR CANCER

Postoperative salivary fistulas still remain a serious and potentially lethal problem in head and neck reconstruction particularly if the fistula is large and involving one half or more of the circumference of the pharyngo-oesophagus. Pedicled flaps have traditionally been the flaps of choice for closure of these fistulas, but the results are often disappointing. During the period 1982 to 1995, we have used either a radial forearm free flap or a jejunal free flap to close large and complex pharyngo-oesophageal fistulas after resection for cancer in 15 patients. Although two patients developed major fistulas that required additional operations for closure, successful closure was achieved in all but one case: the success rate was therefore 14/15 (93%). We consider that jejunal flaps are suitable for circumferential pharyngo-oesophageal reconstruction and forearm flaps for non-circumferential defects.     

Reconstructive experience with the medially based deltopectoral flap

One hundred and five deltopectoral flaps were raised in 100 patients. Fifty-four were delayed prior to use and 51 flaps were used immediately without delay. Delay was used whenever there was a high probability of impaired healing or a modification of a portion of the flap was necessary. In patients with delayed flaps there was major loss in 16.6 per cent and minor loss in 9.2 per cent. In immediate reconstruction of the flap, major loss occurred in 15.7 per cent and minor loss in 17.6 per cent. The most frequent major flap losses occurred during attempts to reconstruct the palate.Placement of the flap into a previously radiated tissue bed, diabetes, and wound infections were the major contributing factors to major flap loss in both groups of patients.     

Reconstruction in the head and neck regions with free radial forearm flaps and split-rib bone grafts

Fifty patients with wound defects in the head and neck region underwent reconstruction with the free radial forearm flap. Mandible defects in 17 patients were reconstructed by split-rib bone grafts. Radiotherapy was administered to 44 patients preoperatively. The free flap was successful in 49 patients, and there was one case of partial flap necrosis. The free flap is soft, thin, and movable. The split-rib bone graft was successful in 15 patients, and there was one case of partial graft necrosis and one case of complete necrosis. Postoperative complications were decreased by 50 percent when compared with the complication rate when split ribs were covered by forehead flaps, deltopectoral flaps, or oral mucosa. Finally, the functional and cosmetic results were excellent.     

Comparative Evaluation in Pharyngo-oesophageal Reconstruction: Radial Forearm Flap compared with Jejunal Flap. A 10-year experience

We reviewed 109 consecutive patients with cancer of the hypopharynx or cervical oesophagus who underwent free flap transfer for immediate reconstruction after total pharyngolaryngo-oesophag-ectomy. The free flaps used were either free jejunal (n = 70) or radial forearm flaps (n = 39). Significantly more fistulas (3/70 compared with 15/39, p < 0.0001) and strictures (6/64 compared with 13/33, p = 0.0008) developed in the radial forearm than the jejunal flap group. However, functional donor site morbidity was minimal and there were no cases of total flap necrosis in the forearm flap group. We consider that the free jejunal flap should be the first choice for total reconstruction of pharyngo-oesophageal defects. However, the forearm flap is suitable for elderly, high risk patients, because it is less invasive and has minimal donor site morbidity, which facilitates early recovery.     

Reconstruction of the chin using an expanded deltopectoral flap following multiple recurrences of oral cancer

An important alternative to free tissue transfer in patients requiring correction of soft tissue chin defects are local and regional flaps, such as the pectoralis major myocutaneous flap and deltopectoral flap. With predictable vascular supply, potential for large size, and good aesthetic match for facial and cervical skin, the deltopectoral flap can offer the reconstructive surgeon additional options in patients who lack vessels suitable for free tissue transfer. The use of an expanded deltopectoral flap for a staged reconstruction of the chin in a patient with cancer recurrences, concomitant resections, radiation and multiple reconstructions is reported.     

Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience.

We have reviewed 145 patients who underwent 148 total reconstructions of the hypopharynx and cervical esophagus between 1970 and 1989. The types and numbers of reconstruction included 45 deltopectoral (DP) flaps, 35 musculocutaneous (MC) flaps, 19 colon interpositions, 23 gastric transpositions, and 26 free jejunal transfers. Median hospitalization was 51 days for DP flaps, 24 days for MC flaps, 28 days for colon, 30 days for gastric, and 14 days for jejunum. Median resumption of oral intake was 92 days for DP flaps, 19 days for MC flaps, 12 days for colon, 13 days for gastric, and 9 days for jejunum. Functional failure, defined as the inability to maintain adequate nutrition without tube feedings, was 40% for MC flaps, 42% for colon interposition, 17% for gastric transposition, and 20% for free jejunal transfer. Microvascular free jejunal transfer has become our method of choice for reconstruction of the hypopharynx and cervical esophagus. Gastric transposition is an alternative when resection of the thoracic esophagus is necessary.     

Free flaps for type III complex pharyngoesophageal defects after enlarged ablative surgery for advanced cancer of larynx and hypopharynx

Free tissue transfer has become a useful technique for reconstruction of type III complex pharyngoesophageal defects after enlarged laryngectomy and partial or total pharyngoesophageal resection. We present a retrospective analysis of our experience with 36 patients who received free flaps for reconstruction of complex pharyngoesophageal defects associated with skin and soft-tissue defects. Free fasciocutaneous flaps and jejunum combined with a deltopectoral flap and musculocutaneous pectoralis major flap, gastro-omental flap, and combined latissimus dorsi musculocutaneous and cutaneous scapular flaps were used for reconstruction. Adjuvant therapy included preoperative or postoperative radiotherapy. Free flap failure occurred in 2 of 36 patients. Twenty-eight patients had good swallowing function. Better results with fewer complications in reconstruction of type III complex pharyngoesophageal defects were obtained with the use of a combined latissimus dorsi and scapular flap.     

Complications after laryngectomy

The charts of 100 consecutive patients who underwent laryngectomy at Memorial Hospital were reviewed to assess those factors that contribute to postoperative complications. Laryngectomy was performed for epidermoid carcinoma in 94 patients and for laryngeal incompetence in 6. Total laryngectomy was performed in 48 patients and partial and circumferential pharyngectomies in addition to laryngectomy in 40 and 12 patients, respectively. Significant complications, which delayed discharge, occurred in 13 patients (27 percent) who had simple laryngectomy, including the formation of two fistulas (4 percent). After laryngopharyngectomy, the complication rate was 77 percent (40 of 52 patients) with pharyngocutaneous fistulas in 19 patients (37 percent). The fistula rate of formation was not increased in irradiated patients; however, the duration of time to closure of a pharyngocutaneous fistula, if it occurred, was longer. Planned pharyngostomy or staged deltopectoral flap reconstruction after extended laryngopharyngectomy was associated with excessive morbidity. Newer techniques of reconstruction utilizing flaps or gastric transposition offer the prospect of reduced morbidity after laryngopharyngectomy.     

A single stage reconstruction of upper and lower lip by modified Bernard technique

A single stage reconstruction of the upper and lower lip by a modification of the Bernard technique is described. The nasolabial flaps which are discarded in the original procedure are raised as island flaps based on the facial arteries and used with advantage to reconstruct the upper lip and the lower gingivobuccal sulcus.     

Successful upper alveolar reconstruction for gingival cancer using a fibular osteoadipofascial flap without osseointegrated implants

An upper alveolar skeletal reconstruction with closure of the palatal fistula using an osteocutaneous free flap is considered an ideal reconstructive strategy after curative surgery for cancer of the lower maxilla. Although installation of osseointegrated implants into the bone has advantages for utilizing a dental prosthesis, it is often time and cost prohibitive. In the case of 1 patient, we reconstructed and fit the patient with a conventional denture, eliminating the need for installation of osseointegrated implants. The patient underwent upper alveolar reconstruction using a fibular osteoadipofascial flap, followed by a skin graft for creation of an alveololabial sulcus. It was then possible for the patient to wear a conventional denture without implants. One explanation for this success is that the regenerated mucosa on the adipofascial flap and skin graft was immobile, which allowed it to serve as a base for the dental prosthesis. The alveololabial sulcus that had been constructed kept the denture in place. This reconstruction confirmed that a fibular osteoadipofascial flap might be a useful choice in restoring a natural upper alveolar osseous and soft tissue structure.     

Surgical treatment of persistent dysphagia in stroke patients using a newly reconstructed conduit from the anterior mouth

Dysphagia is common after stroke and may result in malnutrition and aspiration. To prevent the risk of aspiration and to improve the nutritional status, patients with dysphagic stroke have to give up oral intake and become dependent on tube feeding. Restoration of the patients' ability to resume aspiration free oral feeding is important. A 55-year-old male presented following a brainstem stroke and dysphagia. He was treated with a free jejunal flap to divert food from the anterior mouth to the cervical esophagus. Although the flap underwent partial loss, this was reconstructed with a tubed deltopectoral flap, and following a revision procedure for stricture, the patient's diet was advanced to a regular diet. At follow-up, the patient was able to eat by mouth without tube feeding. The application of this diversion technique to treat patients with a medical disease (i.e., stroke) is a step toward resuming oral feedings in this group of patients.