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Reliable Option for Salvage Pharyngoesophageal Reconstruction

Miyamoto, Shimpei M.D.; Sakuraba, Minoru M.D.; Nagamatsu, Shogo M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1734-1735
doi: 10.1097/PRS.0b013e31820a6432
Letters
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Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital East; Kashiwa, Japan

Correspondence to Dr. Miyamoto, Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan, shimiyam@ncc.go.jp

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Sir:

We read with interest the article entitled “Complex Salvage of a Failed Pharyngoesophageal Reconstruction with Impending Airway Disaster” (Plast Reconstr Surg. 2010;125:208e–210e) by Hsu and Yu. Although the authors should be applauded for their successful salvage of such a complicated case, we would like to point out several issues associated with their resection and reconstruction plans.

A major problem of the resection included the preservation of the posterior wall of the pharynx. If primary closure of the mucosal defect is not possible and a free flap transfer is required, the resection should be circumferential to simplify the reconstructive procedure. Although the remaining mucosa may help to prevent stricture formation, the fistula rate for partial resections has been shown to be higher than that for circumferential ones, regardless of the method of reconstruction.1,2

Flap selection is also an important consideration. Indications for use of an anterolateral thigh flap for pharyngoesophageal reconstruction have recently expanded because of low donor-site morbidity and good speech function with tracheoesophageal puncture.3 However, the safety of fasciocutaneous flaps in previously irradiated patients has not yet been established.1,4 In salvage cases, pharyngocutaneous fistulas, even minor ones, can lead to life-threatening conditions, as seen in the described case, and prevention of fistula formation and secure wound closure should take precedence over postoperative function. Several reports have recommended the preferential use of enteric flaps for salvage pharyngoesophageal reconstruction in patients able to tolerate a laparotomy, because of their excellent wound healing properties.1,5

In our opinion, the optimal reconstructive option for the patient was circumferential reconstruction with free jejunum transfer and neck skin resurfacing with a regional flap. Although several regional flaps can be used (e.g., deltopectoral or pectoralis major myocutaneous flaps), we prefer the pectoralis major muscle flap with a skin graft on the muscle (Figs. 1 and 2). If a skin defect just cranial to the permanent tracheostoma is reconstructed with a skin island, even a thin flap will overhang the stoma, resulting in prolonged endotracheal intubation. Using this method, the pectoralis major muscle becomes atrophic and patency of the stoma is maintained. This method can be used safely, even in female patients, with minimal breast deformity.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Shimpei Miyamoto, M.D.

Minoru Sakuraba, M.D.

Shogo Nagamatsu, M.D.

Division of Plastic and Reconstructive Surgery

National Cancer Center Hospital East

Kashiwa, Japan

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

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REFERENCES

1. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope 2006;116:173–181.
2. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: A critical review of the literature. J Plast Reconstr Aesthet Surg. 2008;61:1148–1156.
3. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: A clinical and functional outcomes study. Plast Reconstr Surg. 2005;116:1845–1855.
4. Nakatsuka T, Harii K, Asato H, Ebihara S, Yoshizumi T, Saikawa M. Comparative evaluation in pharyngo-oesophageal reconstruction: Radial forearm flap compared with jejunal flap–-A 10-year experience. Scand J Plast Reconstr Surg Hand Surg. 1998;32:307–310.
5. Patel RS, Makitie AA, Goldstein D, et al. Morbidity and functional outcomes following gastro-omental free flap reconstruction of circumferential pharyngeal defects. Head Neck 2009;31:655–663.

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