Both patients showed no complications after surgeries and began swallowing 3 weeks later. They showed good phonatory function without respiratory complications such as bronchoaspiration [see video, Supplemental Digital Content 1, which displays the second patient swallowing water and showing maintenance of voice. We can observe a bulky structure at the right lateral aspect of the neck corresponding to the reconstructed pharynx (jejunal flap), http://links.lww.com/PRSGO/A920].
The prevalence of injuries caused by the ingestion of corrosive substances is mostly related to suicidal intentions in adult patients.1 Caustic ingestion leads to severe systemic consequences and especially damages the upper digestive tract. Alkalis cause full thickness injuries due to liquefactive necrosis, saponification, and blood vessel thrombosis. Emergency surgery is essential to resect all injured organs.2
Reconstructive surgery must be performed once the scarring process is over, and optimal timing for it is reported to be after 2 months.3 , 4
In the first case, reconstructive algorithm was based on the following considerations: the patient had issues with salivary flow control and was a good candidate for laryngeal preservation. However, a single reconstructive procedure with coloplasty was risky due to the extent of the injuries and subsequent resection. Stenosis of the superior extremity of the colon5 requires resection and insetting of a new pedicled colon flap or a free flap.6 We were concerned about these complications, and preferred to ensure results with 2 regulated surgeries. Since microvascular flaps protect the airway and improve ability to swallow,7–9 hypopharyngeal reconstruction was achieved with a radialis free flap, externalized distally (a colostomy bag collected the saliva) to avoid retraction of the flap until the second step was done.
Single coloplasty when the larynx is preserved can increase surgical morbidity, since the larynx may act as an anatomical barrier for colonic flap insetting, producing compression or ischemia of the flap. In these conditions (associated injuries of the digestive tract), the use of visceral flaps may pose a risk. The anatomical barrier was saved by means of a radialis free flap deflected laterally to the prevertebral fascia.
The use of microvascular flaps shows better protection of the airway and an improved ability to swallow with proper rehabilitation when the larynx is preserved.14–16 Location of flaps shall be far enough from the surgical remnants since they present collateral damages like fibrosis, tissue retractions, or vascular alterations. Visceral flaps may collapse when they are placed behind the airway although fasciocutaneous ones may hardly resist the retrolaryngeal insetting. Thus, the procedure seems to be safer when placing the flap in the lateral aspect of the neck.
When the larynx is preserved after circumferential hypopharyngectomy, tubular extra-anatomical free flaps can be an excellent indication for the functional reconstruction of the digestive tract and voice preservation.
In memory of Dr Rosado.
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