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Circumferential Pharyngoesophageal Reconstruction and Total Larynx Preservation with Extra-anatomical Free Flaps

Lasso, Jose M., MD, PhD; Castellano, Michele, MD; Pinilla, Carmen, MD; González-Pozega, Carlota, MD; Pérez-Cano, Rosa, MD

Plastic and Reconstructive Surgery – Global Open: November 2018 - Volume 6 - Issue 11 - p e2008
doi: 10.1097/GOX.0000000000002008
Ideas and Innovations
Spain

Summary: Reconstruction of total circumferential pharyngeal defects following caustic or stenosant lesions of the pharynx present major challenges with respect to minimizing surgical morbidity and restoring functional deficits. With recent advances in microvascular free tissue transfer, the options for pharyngeal reconstruction have multiplied in order to maximize swallowing and voice. There is long experience in the reconstruction of the pharynx and the cervical esophagus in oncological patients after total pharyngolaryngectomy, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 new techniques for total circumferential pharyngeal reconstruction respecting swallowing and voice by means of extra-anatomical bypasses (visceral or fasciocutaneous), upholding the larynx in its original placement.

From the Department of Plastic and Reconstructive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Published online 19 November 2018.

Received for publication May 24, 2018; accepted September 18, 2018.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the Fundación para la Investigación Biomédica Hospital Gregorio Marañón.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Lasso JM, MD, PhD, Department of Plastic and Reconstructive Surgery, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain, E-mail: jmlasso@ucm.es

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

The reconstruction of total circumferential pharyngeal defects presents major challenges with respect to minimizing surgical morbidity and restoring functional deficits, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 ideas for total circumferential pharyngeal reconstruction by means of extra-anatomical bypasses.

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CASE 1

A 32-year-old female patient presenting with mental disorders had consumed a glass of bleach. Computed tomography (CT) scan showed the thickening of the esophageal, gastric, duodenal, and jejunal mucosa and active bleeding of the gastric antrum. Endoscopy showed epiglottitis, erythema from the esophagus to duodenum, hypopharyngeal synechiae, and retraction of the border of epiglottis. Urgent surgery consisted in a tracheostomy, gastrectomy, resection of thoracic esophagus, and esophageal stoma.

Two weeks after a circumferential hypopharyngectomy and a free tubular radialis flap was done. The larynx and trachea were left intact. The flap was anastomosed to the piriform sinus superiorly and coursed laterally in the right side of the neck. Its length was 20 cm. The distal end was sutured to the skin of the supraclavicular area. It served to avoid retraction of the radialis flap and collected saliva until the second surgical step was undertaken 2 months later (Fig. 1).

Fig. 1

Fig. 1

Isoperistaltic left transverse colon interposition on a left superior mesenteric artery pedicle was done via a retrosternal approach. The distal end of the radial flap was released and then anastomosed to the colonic flap (Fig. 2).

Fig. 2

Fig. 2

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CASE 2

A 46-year-old male patient complained of progressive dysphagia after a meal. During the gastroscopy, a foreign object was found and extracted with no apparent complications. Nonetheless, the patient continued to complain of the same symptoms. A CT scan was performed, showing gas and phlegmonous changes in the retropharyngeal region and the mediastinum. Esophageal perforation leaded to acute mediastinitis. The patient underwent resection of the perforated hypopharyngeal segment, and terminal esophagostomy, jejunostomy, and posterolateral thoracotomy were performed. Three months later, a cervical esophageal reconstruction with a jejunal free flap was done. The flap was anastomosed proximally to the oropharynx and distally to the esophagus. The patient’s hyoid bone was left in place upholding the larynx in its original placement to ensure that the tongue base and laryngeal elevation were normal, aryepiglottic and thyroepiglottic muscles pull down the epiglottis (Fig. 3). The course of the jejunal segment was lateral to the larynx and parallel to the remaining cervical pharynx like in first case (Fig. 4).

Fig. 3

Fig. 3

Fig. 4

Fig. 4

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RESULTS

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].

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DISCUSSION

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.

Most isolated pharyngeal injuries are iatrogenic,10 related to malposition of a nasogastric tube, endoscopy, or endotracheal intubation. According to this, the second patient presented a less extensive esophageal defect but had related complications. A free jejunal flap was chosen for reconstruction as it has excellent wound healing properties and is associated with a low fistula rate. Postoperative swallowing function is better because the lubricated surface permits the smooth passage of food.11–13 Free jejunal transfer is a reliable option that depends on the security of the microanastomoses. In the second case, the damage mechanism did not involve the neck vascularization.

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.

Reconstruction of pharyngeal defects with free flaps17 is considered the first choice in oncological patients even if laryngeal preservation is performed.14 , 16 Moerman et al.18 , 19 published a case of circumferential esophageal reconstruction with a mobilized colon, sutured behind the arytenoids, and on the prevertebral fascia, preserving the larynx. He stated that it may be better to perform a total laryngopharyngectomy and colon interposition in cases where the pharyngeal remnant is borderline for primary closure.

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CONCLUSIONS

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.

Video

Video

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ACKNOWLEDGMENTS

In memory of Dr Rosado.

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REFERENCES

1. Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. Am J Gastroenterol. 1992;87:1–5.
2. Cattan P, Munoz-Bongrand N, Berney T, et al. Extensive abdominal surgery after caustic ingestion. Ann Surg. 2000;231:519–523.
3. Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol. 2013;19:3918–3930.
4. Chirica M, Brette MD, Faron M, et al. Upper digestive tract reconstruction for caustic injuries. Ann Surg. 2015;261:894–901.
5. Wu MH, Lai WW, Lin MY, et al. Prevention and management of strictures after hypopharyngocolostomy or esophagocolostomy. Ann Thorac Surg. 1994;58:108–111.
6. Cherki S, Mabrut JY, Adham M, et al. [Reinterventions for complication and defect of coloesophagoplasty]. Ann Chir. 2005;130:242–248.
7. Amin AA, Bassiouny M, Elsebai H, et al. Fasciocutaneous free flaps for hypopharyngeal reconstruction. J Reconstr Microsurg. 2002;18:1–5.
8. Disa JJ, Pusic AL, Hidalgo DA, et al. Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast Reconstr Surg. 2003;111:652–660; discussion 661.
9. Harii K, Ebihara S, Ono I, et al. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg. 1985;75:463–476.
10. Zenga J, Kreisel D, Kushnir VM, et al. Management of cervical esophageal and hypopharyngeal perforations. Am J Otolaryngol. 2015;36:678–685.
11. Okazaki M, Asato H, Sarukawa S, et al. Ninety-degree transposed free jejunal patch transfer for hypopharyngeal reconstruction following partial hypopharyngectomy. Plast Reconstr Surg. 2008;122:143e–144e.
12. Miyamoto S, Sakuraba M, Nagamatsu S. Reconstruction after partial hypopharyngectomy with larynx preservation. Plast Reconstr Surg. 2011;128:327–328; author reply 328.
13. Germain MA, Demers G, Launois B, et al. [Salvage esophagoplasty using free jejunal transplant after repeated failure of other esophagoplasties. 25 cases]. Chirurgie. 1993;119:672–680; discussion 680.
14. Sumer BD, Gastman BR, Nussenbaum B, et al. Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation. Arch Otolaryngol Head Neck Surg. 2009;135:801–806.
15. Calteux N, Hamoir M, de Coninck A. Tumor of the hypopharynx: free jejunal transfer with conservation of the larynx: a case report. J Reconstr Microsurg. 1986;2:153–157.
16. Tong J, Xuezhong L, Dapeng L, et al. Preservation of laryngeal function improves outcomes of patients with hypopharyngeal carcinoma. Eur Arch Otorhinolaryngol. 2015; 272:1785–1791. DOI 10.1007/s00405-014-3115-3122.
17. Disa JJ, Cordeiro PG. Reconstruction of the hypopharynx and cervical esophagus. Clin Plast Surg. 2001;28:349–360.
18. Moerman MB, Bouche KG, Branquaer X, et al. Colon interposition in a patient with total postcricoid stenosis after caustic ingestion and preservation of full laryngeal function. Eur Arch Otorhinolaryngol. 2000;257:27–29.
19. Moerman M, Fahimi H, Ceelen W, et al. Functional outcome following colon interposition in total pharyngoesophagectomy with or without laryngectomy. Dysphagia. 2003;18:78–84.

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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.