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Oga Y, Okumura T, Miwa T, Numata Y, Matsumoto S, Kaneda K, Kimura N, Fukasawa M, Nagamori M, Mori K, Takeda N, Yagi K, Ito M, Nagaoka Y, Takeshita C, Watanabe T, Hirano K, Igarashi T, Tanaka H, Hashimoto I, Shibuya K, Hojo S, Yoshioka I, Abe H, Satake T, Fujii T. Repair using the pectoralis major musculocutaneous flap for refractory anastomotic leakage after total esophagectomy. Surg Case Rep 2023; 9:88. [PMID: 37212955 DOI: 10.1186/s40792-023-01659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/06/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF. CASE PRESENTATION A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up. CONCLUSIONS The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.
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Affiliation(s)
- Yoko Oga
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Tomoyuki Okumura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan.
| | - Takeshi Miwa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Yoshihisa Numata
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Shigeki Matsumoto
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Koji Kaneda
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Nana Kimura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Mina Fukasawa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Masakazu Nagamori
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Kosuke Mori
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Naoya Takeda
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Kenta Yagi
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Miki Ito
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Yasuhiro Nagaoka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Chitaru Takeshita
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Katsuhisa Hirano
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Takamichi Igarashi
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Haruyoshi Tanaka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Isaya Hashimoto
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Shozo Hojo
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
| | - Hideharu Abe
- Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Toshihiko Satake
- Department of Plastic, Reconstructive and Aesthetic Surgery, Toyama University Hospital, Toyama City, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama City, 930-0194, Japan
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Deng L, Li Y, Li W, Liu M, Xu S, Peng H. Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap. Braz J Otorhinolaryngol 2022; 88:53-62. [PMID: 32600962 PMCID: PMC9422472 DOI: 10.1016/j.bjorl.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/03/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. OBJECTIVE This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. METHODS Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. RESULTS All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months. CONCLUSION The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.
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Affiliation(s)
- Lifei Deng
- Cancer Hospital of Jiangxi Province, Department of Head and Neck Surgery, Nanchang, Jiangxi, China
| | - Yan Li
- Cancer Hospital of Shantou University Medical College, Department of Gynecology, Shantou, Guangdong, China
| | - Weixiong Li
- Chaozhou People's Hospital, Department of Head and Neck Surgery, Chaozhou, Guangdong, China
| | - Muyuan Liu
- Cancer Hospital of Shantou University Medical College, Department of Head and Neck Surgery, Shantou, Guangdong, China
| | - Shaowei Xu
- Cancer Hospital of Shantou University Medical College, Department of Head and Neck Surgery, Shantou, Guangdong, China
| | - Hanwei Peng
- Cancer Hospital of Shantou University Medical College, Department of Head and Neck Surgery, Shantou, Guangdong, China.
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