Pectoralis major musculocutaneous flaps: long-term follow-up of hypopharyngeal reconstruction

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

CONCLUSION

Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology.

OBJECTIVES

A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications.

MATERIAL AND METHODS

A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation.

RESULTS

A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.

Squamous cell carcinoma of the oropharynx and hypopharynx

Oropharyngeal and hypopharyngeal squamous cell carcinomas require an interdisciplinary approach to manage patients appropriately. Tumor stage and histology, functional outcome, and patient comorbidities are important factors to consider. Various surgical approaches as well as chemotherapy and radiation therapy alone or in combination remain the mainstay of therapy.

Free jejunal graft for hypopharyngeal and esophageal reconstruction

AIMS

This study assessed the techniques of the free jejunal graft for the reconstruction of hypopharynx or cervical esophagus and discussed the main aspects related to those procedures.

METHODS AND RESULTS

By using free jejunal grafts, we reconstructed 54 hypopharyngeal and cervical esophageal cancers. In this study, 23 out of 54 patients had a malignant tumor located in the hypopharynx and 31 in the cervical esophagus (27 primary cases and four secondary cases). Despite the multi-step and time-consuming procedure, we did not incur any trans-operative complication. Furthermore, we undertook the larynx preserving cervical esophagectomy and free jejunal graft reconstruction in six patients with cervical esophageal cancer, and those patients acquired a good quality of life.

CONCLUSION

For the reconstruction of hypopharynx or cervical esophagus, the free jejunal graft is a very useful technique and improves the patient's quality of life.

Reconstrução total de faringe: análise de 69 casos

Os autores analisaram retrospectivamente as reconstruções após faringolaringectomias totais e faringolaringo-esofagectomias totais realizadas num período de 18 anos, com o objetivo de comparar os resultados imediatos e tardios das diversas técnicas empregadas. Foram revistos 69 casos submetidos a reconstruções totais de faringe realizadas no Hospital A.C.Camargo, de 1980 a 1997. Hipofaringe e laringe eram os locais da neoplasia em 57 pacientes (82,6%), o esôfago cervical, em sete (10,1 %), e outras localizações em cinco (7,2%). Em 62,4% dos casos, o tumor encontrava-se em estádio avançado, e em 18,8% os pacientes apresentavam recidivas de tumores previamente tratados. As cirurgias consistiram em faringolaringoesofagectomia total e transposição de tubo gástrico (gastric pull-up) em 14 pacientes (20,3%), e com interposição de cólon em cinco (7,3%); e de faringolaringectomia total com reconstrução a partir da rotação de retalho do músculo peitoral maior tubulizado em 16 pacientes (23,2%), com retalho do músculo peitoral maior suturado à fáscia pre-vertebralis em 29 (42,0%) e com outras reconstruções em cinco (7,2%). Das técnicas de reconstrução em faringolaringoesofagectomia, o gastric pull-up apresentou índices menores de complicações e mortalidade pós-operatória. Quando comparamos as reconstruções em faringolaringectomia total, os casos reconstruídos com retalho miocutâneo suturado à fáscia pre-vertebralis apresentaram índices menores de fístula e estenose. No entanto, essas diferenças não foram estatisticamente significativas. Diante destes resultados, nossa conduta em faringolaringectomias totais, quando não é possível a reconstrução da faringe com sutura primária, é realizar a rotação do retalho do músculo peitoral maior suturado à fáscia pre-vertebralis. Quando é necessária a faringolaringoesofagectomia, realizamos reconstrução com gastric pull-up.

One-stage reconstruction of partial laryngopharyngeal defects

Advanced-stage lesions of the hypopharynx or tongue base often involve the larynx. The difficulty of reconstructing large partial laryngopharyngeal defects can result in total laryngectomy being performed to avoid the assumed problems with aspiration. This article describes the first reported experience using the pectoralis musculocutaneous flap for primary one-stage reconstruction of laryngopharyngeal defects following resection of advanced-stage lesions, to reconstruct both the laryngeal and the pharyngeal components of the defect. In this group of 21 patients, there were 16 with hypopharyngeal and 5 with tongue base cancers. Two had received prior treatment, and all received some form of postoperative radiotherapy and/or chemotherapy. Six patients experienced complications, including two fistulae, three wound infections, two myocardial infarctions, and one colon perforation. There were no instances of stenosis of the reconstructed segment. The length of hospitalization ranged from 9 to 60 days, the average being 17 days. Forty-seven percent (21) of the patients were not tolerating an oral diet at the time of discharge. However, 15 patients (71%) ultimately were eating by mouth, with 13 (62%) achieving an oral intake of liquids and solids. This analysis supports the hypothesis that the pectoralis major musculocutaneous flap is an effective one-stage primary reconstruction technique for laryngopharyngeal defects in patients either who have received prior therapy or who will receive postoperative therapy.

Results of reconstruction with free forearm flap following laryngopharyngo-oesophageal resection

The main challenge after total laryngopharyngeal and cervical oesophageal resection for laryngopharyngeal carcinoma, is to provide a suitable feeding conduit which improves the quality of life for the patient. Réconstruction with a tubed free forearm flap can solve the feeding problem to some extent, providing a thin and pliable fasciocutaneous conduit that accommodates well with the thin mucosa of the pharynx and oesophagus. In this study immediate reconstruction of the pharyngo-oesophagus by free forearm flaps is reported in nine patients with advanced laryngopharyngeal and oropharyngeal carcinoma. The vascularization of the flap is very good, thus rendering this flap to be reliable. The average time for the commencement of oral feeding was 16 days. There was one flap failure (11 per cent), due to venous thrombosis which was replaced by a deltopectoral flap. Long term stenosis did not occur because of the two triangles created at the distal end of the flap which were inserted to the opposite triangular defects at the proximal oesophageal stump.

Reconstruction of the pharynx and cervical esophagus

The recent twenty years have brought major advances in reconstruction of pharyngoesophageal defects. Early dependence on multiple staged procedures initially were replaced by colon interposition and gastric pull-up. Subsequent elucidation of the musculocutaneous concept has added useful techniques such as the sternocleidomastoid and pectoralis major musculocutaneous flaps. Increasing experience with microsurgical reconstruction and a larger number of flaps available have made free tissue transfer a common and reliable method of reconstruction of significant defects. The choice of reconstruction depends to greatest degree on the oncologic needs of the situation. If the entire esophagus or significant part of the thoracic esophagus is involved by tumor then total esophagectomy and gastric pull-up or colon interposition is indicated. For most hypopharyngeal and laryngopharyngeal tumors, and a significant number of cervical esophageal tumors, segmental resection of the area with the appropriate node dissection and replacement with a jejunal free autograft or radial forearm free flap gives a high likelihood of success. Thoracic musculocutaneous flaps may be useful if proper precautions are observed in the reconstructive technique. This article presents the accumulated experience with these techniques and management of the subsequent problems.

Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck

The pectoralis major myocutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant donor site deformity, especially in women. This study compared 30 patients with major head and neck cancer-related defects who underwent reconstruction with a rectus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was significantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruction methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.

Swallowing function following hypopharyngeal reconstruction with the pectoralis major musculocutaneous flap

Swallowing function was studied in three patients following the pectoralis major musculocutaneous reconstruction of the hypopharynx and cervical esophagus after extensive resection for hypopharyngeal cancer. Fluoroscopy and endoscopy revealed the formation of a sphincter-like ring at the proximal end of the remaining intact esophagus. This ring may act to prevent reflux from the lower esophagus, although its sphincteric power is weak. Manometric testing showed that no swallowing pressure was produced in the reconstructed gullet; therefore, bolus propulsion at the pharyngeal stage occurs mainly by gravity. Follow-up studies on swallowing indicate a minimum length of the suture line of 11 cm in order to prevent esophageal stenosis due to anastomotic stricture at the distal mucocutaneous junction.

Microvascular flaps in head and neck reconstruction

Twenty-six patients with head and neck tumors were submitted to 27 microvascular reconstructive procedures. In 15, the mandible was reconstructed using the rib (4), iliac crest (7), and scapula (4). Nine patients underwent craniofacial reconstructions with the latissimus dorsi (5), rectus abdominis (2), greater omentum (2), and scapular (1) flaps. Two patients received a jejunum (1) and a stomach plus greater omentum (1) flaps for pharyngoesophageal reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 22 patients (85%), with both functional and morphological rehabilitation. There were five flap losses (two in the same patient) due to thrombosis of the microvascular anastomoses. There was no operative mortality, and the average operative time was 11 hours. The good results observed in these very advanced cases show that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.

Reconstruction of the pharynx after resection for cancer. A comparison of methods

Repair of the pharynx after extirpation of malignancy may require the introduction of independently vascularized tissue either at the time of resection (primary reconstruction) or later for undesirable sequelae, such as fistula or stenosis. A ten-year retrospective study compares two methods of pharyngeal reconstruction, the pectoralis major musculocutaneous flap (MCF) and the jejunal free autograft. One hundred and seventeen patients undergoing laryngopharyngectomy at Emory University affiliated hospitals between 1977 and 1987 were reconstructed with either the pectoralis major musculocutaneous flap (24 patients) or with the jejunal free autograft (93 patients) Primary repair with the pectoralis MCF was attempted on 12 patients (Group I) with initial success in 5 patients (42%), fistula in 7 patients (58%), and salvage surgery necessary in 6 patients (86%). Primary reconstruction with jejunal free autograft (Group II) was performed in 70 patients with 44 initial successes (63%), 9 graft failures (13%), 5 of which were salvaged by a second jejunal free autograft. Seventeen fistulas occurred (24%). Of these, nine (53%) closed with nonoperative therapy and five (29%) required surgery. Secondary reconstruction with the pectoralis major MCF was attempted in 12 patients with initial success in 3 patients (25%), and fistula in 9 patients (75%). Of these 9 fistula patients, 3 (33%) closed with nonoperative therapy and 6 required salvage surgery, which was successful in only 2 patients. Secondary repair with jejunal free autograft was performed in 23 patients with 13 (56%) initial successes and 8 patients resolving with nonoperative therapy (89%) for a total success rate of 21/23 or 91%. The higher initial success rates and more expeditious resolution of problems demonstrates that the jejunum is the superior method of reconstruction for the pharynx.