Moody Lisa, Hunter Cedric, Nazerali Rahim, Lee Gordon K
From the Stanford University Medical Center, Palo Alto, CA.
Ann Plast Surg. 2016 May;76 Suppl 3:S209-12. doi: 10.1097/SAP.0000000000000724.
Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.
A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.
Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.
Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.
对于重建整形外科医生而言，肿瘤切除或吞入性损伤后的食管重建是一个难题。游离带蒂筋膜皮瓣和肠瓣已成为重建的主要手段。游离空肠瓣具有替代同类组织且瘘发生率较低的优势。此外，已有人描述了“肠系膜包裹”改良术和预防性胸大肌的应用，以进一步降低吻合口漏和瘘的发生率。本研究的目的是描述预防性带蒂胸锁乳突肌（SCM）瓣在预防吻合口漏和瘘方面的应用。
对2008年至2012年由同一位外科医生用游离空肠瓣进行环周性咽食管缺损重建的患者进行回顾性研究。选择那些接受预防性带蒂SCM瓣以加强其一空肠吻合口的患者进行本研究，并分析其结果。收集并分析患者的人口统计学资料、合并症、并发症及临床结果。
3例患者用带蒂SCM瓣加强了一空肠吻合口。平均年龄为60岁，平均随访27个月。2例患者术后接受了放疗，1例患者术前和术后均接受了放疗。受区血管包括面动脉、颈内静脉和面静脉。皮瓣成活率为100%。在未用SCM肌加强的吻合口处发生了1例狭窄和1例瘘。用SCM肌加强的空肠吻合口部位未出现并发症。在3例患者的6个吻合口中，用SCM肌加强的部位瘘发生率为0%，狭窄发生率为0%，而未用SCM肌皮瓣的部位瘘发生率为33%，狭窄发生率为33%。1例患者被诊断为局部肿瘤复发，最终死于疾病进展。所有患者均能耐受经口饮食，无需补充喂养。所有患者均能通过电子喉或食管语音实现可理解的言语。
咽食管缺损的重建在技术上具有挑战性，需要进行广泛的规划和仔细的操作。游离空肠瓣可恢复消化道连续性，功能效果良好。使用预防性SCM瓣加强空肠吻合口可降低瘘发生率。
