Repair using the pectoralis major musculocutaneous flap for refractory anastomotic leakage after total esophagectomy

Many risk factors are associated with AL after esophagectomy, such as radiotherapy, diabetes mellitus, body mass index, age, congestive heart failure, atherosclerosis, smoking, that all exhibit insufficient blood supply at the anastomotic site [5,6,7]. In the present case, although the patient has several AL risk factors, a total esophagectomy was performed as it was the only curative treatment against the carcinosarcoma.

Most post-esophagectomy AL is successfully treated by conservative treatments, such as wound debridement, irrigation, and drainage [3]. However, a small number of ALs develop RF, defined as a non-curative anastomotic site–cutaneous fistula existing for longer than 2 months under conservative treatment [5].

In the present case, after debridement, irrigation, and antibiotic administration, the inflammation of the wound gradually healed, accompanied by expansion of the anastomotic wound defect. It takes about 2 months for the wound to stabilize without further changes, resulting in salvage surgery performed at POD71 (65 days after the onset of AL).

Surgical repair for RF after esophagectomy requires sufficient debridement of surrounding tissues, dead cavity filling, and patches larger than the leakage to prevent re-leakage and/or stricture. Autogenous tissues are used for the surgical repair of intractable AL. The free gastrointestinal graft, such as free jejunal graft, is favored for head and neck reconstructions, as the risks of stenosis or fistula are lower. However, this requires microvascular anastomosis [4]. A free flap, such as the anterolateral thigh flap, secures sufficient tissue volume, but also requires microvascular anastomosis [4]. On the other hand, a pedicle flap such as the PMMF, provides sufficient tissue volume yet doesn’t require microvascular anastomosis. Thus, it is used in situations where the free graft is not ideal [4, 8]. The PMMF is a readily available source of vascularized tissue, easily harvested for use in the head and neck. Especially in cases with poor wound healing, such as irradiated patients and those with postoperative salivary contamination, as the vascularized soft tissue coverage of this muscle flap is effective in preserving the major vessels [9]. Consequently, the use of a pedicled flap is broadly accepted as a reconstruction option in head and neck surgery [10]. On the other hand, reconstruction using PMMF after esophageal surgery is uncommon, accounting about 1% of AL reconstructions [4].

To date, 20 cases in total are reported have undergone reconstruction using PMMF for AL after esophagectomy (Table 1). Most of them were performed for RFs of esophago-gastric or esophago-colon anastomosis, at an average 68.5 days after initial surgery [4, 5, 8, 11,12,13,14,15]. In RFs following AL of anastomoses reconstructed by the subcutaneous route, the leakage defect was primary closed and then the PMMF was covered as reinforcement of the closure with the skin surface facing outside [8, 15].

Table 1 Literature review of repair using PMMF for AL after esophagectomy

In RFs following retrosternal or posterior mediastinal reconstruction in which the defect was too large to primary close, PMMF was inserted to the defect with the skin side of the flap placed on the lumen side, avoiding both overextension and stenosis [11,12,13,14].

The skin directed toward the lumen was thought to prevent damage of the flap from exposure to digestive fluids, as well [11]. Re-leakage after repair was seen in some cases, but all have healed by conservative treatment, conceivably owing to the volume of the PMMF to fill the tissue defect [8, 11, 13, 14]. Reports have also shown that majority of the patients were able to start oral intake 10–15 days after PMMF repair, unless re-leakage was observed [8, 13, 15], providing us with a clinical indicator of when to start oral intake after surgery.

In the present case, the defect extended to 3/4 circumference of the anastomosis and was contaminated with digestive fluid, so primary closure was difficult. In addition, due to the previous reconstruction using a free jejunal graft and radiation therapy, as well as history of carotid artery occlusion, securing a recipient vascular bed for microvascular anastomosis was also considered difficult. Taken together, the PMMF was selected for reconstruction with the skin surface inward to successfully repair.

In post-irradiation cases such as the present case, considerable technical tips for designing the PMMF are to obtain a larger PMMF with sufficient thickness of fat tissue so that the gap could be filled after removal of scar tissue around the fistula, and to confirm the maintenance of blood flow at the margins with intraoperative blood flow visualization using ICG fluorescence.

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