Microvascular Free Transfer of A Compound Flap of Stomach and Omentum
When the omentum has been used and there is no other cutaneous cover, most surgeons will use an immediate skin graft, in contrast to leaving it exposed for 10 days, as the authors indicate.
The merit of this procedure is to allow a one-stage reconstruction that closes large pharyngoesophageal defects with particularly well vascularized tissue. Despite some difficulties, it is a safe and reliable procedure. Anastomoses are located away from the recipient site in the axillary area where vessels run deep, and the donor site has not been irradiated and is usually free of major atherosclerotic processes. Also, the reconstruction is functional. Obviously, the procedure should not replace well-known simpler methods (local skin flaps, distant cutaneous or musculocutaneous flaps) that are recommended whenever possible. Furthermore, free flaps to the oral cavity, even with moderately irradiated tissues and vessels (3), have their own indications, as do free transfers of gastrointestinal tissue of other types, such as jejunum (4, 5, 6, 7) (see Chapter 225), sigmoid (8, 9, 10, 11, 12), and gastric antrum (13).
The compound stomach-omentum flap should be selectively used with the following indications: for closure of inveterate pharyngostoma in heavily irradiated tissue, most likely after several unsuccessful previous attempts at closure by other methods; for closure of long-standing partial or subtotal defects of the cervical esophagus under unfavorable local conditions; and for primary reconstruction of large defects of the pharyngeal wall.
The portion of stomach included in the transfer has an excellent blood supply and provides an especially good solution for reconstruction of any partial and subtotal defect of pharyngeal or esophageal wall. The greater omentum, thanks to its own rich blood supply, also is known for its properties of defense against infection, its ability to participate in biologic debridement, its potential for adapting its shape to any anatomic contour, and its ability to granulate, thus offering an excellent bed for skin grafting. Apart from general contraindications, such as diabetes, severe atherosclerosis, malnutrition, and anemia, this procedure is also not feasible in patients who have had past gastric surgery such as gastrectomy or gastrostomy.
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