Microvascular Free Transfer of Intestine
R. S. STAHL
M. J. JURKIEWICZ
The aggressiveness of pharyngoesophageal malignancies and strictures makes unencumbered wide resection and effective palliation essential goals in their treatment. It is applications such as these for which microvascular free transfers of intestine are well suited (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16).
Because of poor survival rates of patients with pharyngoesophageal malignancies, the optimal reconstructive procedure would have one stage, a low complication rate, and a brief hospitalization and would allow an adequate resection of the neoplasm with an acceptable operative mortality. The need for obligate stoma formation should be eliminated. Not only should airway patency be preserved and deglutition be restored early, but these functions would hopefully be retained as long as possible with recurrent disease. Donor tissue should be from beyond the field of preoperative radiotherapy and relatively resistant to harm from postoperative irradiation. Reconstruction would be facilitated by mucosa-bearing tissue and as little violation of body cavities as possible.
Multiple other methods of pharyngoesophageal reconstruction exist, each having its own merits. Disadvantages of these techniques variably include the need for multiple stages and prolonged recuperation, limitations by extent of neck dissection or perioperative radiation, fistula formation, pharyngostomes, stricture formation, multiple gastrointestinal suture lines, violation of multiple body cavities, and the requirement of advanced or highly specialized surgical techniques.
FLAP DESIGN AND DIMENSIONS
While approximation of resection margins is usually possible in the hypopharynx and upper esophagus, excessive tension all too often results in stricture, fistula, or limitation of tongue mobility. Local mucosal flaps are often satisfactory for small or less than circumferential defects. Regional unipedicled cervical flaps (17) provide a logical, regional, albeit multistage, means of reconstruction. The Wookey flap (18) is also limited by the extent of previous neck dissection and radiation and requires the presence of a pharyngostome and an esophagostome.
The medially based deltopectoral flaps (19) employ tissue with a known arterial supply from beyond irradiated or dissected cervical tissue to restore upper aerodigestive continuity. This procedure also requires the interim use of stomata and typically requires two or more stages. Reversed split-thickness skin grafts supported by tantalum or steel mesh (20, 21) have been used, but they frequently result in stricture formation or mesh migration and erosion.
In the fortuitous event that the anterior upper half of the trachea and larynx is spared from tumor, this tissue may be used to reconstitute the anterior esophageal wall (22, 23). It has been noted that split-thickness skin grafts may be used for recreation of the posterior pharyngeal wall if necessary. While providing a conservative means of reconstructing the hypopharynx in a single-stage procedure, this technique is limited by the restrictions it places on margins of resection, as well as postoperative stricture formation.