Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

Deng, Lifei; Li, Yan; Li, Weixiong; Liu, Muyuan; Xu, Shaowei; Peng, Hanwei

doi:10.1016/j.bjorl.2020.05.009

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Brazilian Journal of Otorhinolaryngology

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Brasil

Español English

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Sumário

Original article • Braz. j. otorhinolaryngol. 88 (01) • 2022 • https://doi.org/10.1016/j.bjorl.2020.05.009 copy

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear.

Objective

This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review.

Methods

Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed.

Results

All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months.

Conclusion

The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

Keywords
Esophagectomy; Anastomotic leakage; Reconstruction; Pectoralis muscle; Myocutaneous flap

Case no.	Age	Sex	Subsite	Stage	Comorbidities	Main techniques used in esophagectomy	The time fistula occurred	Repair time (months)	Followup time (month)	Result
1	47	Male	MTE	T3N1M0	None	Left thoracotomy, two-field lymphadenectomy, hand-sewn anastomosis, posterior mediastinal route	Severe anastomotic site bleeding 8 h postoperatively, fistula in 2nd postoperative day	3	27	Postoperative radiation performed, survive, normal oral intake
2	68	Male	MTE	T2N0M0	HT, HL	Right thoracotomy, three-field lymphadenectomy, mechanic anastomosis, retrosternal route	2nd POD	3	25	Survive, oral intake, tolerate soft diet
3	56	Male	MTE	T2N0M0	None	Right thoracoscopy, three-field lymphadenectomy, mechanic anastomosis, posterior mediastinal route, endoscopic	5th POD	8	53	Survive, normal oral intake
4	51	Female	UTE	T1N0M0	HL	Left thoracotomy, hand-sewn anastomosis, posterior mediastinal route	3rd POD	2	42	Survive with normal oral intake
5	60	Male	MTE	T2N0M0	HT, DM	Right thoracoscopy, two-field lymphadenectomy, mechanic anastomosis, posterior mediastinal route	2nd POD	3	15	Normal oral intake, died in 15 months after operation due to tumor recurrence
6	49	Female	MTE	T2N0M0	None	Left thoracotomy, two-filed lymphadenectomy, hand-sewn anastomosis, posterior mediastinal route	3rd POD	3	34	Survive, normal oral intake

Year	Author	Type of flap	Summary of the involved cases	Outcome
1998	Heitmiller, RF²⁴24 Heitmiller RF, McQuone SJ, Eisele DW. The utility of the pectoralis myocutaneous flap in the management of select cervical esophageal anastomotic complications. J Thorac Cardiovasc Surg. 1998;115:1250-4.	PMF	Cervical anastomotic stricture (n = 2), anastomotic leakage (n = 1)	Small leakage (n = 2), seroma in the donor site (n = 1); all healed with good function outcome
1998	Williums, JK²³23 Williams JK, Wood RJ, Hawes A, Mansour KA. The use of the pectoralis myocutaneous flap for repair of a retrosternal esophagocolonic anastomotic leak. Plast Reconstr Surg. 1998;101:802-5.	PMF	Retrosternal esophago-colol anastomotic leakage (n = 1)	Healed with good function outcome
2006	Hirao, M²²22 Hirao M, Yoshitatsu S, Tsujinaka T, Nishiyama A, Fujitani K, Nakamori S, et al. Pectoralis myocutaneous flap with T-tube drainage for cervical anastomotic leakage after salvage operation. Esophagus. 2006;3:33-6.	PMF with T-tube drainage	Cervical esophageal anastomosis after esophagectomy for cancer using a jejunum interposition (n = 1)	Healed with good function outcome
2010	Morita, M²¹21 Morita M, Ikeda K, Sugiyama M, Saeki H, Egashira A, Yoshinaga K, et al. Repair using the pectoralis major muscle flap for anastomotic leakage after esophageal reconstruction via the subcutaneous route. Surgery. 2010;147:212-8.	PMF	Anastomotic leakage after esophageal reconstruction via the subcutaneous route (n = 6)	Primarily healed (n = 5), leakage recurrence and healed after conservative wound care (n = 1)
2014	Nakajima, M²⁰20 Nakajima M, Satomura H, Takahashi M, Muroi H, Kuwano H, Kato H. Effectiveness of sternocleidomastoid flap repair for cervical anastomotic leakage after esophageal reconstruction. Dig Surg. 2014;31:306-11.	Sternocleidomastoid muscle flap	Cervical anastomotic leakage after esophagectomy for esophageal cancer (n = 8)	Healed with good function result
2015	Yin, K¹⁹19 Yin K, Xu H, Cooke DT, Pu LL. Successful management of oesophageal conduit necrosis by a single-stage reconstruction with the pedicled pectoralis major myocutaneous flap. Interact Cardiovasc Thorac Surg. 2015;21:124-6.	PMF	Colon conduit necrosis and cervical-oesophageal discontinuity (n = 1)	Healed with good function result

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.