Island pectoralis major myocutaneous

Island pectoralis major myocutaneous flap for pharyngo-oesophageal strictures prior to oesphagocoloplasty

Departments of Surgery and Cardiothoracic Surgery*, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry 605 006, India

Introduction

Methods

Discussion

References

Pharyngo-oesophageal strictures are not uncommon in corrosive injuries either alone or in association with dense strictures further down the oesophagus. Strictures at the pharyngo-oesophageal junction require preliminary correction prior to oesophageal bypass since surgical bypass to the pharynx above the cricopharyngeal junction is associated with risk of aspiration. A one stage island pectoralis major myocutaneous flap has been used in four patients who had a non-dilatable dense cricopharyngeal stricture leading to a segment of near normal oesophagus followed by dense stricturing of the thoracic oesophagus. This procedure was followed by oesphagocolic bypass at a second stage from the cervical oesophagus to the stomach. The preliminary pectoralis major flap correction avoids problems such as aspiration or choking associated with pharyngo-colic anastomosis for oesophageal bypass. All four patients had uncomplicated healing. Post-operative endoscopy showed easy passage through the cricopharynx with a dilated cervical oesophagus partly lined by skin. Normal swallowing was restored by a second stage oesphago-colic bypass 6 weeks after the pectoralis major flap repair in two patients while the other two are awaiting the second stage. Island pectoralis major myocutaneous flap is simple, has a dependable vascularity and offers one stage correction for isolated cricopharyngeal corrosive stricture. It can also be used prior to oesophagocolic bypass in patients who have further strictures in the thoracic oesophagus.

Key words: Corrosive injury, myocutaneous flap, oesophageal stricture, oesophago-coloplasty, pectoralis major

Corrosive injuries of the oesophagus usually produce dense and long strictures. However, it is not uncommon to find isolated single or multiple strictures separated by an apparently normal oesophagus. One site at which such a strictures occurs commonly is the pharyngo-oesophageal junction. This is due to corrosive induced spasm of the cricopharyngeal musculature resulting in prolonged contact of the toxic agent with the mucosa at this site. Cricopharyngeal stricture may be a solitary lesion. More often the cervical oesophagus distal to this is spared with dense stricturing of the thoracic oesophagus. Although dilatation is the primary modality of treatment for pharyngo-oesophageal stenosis, not infrequently there is rapid restenosis requiring surgical bypass. Any type of surgical bypass above the level of the cricopharyngeal junction leads to difficulties in swallowing with aspiration of food and choking. We report the correction of such cricopharyngeal strictures by an island pectoralis major myocutaneous flap (PMMC).

This procedure was used in four patients. A preliminary barium meal examination revealed obstruction at the cricopharyngeal region with a relatively normal cervical oesophagus and near total obstruction of the thoracic oesophagus. Impassable cricopharyngeal obstruction was confirmed by upper gastro-intestinal endoscopy. All three patients had failed to respond to repeated dilatations. The cricopharyngeal stricture, though dense, is usually a short segment stricture (Figure 1a). The stricture can be approached through a right sided neck incision along the anterior border of the sternomastoid. The pharyngo-oesophageal junction is exposed with the help of an indwelling nasogastric tube. The stricture is laid open along the right midlateral border with the incision extending 2 cm on either side to normal mucosa. The gap in the pharynx is closed with an island pectoralis major myocutaneous flap with the skin of the myocutaneous flap forming the lining of the oesophagus. The flap measures approximately 2-3 cm in width and 6-7 cm in length and is marked infero-medial to the nipple with the long axis of the overlying skin island being parallel to the direction of the muscle fibres (Figure 2). The donor site is closed primarily. The myocutaneous flap is turned on itself and is tunnelled subcutaneously to reach the gap in the pharynx with the skin island facing the pharynx. It is sutured in place with interrupted three ‘O’ polyglactin (vicryl) sutures with the knots lying in the lumen. This procedure corrects the pharyngo-oesophageal obstruction and permits an oesophageal bypass to be performed to the cervical oesophagus below the level of the PMMC flap as a second stage in those cases where further strictures are present in the thoracic oesophagus (Figure 1b). The second stage oesophagocolic bypass procedure can be done 4-6 weeks after the patch pharyngo-oesophagoplasty through a left-sided neck approach (Figure 1c). In patients who have an isolated crico-pharyngeal stricture, PMMC flap inlay by itself is curative.

This procedure has been done in four patients. The pectoralis major flap repair was followed 6 weeks later by oesophagocolic bypass in two patients. Both patients had uneventful healing. Swallowing was restored to normal without symptoms of aspiration. The other two patients are awaiting the second stage procedure.

Figure 1: (a) Oesophagogram showing cricopharyngeal stricture (upper arrow) and dense thoracic oesophageal stricture (lower arrow). (b) After the first stage - cricopharyngeal stricture corrected by PMMC flap (arrow). (c) After completion of second stage oesophago-coloplasty showing free flow of barium

Isolated strictures of the pharyngo-oesophageal junction have been corrected using free intestinal grafts,1 free forearm flaps2 or circular myotomies.3 The former two procedures require expertise in microsurgical techniques and the latter is uncertain in its effect. Island PMMC flap is a simple procedure, has a reliable vascular supply and offers a one-stage correction for isolated cricopharyngeal corrosive stricture. It can also be used prior to oesphago-colic bypass when there is distal impassable stricturing of the thoracic oesophagus. The main advantage of the procedure is that it avoids a pharyngocolic anastomosis above the level of the cricopharynx, which is invariably associated with choking and aspiration during deglutition. A preliminary PMMC opens access to the cervical. oesophagus, which is usually spared in corrosive ingestion, thus, permitting an oesophagocolic anastomosis.

Figure 2: (a-c) The pharyngo-oesophageal stricture being laid open before interposing a PMMC flap. The site of a second stage oesophago-coloplasty. (d&c) PMMC flap turned on itself to reach the pharynx

1. Isakov IUF, Stepanov EA, Razumovskii ALU, Romanov AV, Chernyshov AP, Bataev KHM. Plastic surgery of the pharynx and cervical oesophagus using a revascularised intestinal segment in children. Khirurgiia 1995; 4: 3-6
2. Hung-chi Chen, Yueh-bih Tang, Noordhoff MS. Patch oesphagoplasty with free forearm flap for focal stricture of the pharyngo-oesophageal junction and cervical oesophagus. Plast Reconstr Surg 1992; 90: 45-52
3. Izzidien AI, Samarrai AY. Circular myotomy for oesophageal stricture. J Pediatr Surg 1988; 23: 371-3

Copyright date: 23rd February 2001
Correspondence: Dr N Ananthakrishnan, Director-Professor and Head, Department of Surgery, JIPMER, Pondicherry-605006, India

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