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Tubed Gastro-omental Free Flap for Pharyngoesophageal Reconstruction
Eric M. Genden, MD;
Matthew R. Kaufman, MD;
Brian Katz, MD;
Anthony Vine, MD;
Mark L. Urken, MD
Arch Otolaryngol Head Neck Surg. 2001;127:847-853.
ABSTRACT
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Background Malignant lesions of the pharyngoesophagus often require total laryngopharyngectomy
and mediastinal dissection. As a result of the current treatment paradigms
for advanced laryngopharyngeal cancers, it is common that the surgical field
has been previously irradiated or exposed to systemic chemotherapy, resulting
in fistula rates as high as 78% and mortality as high as 8%. The free vascularized
tubed gastric antrum and the accompanying greater omentum offer a single-staged
method of pharyngoesophageal reconstruction, with the added benefit of protection
of the great vessels, the tracheal stump, and the mediastinal contents in
a high-risk surgical field.
Objective To assess the gastro-omental free flap as a method of pharyngoesophageal
reconstruction in patients who have been previously treated with multimodality
therapy.
Methods Five consecutive cases of gastro-omental free flap reconstruction after
total laryngopharyngectomy were retrospectively reviewed. Each case was assessed
for intraoperative, perioperative, and postoperative complications at the
primary site of reconstruction and the donor site. Patients were also evaluated
for their ability to maintain an oral diet. Patients were followed up for
a minimum of 6 months after surgery.
Results Five patients aged 44 to 70 years (mean, 59 years) underwent gastro-omental
free flap reconstruction after total laryngopharyngectomy. Five patients had
received previous external beam irradiation, 2 had received systemic chemotherapy,
and 4 had undergone previous surgery. There were no fistulae or flap complications.
Three patients were successfully treated with esophageal dilation for strictures
sustained 2 to 5 months after surgery, and a third patient was successfully
treated with conservative management for a partial gastric outlet obstruction
sustained 2 months after surgery. One patient died 3 months after surgery
of distant metastatic disease. The remaining 4 patients currently tolerate
an oral diet.
Conclusion The tubed gastro-omental free flap offers a safe method of reconstructing
the pharyngoesophageal segment in a surgical field compromised by previous
multimodality therapy.
INTRODUCTION
RECONSTRUCTION of circumferential pharyngoesophageal (PE) defects has
historically represented one of the most challenging dilemmas for the head
and neck reconstructive surgeon. For many years, the inability to primarily
reestablish continuity of the cervical esophagus resulted in strategies involving
staged procedures and the need for a chronic pharyngocutaneous fistula, often
leading to infection and a poor functional outcome. Czerny,1
Mikulicz,2 and Trotter3
attempted early on to remedy this problem by using cervical skin flaps in
staged reconstruction. This approach, however, was unreliable and was commonly
associated with a high rate of morbidity as a result of flap necrosis, wound
breakdown, and mediastinal infection. Nearly half a century later, Wookey4 reintroduced this technique, redesigning the cervical
flaps with a more broad-based pedicle, which resulted in more reliable 2-staged
reconstruction. Although this was an improvement, more than 90% of patients
reconstructed in this manner sustained some form of postoperative complication
related to the reconstruction.5 Salivary contamination
of the mediastinum commonly led to disseminated infection and, occasionally,
fatal vascular erosion. The limitations associated with random pattern skin
flaps led to the application of the deltopectoral flap and, soon thereafter,
the pectoralis major myocutaneous flap.
The deltopectoral flap offered reconstructive surgeons a source of reliable,
well-vascularized tissue from a regional site, which was particularly useful
in irradiated patients. This technique was an improvement over previous reconstructive
efforts; however, the disadvantages of a staged procedure and the need to
create a pharyngostome resulted in an unacceptably high complication rate
and a prolonged course before instituting oral nutrition.5
The drive to primarily reconstruct the pharyngoesophagus influenced Withers
et al6 and Baek et al7
to report on the use of a tubed pectoralis major flap as a method of "immediate"
reconstruction of circumferential defects of the pharynx and cervical esophagus.
However, the bulky nature of the pectoralis flap prevented the comfortable
creation of a circumferential skin tube. As a result, most tube-shaped pectoralis
major PE reconstructions required formation of a controlled fistula, either
at the time of the primary reconstruction or as a result of a postoperative
wound dehiscence.
In an effort to address the problems associated with delayed reconstruction,
and the requirement for thin, pliable tissue, a variety of pedicled visceral
flaps were introduced.8-10
The theoretical advantages of the gastric pull-up include a single anastomosis
with less potential for anastomotic failure; a source of thin, pliable, nonirradiated
tissue; and the opportunity for single-staged reconstruction. However, these
advantages did not translate into an extremely safe and reliable method of
reconstruction. Surkin et al5 found that mortality
occurred at a rate of 15%, and 50% of patients sustained major abdominal,
medical, or thoracic complications; however, the gastric pull-up procedure
remains a vital part of the reconstructive surgeon's armamentarium for management
of esophageal defects that extend to the thoracic esophagus.
Although microvascular free tissue transfer has been widely applied
in contemporary head and neck reconstruction, its impact on primary reconstruction
of the pharyngoesophagus has been profound. The drive to circumvent staged
reconstructions and the morbidity associated with postoperative wound dehiscence
has led to widespread application of free tissue transfer for PE reconstruction.
A host of donor sites have been described for the reconstitution of circumferential
defects, including the free colon segment,11
the tubed cutaneous free flap,12 and the tubed
gastro-omental free flap.13 Colonic segments
have been used as free flaps based on the ileocolic, middle colic, and sigmoid
arteries. Although this donor site is no longer the primary choice for reconstruction
of the pharyngoesophagus, the mucosa-lined colon offers an inner lining similar
to the native pharynx.
Application of the free jejunal segment serves as a particularly interesting
landmark in head and neck reconstructive surgery. In 1959, Seidenberg et al14 reported the first case of immediate PE reconstruction
using a revascularized free jejunal segment. Although the patient survived
for only 5 days after surgery as a result of a cerebrovascular accident, the
accomplishment of Seidenberg et al marked the beginning of the current era
in microvascular reconstruction. The free jejunal segment provided an alternative
to the gastric pull-up; however, early in its application, ischemia and pharyngocutaneous
fistulae were not uncommon. Hypothermia, pharmacotherapy, and a variety of
harvesting techniques were reported in an effort to prevent distal necrosis
of the jejunal segment; however, the results have been variable.15-17
As alluded to earlier, flap necrosis, and the resulting pharyngocutaneous
fistulae, is a particular problem in PE segment reconstruction because of
the risk associated with the adjacent great vessels and the potential access
of secretions to the mediastinum. Shangold et al18
reported a meta-analysis of 633 cases of free jejunal transfer in which salivary
fistulae occurred in 18% of cases. Two thirds of the fistulae healed with
conservative management; however, the perioperative mortality in this review
was 4.4%. Although the jejunal segment offers an excellent source of vascularized
tissue for PE segment reconstruction, the risk of salivary fistulae and the
attendant morbidity remains a significant concern, particularly in the patient
who has been previously exposed to radiation and chemotherapy.
Harii et al19 were the first to report
their success using the tube-shaped cutaneous radial forearm flap for PE reconstruction,
which offered an attractive alternative to the necessity for a laparotomy
and the attendant morbidity to harvest a visceral flap. Several different
cutaneous flaps have since been applied in a similar manner, including the
lateral thigh20 and ulnar forearm flaps.21 Tube-shaped cutaneous free flaps offer a source of
thin and pliable tissue. In many ways this is ideal for the primary reconstruction
of PE defects limited to the neck. Although uncommon in patients with hypopharyngeal
cancer, obesity might play a role in the decision-making process. On rare
occasions, cutaneous free flaps might be too thick to create a tube, and,
therefore, visceral flaps represent the most suitable reconstructive alternative.
Although complication rates associated with PE reconstruction have significantly
improved since implementation of free tissue transfer, postoperative salivary
fistulae remain common, particularly in patients who have received preoperative
radiation, chemotherapy, or both.22 The adverse
effects of radiation and chemotherapy on wound healing have been well documented
and often complicate salvage surgery and reconstruction.23
Patients who present with extensive disease of the hypopharynx often require
bilateral neck dissections and a mediastinal dissection. Salivary contamination
of the mediastinum, as a result of an anastomotic dehiscence, particularly
in a patient who previously received radiation or chemotherapy, commonly leads
to prolonged hospitalization and the potential for a fatal complication. Consequently,
dermal grafts, muscle flaps, and staged reconstructions, have been used to
prevent such complications; however, most surgeons have achieved only marginal
success using these techniques.
The gastro-omental free flap is a composite flap consisting of a segment
of tubed gastric antrum in continuity with the greater omentum. First described
by Baudet24 in 1979, the gastro-omental free
flap was originally reported as a method for secondary closure of a pharyngostome.
Subsequently, it has been applied to PE reconstruction.25
The gastro-omental free flap offers several advantages over jejunal or fasciocutaneous
free flap methods of reconstruction. In particular, the richly vascularized
omentum, which has been considered the "policeman of the abdomen" for its
unique ability to protect against the spread of intra-abdominal infection,
can be used to cover and protect the mediastinum and great vessels from salivary
contamination in the event of a salivary or tracheal fistula. We present a
retrospective review of 5 consecutive cases of tubed gastro-omental free flap
reconstruction after total laryngopharyngectomy in patients with previous
external beam irradiation, chemotherapy, or both.
PATIENTS AND METHODS
A retrospective review was performed of 5 consecutive patients undergoing
tubed gastro-omental free flap reconstruction of 5 total laryngopharyngectomy
defects between May 1997, and November 1999. Patients were evaluated for intraoperative,
perioperative, and postoperative recipient site and donor site complications
and postoperative diet.
Five patients (3 men and 2 women) aged 44 to 70 years (mean, 59 years)
underwent PE reconstruction with a tubed gastro-omental free flap after total
laryngopharyngectomy (Table 1).
All of the patients had locally advanced cancer of the pharyngoesophagus.
Four patients had bilateral neck dissections. Two patients had mediastinal
dissections performed in conjunction with manubrial and bilateral clavicular
head resection. Diagnoses included squamous cell carcinoma of the larynx (n
= 3), fibrosarcoma invading the trachea and larynx (n = 1), and liposarcoma
involving the visceral compartment (n = 1). All 5 patients were treated with
preoperative external beam radiation, and 2 patients received preoperative
concomitant systemic chemotherapy (Table
1). Four patients had undergone previous surgery at the primary
site.
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Pharyngoesophageal Reconstruction With a Gastro-omental Free Flap*
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In all cases, the gastro-omental free flaps were harvested using a 2-team
approach. The general surgery team performed a laparotomy incision and isolation
of the gastric antrum and its accompanying omentum. The dominant vascular
supply to the greater curvature of the stomach is the right and left gastroepiploic
artery and vein. The right gastroepiploic artery is derived from the gastroduodenal
artery, and the left gastroepiploic artery is derived from the splenic artery.
Although both arteries give rise to a series of corporeal branches that supply
the stomach and omentum, the right gastroepiploic artery is usually dominant
and, therefore, used for the microvascular anastomosis. Once the appropriate
segment of gastric antrum was isolated, a stapling device was used to harvest
the free flap. It is imperative not to harvest gastric mucosa in the area
of the pylorus to avoid gastric outlet obstruction. A longer pedicle might
be obtained by more proximal dissection and by harvesting the mucosal flap
at a greater distance from the pylorus. Once the mucosal flap is harvested,
the laparotomy incision is closed by the general surgery team while the gastroepiploic
vessels are isolated and prepared on a separate table.
RESULTS
All 5 patients had unremarkable intraoperative courses. A 2-team approach
was used in all cases to perform the surgical extirpation while simultaneously
harvesting the tubed gastro-omental free flap. There were no perioperative
complications, including wound infection, pharyngocutaneous fistulae, flap
necrosis, or microvascular anastomosis complications. In all cases, a segment
of the omentum was exteriorized for monitoring and was eventually excised.
After surgery, 3 patients required esophageal dilation for strictures that
developed 2 to 5 months after surgery at the distal anastomosis. One patient
was treated conservatively for a partial gastric outlet obstruction that manifest
2 months after surgery. Currently, 4 patients tolerate an unrestricted oral
diet, and 1 patient has died of distant metastatic disease. The following
case presentation illustrates the value of the greater omentum as a protective
barrier for vital structures in the neck and mediastinum.
A 70-year-old man with a history of a T3 N0 M0 squamous cell carcinoma
of the supraglottic larynx was initially diagnosed and treated with primary
external beam radiation. After radiation therapy, persistent disease necessitated
total laryngectomy. Eleven months after surgery, the patient presented to
The Mount Sinai Medical Center, New York, NY, with a stomal recurrence and
was treated with cervical pharyngoesophagectomy, stomal resection including
4 cm of the trachea, bilateral clavicular head and partial sternal resection,
and resection of peristomal skin (Figure 1). Mediastinal dissection was also performed in conjunction with
left radical and right modified neck dissection (Figure 2). After the distal margins were determined to be free of
disease on frozen section, a gastro-omental composite free flap was harvested
through a midline laparotomy incision.
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Figure 1. Specimen after resection of stomal
recurrence in conjunction with mediastinal dissection, bilateral clavicular
head resection, and partial sternal resection.
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Figure 2. Postablative surgical field demonstrating
exposure of the carotid arteries and mediastinum.
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The pharyngoesophagus was reconstructed using tubed gastro-omental mucosa
harvested with a tissue stapling device. The omentum was draped over the great
vessels, around the tracheal stump and the enteric anastomoses (Figure 3). The peristomal cutaneous defect and the distal tracheal
remnant were reconstructed using a fenestrated pectoralis myocutaneous flap.
After surgery, the distal aspect of the pectoralis flap sustained necrosis
that required intraoperative debridement (Figure 4). The underlying great vessels and the tracheal remnant
were protected by the greater omentum, which had contracted around the underlying
structures, keeping them from exposure. During the following several weeks,
wet to dry dressings were applied to the exposed omentum as it contracted
around the tracheal stoma (Figure 5).
On postoperative day 14, the patient was discharged from the hospital with
an oral diet (Figure 6).
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Figure 3. The greater omentum is draped
over the carotid arteries and around the tracheal stump. The greater curvature
of the stomach is used to reconstruct the pharyngoesophagus.
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Figure 4. Necrosis of the distal aspect
of the fenestrated pectoralis myocutaneous flap. After debridement of the
distal portion of the pectoralis flap, the underlying greater omentum prevented
great vessel exposure and stomal breakdown.
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Figure 5. Contraction of the peristomal
tissues and the greater omentum 4 weeks after surgery.
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Figure 6. Barium swallow on postoperative
day 14 depicting a patent pharyngoesophageal segment.
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COMMENT
Carcinoma of the hypopharynx is characteristically aggressive and often
extensive at the time of diagnosis.26 Hypopharyngeal
carcinoma notoriously spreads submucosally to adjacent structures commonly
involving the medial wall of the piriform sinus, the aryepiglottic fold, or
the glottic larynx at the time of diagnosis.26-27
The rich lymphatic and vascular supply within this region of the aerodigestive
tract accounts for the high rates of local spread early in the disease process.
At the time of diagnosis, 60% to 75% of patients have detectable metastatic
disease in the middle and lower jugular chains and occult metastases in the
paratracheal and retropharyngeal lymph nodes.28-29
Surgical treatment of hypopharyngeal carcinoma has evolved considerably
during the past 40 years. In the early 1960s, surgery was the primary modality
of therapy. With the introduction of regional flaps and the colonic interposition,
surgical therapy was more widely applied in the late 1960s and 1970s, using
radiation therapy as an adjuvant modality. Poor long-term results led Biller
et al,30 Ogura and Mallen31
and Ogura et al32 to consider preoperative
irradiation at 2000 to 4500 rad (20-45 Gy) followed by surgical therapy. This
treatment strategy became the standard of care in the early 1970s. However,
by the mid-1970s, unacceptably high morbidity and mortality rates as a result
of wound breakdown, mediastinitis, and a negligible improvement in disease
control prompted several prospective studies33-34
evaluating the role of surgery and preoperative irradiation. The failure to
achieve a therapeutic advantage with these treatment strategies, coupled with
the introduction of microvascular free tissue transfer for head and neck reconstruction,
led to the introduction of wide-field resection and primary reconstruction,
followed by postoperative radiation therapy.34
Early studies35-36 demonstrated
that the combination of surgery followed by postoperative irradiation did
not improve the 5-year survival rate; however, it did affect the pattern of
recurrence, increasing the rate of distant metastatic disease. Consequently,
preoperative chemotherapy has been more commonly instituted in an effort to
reduce the rate of distant metastatic disease.
Currently, organ preservation protocols are commonly applied to the
treatment of hypopharyngeal carcinoma and extensive stomal recurrence. As
a result, patients commonly are primarily treated with chemotherapy and radiation,
with surgical therapy reserved for salvage. Although a definitive improvement
in disease-free survival has not yet been established, it is clear that this
form of nonsurgical therapy results in a compromise in wound healing.23 Despite the advantage of transferring vascularized
tissue into a compromised recipient bed, fistula rates, wound breakdown, and
peristomal dehiscence after microvascular reconstruction of the pharyngoesophagus
remain unacceptably high.37 Similarly, surgery
for stomal recurrence represents a difficult reconstructive dilemma, particularly
in a patient who has been previously exposed to radiation, chemotherapy, or
both. Wound breakdown in this area after ablative surgery can lead to disastrous
consequences.
For more than half a century, surgeons have used the gastric mucosa
for PE reconstruction as either a reversed gastric tube or a gastric pull-up.
In 1961, Hiebert and Cummings38 were the first
to successfully transfer a segment of gastric antrum for primary cervical
esophageal reconstruction. Although this method of reconstruction did not
include the gastric omentum, in 1979 Baudet24
recognized the utility of the omentum and transferred a composite gastro-omental
flap for the secondary closure of a pharyngostome. The greater omentum has
intrigued physicians for centuries. Referred to as the "abdominal policeman"
because of its superb defense against abdominal infection and its unique absorptive
capabilities, omental flaps were initially used for repairing intraperitoneal
defects and chest wall defects, reconstructing pelvic fistulae, and reinforcing
the aortic graft.39 The rich vascularity and
pliability of the omentum allows for contouring and minimal scar formation.
Microvascular transfer of the greater omentum was first achieved in a clinical
setting by McLean and Buncke40 for reconstruction
of a scalp defect after tumor resection. Baudet's application of the combined
gastro-omental patch graft for PE reconstruction shortly thereafter provided
a composite flap consisting of mucosa for esophageal lining and a vascularized
omental graft that could be used to protect the surrounding great vessels
and the tracheal stump from the potential risk of salivary contamination. Since Baudet's original description of the gastro-omental free flap, which
was used as a patch graft, there have been few studies41-42
related to use of this donor site for PE reconstruction.
In our series of 5 patients with PE defects who underwent reconstruction
with a tubed gastro-omental free flap, all 5 had failed previous multimodality
therapy. To guard against the associated risk of fistula formation and great
vessel exposure, the omentum was used as a protective wrap, draped over the
great vessels and around the tracheal stump. The vascular nature of the omentum
provided an adequate bed for placement of a split-thickness skin graft, providing
a protective barrier around the enteric anastomosis and vital structures in
the neck and mediastinum should a salivary fistula occur. Panje et al43 previously demonstrated that the omentum serves as
an excellent source of carotid coverage and that the omentum will often atrophy
by as much 50% of its original volume. We found that the omentum served an
important role in the reconstruction and the final clinical outcome. Protection
of the great vessels, the tracheal stump, and the mediastinum is particularly
important in a patient who has previously been exposed to multimodality therapy.
The greater omentum provides a protective barrier for the development of a
salivary fistula from the PE segment by wrapping the pharyngogastric and gastroesophageal
anastomoses. In addition, it can also provide a significant protective barrier
around the trachea from the seeding of the neck and mediastinum with tracheal
secretions, especially in the case of a short tracheal stump. The thinness,
maneuverability, and vascularity of the greater omentum are the key features
that distinguish this tissue and provide for a greater protective capability
than any other tissue currently available. Although muscle is often useful
for this purpose, it lacks the pliability characteristic of the greater omentum.
It is clearly the key element of this composite flap, which we believe distinguishes
it from other visceral flaps such as the free jejunum or tubed cutaneous flaps
and justifies performance of a laparotomy with its attendant morbidity.
In our series, there were no complications with regard to graft failure,
fistula formation, great vessel exposure, or stomal dehiscence despite the
compromised wound bed. Before surgery, 1 patient sustained a gastric outlet
obstruction as a result of harvesting a segment of stomach that was too close
to the pylorus in the harvest segment. Three patients sustained mild esophageal
stenoses at the junction of the inferior anastomosis; however, all 3 patients
responded to serial dilation, and 4 patients currently tolerate an unrestricted
oral diet. We have since modified the distal anastomosis by opening a larger
component of the distal anastomotic border and "fish mouthing" the proximal
thoracic esophagus to increase the surface area of the esophagogastric repair.
The gastro-omental free flap can be harvested using a 2-team approach
without difficulty. Although the volume of omentum associated with the gastric
harvest varies in individuals,44 the rich vascular
network allows for trimming and tailoring of the omentum with minimal risk
of vascular compromise. The greater curvature of the stomach can be harvested
according to the length and width of tissue needed to achieve the PE reconstruction.
However, it is imperative not to narrow or alter the anatomical features of
the pylorus in the harvest because gastric outlet obstruction might occur.
We prefer to harvest the antrum using a stapling device, which provides a
mechanism to simultaneously prepare the gastric segment for transfer and achieve
closure of the remaining portion of the stomach. This harvest technique reduces
the surgical risk of intra-abdominal sepsis. It is imperative that the harvest
of the stomach not commence before the distal frozen section is obtained.
Oncologic clearance of the cancer in the neck is critical to document before
harvest of the greater curvature because gastric pull-up is eliminated as
a reconstructive option. Should replacement of the thoracic esophagus be required
after a free gastro-omental flap, use of the colon interposition would be
required.
There are several contraindications to using this donor site, including
previous gastric surgery and active peptic ulcer disease. Although only 1
patient in our series sustained a donor site complication, intra-abdominal
complications, such as peritonitis, gastric leak, intra-abdominal abscess,
and gastric outlet obstruction, are potential complications. In addition,
performance of a laparotomy results in more difficult recovery, with respiratory
complications more prevalent in the early postoperative period.
In conclusion, the tubed gastro-omental free flap offers a safe method
of reconstructing the pharyngoesophagus in a surgical field compromised by
previous chemotherapy, radiation, and previous surgery. The unique properties
of the omentum protect the great vessels, the tracheal stump, and the mediastinum,
transforming a surgical procedure with high morbidity and mortality rates
into a relatively safe procedure. Because of the inherent properties of the
greater omentum, this composite flap is our reconstructive method of choice,
especially when the dissection and impaired wound healing predispose to mediastinal
sepsis and disruption of the tracheocutaneous anastomosis in the creation
of a permanent laryngostome.
AUTHOR INFORMATION
Accepted for publication March 15, 2001.
Presented at the annual meeting of the American Head and Neck Society,
Fifth International Conference on Head and Neck Cancer, San Francisco, Calif,
July 30, 2000.
Corresponding author: Eric M. Genden, MD, Department of Otolaryngology–Head
and Neck Surgery, Box 1189, The Mount Sinai School of Medicine, One Gustave
L. Levy Place, New York, NY 10029.
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Genden, Kaufman, and Urken) and Surgery (Drs Katz and Vine), Mount Sinai
School of Medicine, New York, NY.
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