Long-Term Outcomes of Simultaneous Skin and Bowel Flaps for Esophageal Reconstruction

Abstract

Esophageal reconstruction can be performed with skin or bowel flaps. The choice of flap remains controversial, as the long-term outcomes of skin flaps cannot always be assessed in patients with limited life expectancies due to advanced malignancy, unlike the pediatric and benign cases which have had esophageal reconstruction using bowel flaps. We report the long-term clinical and histopathological outcomes in a series of 45 cases repaired with combined skin and bowel flaps.Four patients developed symptomatic strictures after corrosive esophageal injuries were repaired with a combination of a tubed free radial forearm fasciocutaneous flap and a pedicled bowel flap. On average, 24 years had passed since uneventful initial esophageal reconstructions. Barium esophagograms were obtained in all cases and pathological examination was performed upon all surgical specimens.The cutaneous portions of the reconstructed esophagus exhibited a variety of findings on barium examination. Each of the 4 cases developed an esophagocutaneous fistula after revision; an average of 4 surgeries was required to close these fistulae. The inner surfaces of the portion of esophagus repaired with skin flaps showed extensive ulceration, polypoid lesions, and fibrosis. Pathology specimens from skin flaps showed extensive acute and chronic inflammation, microabscesses, fibrosis, and acanthosis, with depletion and degeneration of the pilosebaceous units. By contrast, adjacent parts of the esophagus repaired with bowel were widely patent with normal appearing mucosa.Our findings indicate that a bowel flap is durable with good tolerance to gastrointestinal content over long periods, whereas skin flaps often developed morphological changes and could not maintain long-term esophageal function without eventual stricture and dysphagia. We therefore recommend use of bowel flaps for esophageal reconstruction in patients with long life expectancy.

Early Markers of Angiogenesis and Ischemia during Bowel Conduit Neovascularization

“…Free tissue transfer based on bowel conduits for pharyngolaryngectomy reconstruction has been used for many years with very promising outcomes. 10,14,15,19 From the clinical standpoint and based on many years of clinical observation by the senior author, 3,5,8,11,12,18,19 the physiological response of some of these bowel conduits during ischemic events is different. The lack of serosa in the posterior aspect of the ileum and colon compared with an intact serosal layer throughout the circumference of the jejunum is a possible hypothesis for the difference in behavior of these conduits during a period of ischemic/reperfusion injury.…”

“…Reconstruction of the pharyngoesophageal tract with bowel flaps has been described as a good and reliable method to restore the continuity of the aerodigestive tract. [1][2][3][4][5] However, when clinical factors such as a radiated field, contaminated recipient site or depleted recipient vessels are encountered, an alternative surgical approach is necessary. With any ischemic insult, bowel mucosa becomes very sensitive to prolonged absence of vascular supply or congestion, leading to epithelial damage, bacteria translocation, and possible failure of the conduit.…”

Back‐up procedures following complicated gastric pull‐up procedure for esophageal reconstruction: Salvage with intestinal flaps

“…In contrast, intestinal flaps tolerate reflux well and have a low rate of peptic ulceration incidence . Recent data regarding follow‐up results in esophageal reconstruction, strongly suggest the superiority of intestinal flaps over the skin flaps, particularly in the long‐term follow‐up …”

How to ensure immediate and long-term good blood supply by the careful dissection of the marginal artery and supercharge with neck vessels in esophageal reconstruction with the colon segment interposition: 35 years of experience

“…Skin flaps lack motility and secretion properties; also the skin is not resistant to gastric juice, thus long-term exposure causes histopathological changes and eventually stricture formation. 6 Prior gastrectomy, esophagogastric junction tumors, or synchronous gastric diseases preclude the use of gastric pull-up; and hypopharyngeal or high cervical anastomosis of the stomach might be related to higher anastomotic complications (leakage and stricture formation) because of impaired blood supply and gastric acid reflux. 7 Colon flaps provide a long segment of conduit with reliable vascularity, and the mucosa is resistant to acidity.…”