Original Paper Received: May 17, 2014 Accepted after revision: September 2, 2014 Published online: November 5, 2014
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
Effectiveness of Sternocleidomastoid Flap Repair for Cervical Anastomotic Leakage after Esophageal Reconstruction Masanobu Nakajima a Hitoshi Satomura a Masakazu Takahashi a Hiroto Muroi a Hiroyuki Kuwano b Hiroyuki Kato a
a
Department of Surgery I, Dokkyo Medical University, Mibu, and b Department of General Surgical Science (Surgery I), Gunma University Graduate School of Medicine, Maebashi, Japan
Key Words Esophageal cancer · Anastomotic leakage · Esophagectomy · Sternocleidomastoid flap
Abstract Background/Aims: The purpose of this study was to investigate the effectiveness of sternocleidomastoid (SCM) flap repair for anastomotic leakage after esophagectomy. Methods: A refractory cutaneous fistula from the gastric stump developed in 8 patients with esophageal cancer who underwent esophagogastric anastomosis after esophagectomy. All patients underwent SCM flap repair. The cutaneous fistula was removed and resutured. The sternal head of the left SCM was dissected from the manubrium of the sternum and sutured onto the repaired gastric stump. Results: The operative duration was 80–220 min (median, 120 min). The amount of intraoperative bleeding ranged from 5 to 182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7–15 days (median, 10 days) after the repair operation without discomfort. Conclusions: SCM flap repair is an effective and minimally invasive treatment method for cervical anastomotic leakage after esophageal recon-
© 2014 S. Karger AG, Basel 0253–4886/14/0315–0306$39.50/0 E-Mail [email protected] www.karger.com/dsu
struction. This method may be considered in patients with refractory leakage of the gastric stump after staple anastomosis. © 2014 S. Karger AG, Basel
Introduction
Surgery for esophageal cancer is very time-consuming and complicated. The three most common thoracic esophagectomy techniques are the transhiatal approach, Ivor-Lewis esophagectomy (right thoracotomy and laparotomy) and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis) [1]. In all methods, the gastric conduit is typically utilized for reconstruction after esophagectomy [2]. In Japan, the extended transthoracic esophagectomy with 3-field (cervical, mediastinal and abdominal) lymphadenectomy using the McKeown technique has been performed for the past 3 decades [3]. As a result, leakage of the cervical esophagogastric anastomosis often occurs. Anastomotic leakage is one of the most frequent and troublesome postoperative complications after esophagectomy [4–7]. It may cause mediastinitis or pyothorax Masanobu Nakajima, MD, PhD Department of Surgery I Dokkyo Medical University 880 Kitakobayashi, Mibu, Shimotsuga-gun, Tochigi 321-0293 (Japan) E-Mail mnakajim @ dokkyomed.ac.jp
Color version available online
Fig. 1. Photographs of the repair operation using the SCM flap. a A variant T-shaped incision surrounding the cutaneous fistula is made. The left side of the incision is longer than the right to harvest the left SCM. b The area of leakage and left SCM are exposed. The cutaneous fistula and gastric stump are clamped with an intestinal forceps. c The gastric stump is repaired by hand sewing, and the sternal head of the left SCM is dissected from the manubrium of the sternum. d The SCM flap repair is completed. The resutured gastric stump is covered with the SCM flap, and a 10-Fr closed drain is inserted.
a
b
c
d
in the early postoperative period and prolong the hospital stay. Drainage and infection control are the first steps in the treatment of cervical anastomotic leakage. If the leakage continues after adequate conservative treatment, surgical repair is considered. In our institution, the sternocleidomastoid (SCM) muscle flap is used for the treatment of refractory fistulas after cervical anastomotic leakage. The present study was performed to investigate the effectiveness of the SCM flap for the management of anastomotic leakage after esophagectomy.
Anastomotic leakage was diagnosed in this study by salivary discharge, esophagography or endoscopy. Anastomotic leakage was recognized in 18 patients (11.4%) who underwent cervical esophagogastric mechanical anastomosis. Among them, 10 patients healed within 4 weeks by conservative treatment including drainage and debridement. However, a refractory fistula developed in spite of conservative treatment in 8 patients. Endoscopic observation revealed that the fistula had occurred at the site of gastric stump closure using the linear stapler.
Patients A total of 183 patients with esophageal cancer underwent subtotal esophagectomy and reconstruction at the Department of Surgery I, Dokkyo Medical University Hospital from 2009 to 2013. Of these patients, 158 underwent gastric conduit reconstruction with cervical anastomosis [8]. Among these 158 patients, the posterior mediastinal, retrosternal and subcutaneous routes were utilized in 139, 15 and 4 patients, respectively. In our institution, cervical anastomosis is performed using a 25-mm-diameter circular stapler. After the gastric conduit has been pulled up above the sternum, the gastric stump is opened and the circular stapler is inserted. The center rod of the circular stapler then penetrates through the posterior wall of the gastric conduit and is combined with the anvil, which has already been inserted into the stump of the cervical esophagus. In such a way, end-to-side esophagogastric anastomosis is performed. After the mechanical anastomosis, the opened gastric stump is closed using a linear stapler.
Procedure of SCM Flap Repair Informed consent was obtained from all patients prior to the operation. The repair operation was performed under general anesthesia in the first 2 patients and under regional and intravenous anesthesia in the remaining 6 patients. The operation was performed in 2 steps: repair of the fistula and creation of the muscle flap. The repair began with excision of the fistula. A variant Tshaped incision (left side longer than right side) that included the leakage site was made (fig. 1a). The inflamed skin around the cutaneous fistula was removed, and the area of gastric stump leakage was exposed. Adherent tissues around the anastomosis were then peeled away to avoid increasing the tension of the resutured site (fig. 1b). After debridement of the esophagus and gastric conduit around the leakage site, the cutaneous fistula including the gastric stump leakage site was removed (fig. 2a). Repair of the gastric stump was then performed with interrupted sutures in a singlelayer fashion using 3-0 synthetic absorbable suture (Coated Vicryl; Ethicon Inc., Somerville, N.J., USA; fig. 1c). The next step was the creation of the SCM flap. Because the gastric stump was located to the left of the midline, a left SCM was used in every case. The tissue surrounding the left SCM was dissected, and the sternal head was exposed. The sternal head was then dissected from the manubrium of the sternum (fig. 1c), preserving the clavicular head of the SCM. The separated sternal head was moved to patch the repaired gastric stump. Interrupted su-
SCM Flap for Anastomotic Leakage after Esophagectomy
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
Patients and Methods
307
SCM
Fig. 2. Schema of SCM flap repair. a Initially, the fistula and its surrounding tissue are dissected. The leaking gastric stump is then removed at the dotted line and sutured. b After the sternal head of the left SCM has been dissected from the manubrium of the sternum, the SCM flap is sutured onto the closed gastric stump.
Clavicular head Cutaneous fistula
Sternal head
a
tures were placed between the sternal head and gastric stump using 3-0 synthetic absorbable suture (Coated Vicryl; Ethicon Inc.) surrounding the sutured gastric stump (fig. 1d, 2b). Finally, a closed drain (Blake Silicone Drain, hubless, 10- or 15Fr round; Ethicon Inc.) was inserted near the muscle flap (fig. 1d).
b
eration. No patients reported swallowing discomfort or neck mobility problems. No patients developed surgical site infection.
Discussion Results
The clinical results of all 8 patients who underwent the SCM flap repair are summarized in table 1. Seven of the 8 patients were male (87.5%). The median patient age was 66.1 years (range, 55–80 years). The stages of esophageal cancer were as follows: stage IA, 4 patients; stage IIA, 2 patients; stage IIIA, 1 patient; and stage IIIC, 1 patient (TNM classification, 7th edition, UICC). Every patient had 1 or more comorbidities: 4 patients had hypertension, 3 had diabetes mellitus, 3 had hyperlipidemia, 1 had atrial fibrillation, 1 had an old cerebral infarction, 1 had interstitial pneumonia, 1 had emphysema, and 1 had a cervical spinal cord injury. Gastric conduit reconstruction was performed in all patients. The posterior mediastinal route was used in 7 patients, and the retrosternal route was used in 1. No patients underwent neoadjuvant chemotherapy or chemoradiotherapy. The median postoperative period until confirmation of no anastomotic leakage was 6.5 days (range, 3–11 days). The SCM flap repair was performed 34–100 days (median, 50 days) after esophagectomy. The operative duration was 80–220 min (median, 120 min). The amount of intraoperative bleeding was 5–182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7–15 days (median, 10 days) after the repair op308
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
The postoperative morbidity rate has recently been decreasing because of the development of new surgical procedures, devices and perioperative management protocols. However, the reported incidence of anastomotic leakage has been quite variable, reaching as high as 25% in previous high-volume series [9–11]. According to an international survey, left cervical esophagogastrostomy is one of the most common anastomotic procedures, and the gastric conduit is the most frequently utilized structure for reconstruction [12]. The choice between handsewn and mechanical anastomosis varies among surgeons. Previous studies have found no significant differences in the leakage rate between hand-sewn and stapled anastomoses [13–15]. The leakage rate of cervical anastomosis is generally higher than that of intrathoracic anastomosis. One explanation for this difference is the longer distance that the blood supply must travel for anastomotic healing in the neck than in the intrathoracic region and the resultant shorter anastomosis that is involved in such cases [11]. However, intrathoracic anastomosis is correlated with higher morbidity and mortality rates [16, 17]. Therefore, in our institution, end-to-side cervical esophagogastrostomy using a circular stapler is the first-choice procedure, and the gastric stump is closed with a linear stapler. In the present study, 11.4% of the patients who underwent cervical stapled anastomosis after esophagectomy Nakajima/Satomura/Takahashi/Muroi/ Kuwano/Kato
Table 1. Characteristics of patients who underwent SCM flap repair Case Patients’ backgrounds Esophageal reconstruction No. age, sex stage of comorbidities reconstruction diagnosis of years esophageal route anastomotic cancer leakage after esophagectomy, days
SCM flap repair repair after anesthesia esophagectomy, days
duration bleeding, relapse of g of operation, leakage min
oral intake after repair, days
1
56
Male
IIA
HT, HL
Posterior mediastinal
8
43
General
185
151
None
10
2
62
Male
IA
HT, DM, HL
Posterior mediastinal
3
90
General
230
182
None
15
3
69
Male
IIIC
HT, CI, emphysema
Retrosternal
9
57
Regional and 80 intravenous
15
None
11
4
80
Male
IIA
DM
Posterior mediastinal
8
43
Regional and 130 intravenous
10
None
10
5
61
Male
IA
Cervical spinal cord injury
Posterior mediastinal
4
37
Regional and 112 intravenous
21
None
7
6
68
Male
IA
AF
Posterior mediastinal
11
100
Regional and 102 intravenous
13
None
11
7
55
Female IA
DM, HL
Posterior mediastinal
5
70
Regional and 96 intravenous
10
None
10
8
78
Male
HT, DM, IP
Posterior mediastinal
4
34
Regional and 128 intravenous
5
None
10
IIIA
HT = Hypertension; HL = hyperlipidemia; DM = diabetes mellitus; CI = cerebral infarction; AF = atrial fibrillation; IP = interstitial pneumonia.
and gastric conduit reconstruction developed anastomotic leakage. Leakage was confirmed at the gastric stump in all of these patients. In general, leakage of the esophagogastric anastomosis is caused by 3 well-established factors: the lack of serosa, the presence of a segmental blood supply and the presence of tension [18]. The presence of a segmental blood supply may have contributed in the present study. Most blood flow in the gastric conduit is supplied by the right gastroepiploic artery, and venous drainage occurs through the right gastroepiploic vein. In end-to-side esophagogastric anastomosis, the blood supply and drainage in the gastric stump are compromised. Therefore, constant leakage may occur in this portion. Moreover, the rate of leakage may increase in patients with a narrow mediastinal space at the cervicothoracic junction because of the pressure on the gastric conduit. When cervical anastomotic leakage becomes apparent, conservative treatments such as wound deterging and drainage are usually carried out. Leakage is curable by tissue recovery and granulation in most cases, and intractable esophagocutaneous fistula rarely develops. Intrac-
table fistulas require more aggressive treatment, such as covered stents [19, 20], primary closure and vascularized pedicle tissue flaps [7, 21, 22]. Covered stent insertion into the cervical esophagus often causes strong pharyngeal discomfort or stent migration. Leakage relapse occurs at a high rate after simple primary closure. Therefore, vascularized pedicle tissue flaps are used to repair perforations or fistulas around the cervical anastomosis. In previous reports, the pectoralis major muscle flap has been used comparatively more often for repair [7, 22–24]. The pectoralis major muscle flap is a good method with which to prevent recurrent fistula formation because of its abundant muscle volume. However, because an additional large skin incision and muscle translocation from the thoracic wall to the cervical area are required, this surgery is relatively invasive. In contrast, the SCM flap can easily be harvested from the same operative field, and the extent of translocation is minimal. The SCM flap is usually used for reconstruction after head and neck surgery [25–29]. The SCM is the largest of the cervical muscles. It originates from the manubrium of the sternum and clavicle and stops at the mastoid. Its
SCM Flap for Anastomotic Leakage after Esophagectomy
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
309
Occipital artery SCM branches
Superior thyroid artery SCM branch
Transverse cervical artery SCM branch
Fig. 3. Blood supply of the SCM region. The occipital artery travels
beneath the SCM and sends out the branches of the SCM. The superior thyroid artery is the first branch of the external carotid artery and sends out a branch of the SCM. The transverse cervical artery originates from the thyrocervical trunk and sends out another branch of the SCM.
feeding artery originates from the occipital artery in the upper portion, the superior thyroid artery in the middle portion and the transverse cervical artery in the lower portion (fig. 3). Because the branches from the occipital artery and the superior thyroid artery are preserved, ischemic change rarely occurs after dividing and mobilizing the SCM up to its middle at the sternal head. Among our 8 patients, the posterior mediastinal route was used in 7 and the retrosternal route was used in 1. In the cases involving the posterior mediastinal route, the anastomotic site was deeper than in the other possible routes. Therefore, the anastomotic repair was more difficult than in the other two routes. Adequate dissection and exposure of the anastomotic site are essential for reliable repair. Fortunately, all leakage sites occurred at the gastric stump in our series. Because the gastric stump was usually located in front of the anastomotic site, the repair procedure was not particularly difficult to perform. Additionally, adequate mobilization of the muscle flap is required for coverage of the repaired site. Mobilization of the sternal head of the SCM is easy to perform, and the SCM flap can cover the anastomotic site by moderate mobilization even when the reconstruction route is through 310
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
the posterior mediastinum. That is, the SCM flap can cover the leaking gastric stump in cases of cervical anastomosis using any reconstruction route. The covering tissue is thin in many cases of cervical anastomotic leakage, and a refractory fistula may thus develop. We believe that the merit of the muscle flap for cervical anastomotic leakage is coverage of the repaired site by thick, strong tissue. This tissue pad adequately covers the vulnerable repaired tissue and prevents relapse of leakage. We performed the repair operation using the SCM flap under general anesthesia in the first 2 patients and under regional and intravenous anesthesia in the remaining 6; all operations were successfully completed with no intraoperative complications. This repair operation using the SCM is thought to be less invasive. Moreover, we experienced no leakage relapse. With respect to the timing of the repair operation, Hayashi et al. [30] recommended performing the operation 3 weeks after the first surgery because the rate of leakage relapse was high in patients who underwent the repair operation within 3 weeks after the first surgery. In our institute, the repair operation is performed ≥4 weeks after the first surgery because the inflammation in the anastomotic area has usually recovered by that time. With respect to the esophagectomy method, IvorLewis esophagectomy with intrathoracic anastomosis is reportedly performed [8]. In our institute, intrathoracic anastomosis is not performed in principle because anastomotic leakage often induces fatal mediastinitis or pyothorax [31]. Our method is considered to be unsuitable for intrathoracic anastomotic leakage because the flap does not reach the area of leakage. In this series, the point of leakage was the gastric stump in all patients. We experienced no cases of leakage on the circular stapled line. Leakage on the circular stapled line often develops into major leakage. The efficacy of the SCM flap for major leakage is unknown. Further investigation of the appropriateness of the SCM flap for major leakage is needed. In conclusion, SCM flap repair is an effective and minimally invasive method for cervical anastomotic leakage after esophageal reconstruction. This method may be considered in cases of refractory leakage of the stapled gastric stump.
Disclosure Statement The authors declare that no conflict of interest exists.
Nakajima/Satomura/Takahashi/Muroi/ Kuwano/Kato
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SCM Flap for Anastomotic Leakage after Esophagectomy
12 Boone J, Livestro DP, Elias SG, Borel Rinkes IH, van Hillegersberg R: International survey on esophageal cancer. 1. Surgical techniques. Dis Esophagus 2009;22:195–202. 13 Valverde A, Hay JM, Fingerhut A, Elhadad A: Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research. Surgery 1996;120:476–483. 14 Hsu HH, Chen JS, Huang PM, Lee JM, Lee YC: Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial. Eur J Cardiothorac Surg 2004; 25: 1097– 1101. 15 Walther B, Johansson J, Johnsson F, Von Holstein CS, Zilling T: Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis. Ann Surg 2003;238:803–812. 16 Biere SS, Maas KW, Cuesta MA, van der Peet DL: Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-analysis. Dig Surg 2011; 28: 29–35. 17 Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD: Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008;85:424–429. 18 Peracchia A, Bardini R, Ruol A, Asolati M, Scibetta D: Esophagovisceral anastomotic leak. A prospective statistical study of predisposing factors. J Thorac Cardiovasc Surg 1988;95:685–691. 19 Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T, Zacherl J: Postoperative esophageal leak management with the Polyflex esophageal stent. Ann Thorac Surg 2005; 79:398–403. 20 Freeman RK, Ascioti AJ, Wozniak TC: Postoperative esophageal leak management with the Polyflex esophageal stent. J Thorac Cardiovasc Surg 2007;133:333–338. 21 Chen HC, Tang YB, Noordhoff MS: Patch esophagoplasty with musculocutaneous flaps as treatment of complications after esophageal reconstruction. Ann Plast Surg 1987; 19: 448–453.
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22 Hirao M, Yoshitatsu S, Tsujinaka T, Nishiyama A, Fujitani K, Nakamori S, Sawamura T, Mishima H, Ikenaga M, Masuda N, Kashiwazaki M: Pectoralis myocutaneous flap with Ttube drainage for cervical anastomotic leakage after salvage operation. Esophagus 2006; 3:33–36. 23 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;115:1250–1254. 24 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;101:802–805. 25 Coleman JJ 3rd: Reconstruction of the pharynx and cervical esophagus. Semin Surg Oncol 1995;11:208–220. 26 Losken A, Rozycki GS, Feliciano DV: The use of the sternocleidomastoid muscle flap in combined injuries to the esophagus and carotid artery or trachea. J Trauma 2000; 49: 815–817. 27 Richardson JD: Management of esophageal perforations: the value of aggressive surgical treatment. Am J Surg 2005;190:161–165. 28 Lin CH, Lin CH, Wu CW, Liao CT: Sternocleidomastoid muscle flap: an option to seal off the esophageal leakage after free jejunal flap transfer – a case report. Chang Gung Med J 2009;32:224–229. 29 Sanchez JA, Panait L: Surgical repair of longsegment cervical esophageal injury with a sternocleidomastoid myocutaneous flap. Ann Thorac Surg 2012;94:305–307. 30 Hayashi K, Watanabe H, Kato H, Tachimori Y: A clinical study of the reanastomotic cases with thoracic esophageal cancer after resection and reconstruction with special reference to anastomotic method and results (in Japanese). Jpn J Gastroenterol Surg 1990; 23: 2315–2321. 31 Crestanello JA, Deschamps C, Cassivi SD, Nichols FC, Allen MS, Schleck C, Pairolero PC: Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg 2005;129:254–260.
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Copyright: S. Karger AG, Basel 2015. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
Effectiveness of Sternocleidomastoid Flap Repair for Cervical Anastomotic Leakage after Esophageal Reconstruction Masanobu Nakajima a Hitoshi Satomura a Masakazu Takahashi a Hiroto Muroi a Hiroyuki Kuwano b Hiroyuki Kato a
a
Department of Surgery I, Dokkyo Medical University, Mibu, and b Department of General Surgical Science (Surgery I), Gunma University Graduate School of Medicine, Maebashi, Japan
Key Words Esophageal cancer · Anastomotic leakage · Esophagectomy · Sternocleidomastoid flap
Abstract Background/Aims: The purpose of this study was to investigate the effectiveness of sternocleidomastoid (SCM) flap repair for anastomotic leakage after esophagectomy. Methods: A refractory cutaneous fistula from the gastric stump developed in 8 patients with esophageal cancer who underwent esophagogastric anastomosis after esophagectomy. All patients underwent SCM flap repair. The cutaneous fistula was removed and resutured. The sternal head of the left SCM was dissected from the manubrium of the sternum and sutured onto the repaired gastric stump. Results: The operative duration was 80–220 min (median, 120 min). The amount of intraoperative bleeding ranged from 5 to 182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7–15 days (median, 10 days) after the repair operation without discomfort. Conclusions: SCM flap repair is an effective and minimally invasive treatment method for cervical anastomotic leakage after esophageal recon-
© 2014 S. Karger AG, Basel 0253–4886/14/0315–0306$39.50/0 E-Mail [email protected] www.karger.com/dsu
struction. This method may be considered in patients with refractory leakage of the gastric stump after staple anastomosis. © 2014 S. Karger AG, Basel
Introduction
Surgery for esophageal cancer is very time-consuming and complicated. The three most common thoracic esophagectomy techniques are the transhiatal approach, Ivor-Lewis esophagectomy (right thoracotomy and laparotomy) and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis) [1]. In all methods, the gastric conduit is typically utilized for reconstruction after esophagectomy [2]. In Japan, the extended transthoracic esophagectomy with 3-field (cervical, mediastinal and abdominal) lymphadenectomy using the McKeown technique has been performed for the past 3 decades [3]. As a result, leakage of the cervical esophagogastric anastomosis often occurs. Anastomotic leakage is one of the most frequent and troublesome postoperative complications after esophagectomy [4–7]. It may cause mediastinitis or pyothorax Masanobu Nakajima, MD, PhD Department of Surgery I Dokkyo Medical University 880 Kitakobayashi, Mibu, Shimotsuga-gun, Tochigi 321-0293 (Japan) E-Mail mnakajim @ dokkyomed.ac.jp
Color version available online
Fig. 1. Photographs of the repair operation using the SCM flap. a A variant T-shaped incision surrounding the cutaneous fistula is made. The left side of the incision is longer than the right to harvest the left SCM. b The area of leakage and left SCM are exposed. The cutaneous fistula and gastric stump are clamped with an intestinal forceps. c The gastric stump is repaired by hand sewing, and the sternal head of the left SCM is dissected from the manubrium of the sternum. d The SCM flap repair is completed. The resutured gastric stump is covered with the SCM flap, and a 10-Fr closed drain is inserted.
a
b
c
d
in the early postoperative period and prolong the hospital stay. Drainage and infection control are the first steps in the treatment of cervical anastomotic leakage. If the leakage continues after adequate conservative treatment, surgical repair is considered. In our institution, the sternocleidomastoid (SCM) muscle flap is used for the treatment of refractory fistulas after cervical anastomotic leakage. The present study was performed to investigate the effectiveness of the SCM flap for the management of anastomotic leakage after esophagectomy.
Anastomotic leakage was diagnosed in this study by salivary discharge, esophagography or endoscopy. Anastomotic leakage was recognized in 18 patients (11.4%) who underwent cervical esophagogastric mechanical anastomosis. Among them, 10 patients healed within 4 weeks by conservative treatment including drainage and debridement. However, a refractory fistula developed in spite of conservative treatment in 8 patients. Endoscopic observation revealed that the fistula had occurred at the site of gastric stump closure using the linear stapler.
Patients A total of 183 patients with esophageal cancer underwent subtotal esophagectomy and reconstruction at the Department of Surgery I, Dokkyo Medical University Hospital from 2009 to 2013. Of these patients, 158 underwent gastric conduit reconstruction with cervical anastomosis [8]. Among these 158 patients, the posterior mediastinal, retrosternal and subcutaneous routes were utilized in 139, 15 and 4 patients, respectively. In our institution, cervical anastomosis is performed using a 25-mm-diameter circular stapler. After the gastric conduit has been pulled up above the sternum, the gastric stump is opened and the circular stapler is inserted. The center rod of the circular stapler then penetrates through the posterior wall of the gastric conduit and is combined with the anvil, which has already been inserted into the stump of the cervical esophagus. In such a way, end-to-side esophagogastric anastomosis is performed. After the mechanical anastomosis, the opened gastric stump is closed using a linear stapler.
Procedure of SCM Flap Repair Informed consent was obtained from all patients prior to the operation. The repair operation was performed under general anesthesia in the first 2 patients and under regional and intravenous anesthesia in the remaining 6 patients. The operation was performed in 2 steps: repair of the fistula and creation of the muscle flap. The repair began with excision of the fistula. A variant Tshaped incision (left side longer than right side) that included the leakage site was made (fig. 1a). The inflamed skin around the cutaneous fistula was removed, and the area of gastric stump leakage was exposed. Adherent tissues around the anastomosis were then peeled away to avoid increasing the tension of the resutured site (fig. 1b). After debridement of the esophagus and gastric conduit around the leakage site, the cutaneous fistula including the gastric stump leakage site was removed (fig. 2a). Repair of the gastric stump was then performed with interrupted sutures in a singlelayer fashion using 3-0 synthetic absorbable suture (Coated Vicryl; Ethicon Inc., Somerville, N.J., USA; fig. 1c). The next step was the creation of the SCM flap. Because the gastric stump was located to the left of the midline, a left SCM was used in every case. The tissue surrounding the left SCM was dissected, and the sternal head was exposed. The sternal head was then dissected from the manubrium of the sternum (fig. 1c), preserving the clavicular head of the SCM. The separated sternal head was moved to patch the repaired gastric stump. Interrupted su-
SCM Flap for Anastomotic Leakage after Esophagectomy
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
Patients and Methods
307
SCM
Fig. 2. Schema of SCM flap repair. a Initially, the fistula and its surrounding tissue are dissected. The leaking gastric stump is then removed at the dotted line and sutured. b After the sternal head of the left SCM has been dissected from the manubrium of the sternum, the SCM flap is sutured onto the closed gastric stump.
Clavicular head Cutaneous fistula
Sternal head
a
tures were placed between the sternal head and gastric stump using 3-0 synthetic absorbable suture (Coated Vicryl; Ethicon Inc.) surrounding the sutured gastric stump (fig. 1d, 2b). Finally, a closed drain (Blake Silicone Drain, hubless, 10- or 15Fr round; Ethicon Inc.) was inserted near the muscle flap (fig. 1d).
b
eration. No patients reported swallowing discomfort or neck mobility problems. No patients developed surgical site infection.
Discussion Results
The clinical results of all 8 patients who underwent the SCM flap repair are summarized in table 1. Seven of the 8 patients were male (87.5%). The median patient age was 66.1 years (range, 55–80 years). The stages of esophageal cancer were as follows: stage IA, 4 patients; stage IIA, 2 patients; stage IIIA, 1 patient; and stage IIIC, 1 patient (TNM classification, 7th edition, UICC). Every patient had 1 or more comorbidities: 4 patients had hypertension, 3 had diabetes mellitus, 3 had hyperlipidemia, 1 had atrial fibrillation, 1 had an old cerebral infarction, 1 had interstitial pneumonia, 1 had emphysema, and 1 had a cervical spinal cord injury. Gastric conduit reconstruction was performed in all patients. The posterior mediastinal route was used in 7 patients, and the retrosternal route was used in 1. No patients underwent neoadjuvant chemotherapy or chemoradiotherapy. The median postoperative period until confirmation of no anastomotic leakage was 6.5 days (range, 3–11 days). The SCM flap repair was performed 34–100 days (median, 50 days) after esophagectomy. The operative duration was 80–220 min (median, 120 min). The amount of intraoperative bleeding was 5–182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7–15 days (median, 10 days) after the repair op308
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The postoperative morbidity rate has recently been decreasing because of the development of new surgical procedures, devices and perioperative management protocols. However, the reported incidence of anastomotic leakage has been quite variable, reaching as high as 25% in previous high-volume series [9–11]. According to an international survey, left cervical esophagogastrostomy is one of the most common anastomotic procedures, and the gastric conduit is the most frequently utilized structure for reconstruction [12]. The choice between handsewn and mechanical anastomosis varies among surgeons. Previous studies have found no significant differences in the leakage rate between hand-sewn and stapled anastomoses [13–15]. The leakage rate of cervical anastomosis is generally higher than that of intrathoracic anastomosis. One explanation for this difference is the longer distance that the blood supply must travel for anastomotic healing in the neck than in the intrathoracic region and the resultant shorter anastomosis that is involved in such cases [11]. However, intrathoracic anastomosis is correlated with higher morbidity and mortality rates [16, 17]. Therefore, in our institution, end-to-side cervical esophagogastrostomy using a circular stapler is the first-choice procedure, and the gastric stump is closed with a linear stapler. In the present study, 11.4% of the patients who underwent cervical stapled anastomosis after esophagectomy Nakajima/Satomura/Takahashi/Muroi/ Kuwano/Kato
Table 1. Characteristics of patients who underwent SCM flap repair Case Patients’ backgrounds Esophageal reconstruction No. age, sex stage of comorbidities reconstruction diagnosis of years esophageal route anastomotic cancer leakage after esophagectomy, days
SCM flap repair repair after anesthesia esophagectomy, days
duration bleeding, relapse of g of operation, leakage min
oral intake after repair, days
1
56
Male
IIA
HT, HL
Posterior mediastinal
8
43
General
185
151
None
10
2
62
Male
IA
HT, DM, HL
Posterior mediastinal
3
90
General
230
182
None
15
3
69
Male
IIIC
HT, CI, emphysema
Retrosternal
9
57
Regional and 80 intravenous
15
None
11
4
80
Male
IIA
DM
Posterior mediastinal
8
43
Regional and 130 intravenous
10
None
10
5
61
Male
IA
Cervical spinal cord injury
Posterior mediastinal
4
37
Regional and 112 intravenous
21
None
7
6
68
Male
IA
AF
Posterior mediastinal
11
100
Regional and 102 intravenous
13
None
11
7
55
Female IA
DM, HL
Posterior mediastinal
5
70
Regional and 96 intravenous
10
None
10
8
78
Male
HT, DM, IP
Posterior mediastinal
4
34
Regional and 128 intravenous
5
None
10
IIIA
HT = Hypertension; HL = hyperlipidemia; DM = diabetes mellitus; CI = cerebral infarction; AF = atrial fibrillation; IP = interstitial pneumonia.
and gastric conduit reconstruction developed anastomotic leakage. Leakage was confirmed at the gastric stump in all of these patients. In general, leakage of the esophagogastric anastomosis is caused by 3 well-established factors: the lack of serosa, the presence of a segmental blood supply and the presence of tension [18]. The presence of a segmental blood supply may have contributed in the present study. Most blood flow in the gastric conduit is supplied by the right gastroepiploic artery, and venous drainage occurs through the right gastroepiploic vein. In end-to-side esophagogastric anastomosis, the blood supply and drainage in the gastric stump are compromised. Therefore, constant leakage may occur in this portion. Moreover, the rate of leakage may increase in patients with a narrow mediastinal space at the cervicothoracic junction because of the pressure on the gastric conduit. When cervical anastomotic leakage becomes apparent, conservative treatments such as wound deterging and drainage are usually carried out. Leakage is curable by tissue recovery and granulation in most cases, and intractable esophagocutaneous fistula rarely develops. Intrac-
table fistulas require more aggressive treatment, such as covered stents [19, 20], primary closure and vascularized pedicle tissue flaps [7, 21, 22]. Covered stent insertion into the cervical esophagus often causes strong pharyngeal discomfort or stent migration. Leakage relapse occurs at a high rate after simple primary closure. Therefore, vascularized pedicle tissue flaps are used to repair perforations or fistulas around the cervical anastomosis. In previous reports, the pectoralis major muscle flap has been used comparatively more often for repair [7, 22–24]. The pectoralis major muscle flap is a good method with which to prevent recurrent fistula formation because of its abundant muscle volume. However, because an additional large skin incision and muscle translocation from the thoracic wall to the cervical area are required, this surgery is relatively invasive. In contrast, the SCM flap can easily be harvested from the same operative field, and the extent of translocation is minimal. The SCM flap is usually used for reconstruction after head and neck surgery [25–29]. The SCM is the largest of the cervical muscles. It originates from the manubrium of the sternum and clavicle and stops at the mastoid. Its
SCM Flap for Anastomotic Leakage after Esophagectomy
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
309
Occipital artery SCM branches
Superior thyroid artery SCM branch
Transverse cervical artery SCM branch
Fig. 3. Blood supply of the SCM region. The occipital artery travels
beneath the SCM and sends out the branches of the SCM. The superior thyroid artery is the first branch of the external carotid artery and sends out a branch of the SCM. The transverse cervical artery originates from the thyrocervical trunk and sends out another branch of the SCM.
feeding artery originates from the occipital artery in the upper portion, the superior thyroid artery in the middle portion and the transverse cervical artery in the lower portion (fig. 3). Because the branches from the occipital artery and the superior thyroid artery are preserved, ischemic change rarely occurs after dividing and mobilizing the SCM up to its middle at the sternal head. Among our 8 patients, the posterior mediastinal route was used in 7 and the retrosternal route was used in 1. In the cases involving the posterior mediastinal route, the anastomotic site was deeper than in the other possible routes. Therefore, the anastomotic repair was more difficult than in the other two routes. Adequate dissection and exposure of the anastomotic site are essential for reliable repair. Fortunately, all leakage sites occurred at the gastric stump in our series. Because the gastric stump was usually located in front of the anastomotic site, the repair procedure was not particularly difficult to perform. Additionally, adequate mobilization of the muscle flap is required for coverage of the repaired site. Mobilization of the sternal head of the SCM is easy to perform, and the SCM flap can cover the anastomotic site by moderate mobilization even when the reconstruction route is through 310
Dig Surg 2014;31:306–311 DOI: 10.1159/000368090
the posterior mediastinum. That is, the SCM flap can cover the leaking gastric stump in cases of cervical anastomosis using any reconstruction route. The covering tissue is thin in many cases of cervical anastomotic leakage, and a refractory fistula may thus develop. We believe that the merit of the muscle flap for cervical anastomotic leakage is coverage of the repaired site by thick, strong tissue. This tissue pad adequately covers the vulnerable repaired tissue and prevents relapse of leakage. We performed the repair operation using the SCM flap under general anesthesia in the first 2 patients and under regional and intravenous anesthesia in the remaining 6; all operations were successfully completed with no intraoperative complications. This repair operation using the SCM is thought to be less invasive. Moreover, we experienced no leakage relapse. With respect to the timing of the repair operation, Hayashi et al. [30] recommended performing the operation 3 weeks after the first surgery because the rate of leakage relapse was high in patients who underwent the repair operation within 3 weeks after the first surgery. In our institute, the repair operation is performed ≥4 weeks after the first surgery because the inflammation in the anastomotic area has usually recovered by that time. With respect to the esophagectomy method, IvorLewis esophagectomy with intrathoracic anastomosis is reportedly performed [8]. In our institute, intrathoracic anastomosis is not performed in principle because anastomotic leakage often induces fatal mediastinitis or pyothorax [31]. Our method is considered to be unsuitable for intrathoracic anastomotic leakage because the flap does not reach the area of leakage. In this series, the point of leakage was the gastric stump in all patients. We experienced no cases of leakage on the circular stapled line. Leakage on the circular stapled line often develops into major leakage. The efficacy of the SCM flap for major leakage is unknown. Further investigation of the appropriateness of the SCM flap for major leakage is needed. In conclusion, SCM flap repair is an effective and minimally invasive method for cervical anastomotic leakage after esophageal reconstruction. This method may be considered in cases of refractory leakage of the stapled gastric stump.
Disclosure Statement The authors declare that no conflict of interest exists.
Nakajima/Satomura/Takahashi/Muroi/ Kuwano/Kato
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