Reconstruction of Upper Cervical
Esophagus
Moshe Rubinstein, MD; Doras Creter, MD; Yaacov Rotem, MD
\s=b\ We describe a surgical technique for reconstruction of the upper cervical esophagus after a segment has been excised. The technique involves the downward rotation of a full thickness pharyngeal flap to close the defect. The flap is obtained from the posterior wall of the hypopharynx and oropharynx. We describe a case in which this technique was used.
(Arch Otolaryngol 101:695-697, 1975) difficulties encountered in reconstruction of the esophagus after excision of a circular segment depend mainly on the location of the lesion. A stricture that is localized in the inferior or middle portion of the esophagus can be managed quite sat¬ isfactorily by standard procedures. Defects of the cervical esophagus
The
are more
difficult to treat, especially
if the lesion to be excised is situated in the upper segment and the larynx is preserved. Delay or interruption of the peristaltic wave in this critical re¬ gion could cause aspiration.1 We discuss reconstruction after re¬ section of a segment from the upper cervical esophagus with a normal air¬ way. The pathologic features that justify such surgical procedures could Accepted
for publication June 26, 1975. From the departments of otolaryngology (Drs Rubinstein and Creter) and pediatrics (Dr Rotem), The Chaim Sheba Medical Center, Tel Hashomer, and Tel Aviv University Medical School, Tel Aviv, Israel. Reprint requests to the Department of Otolaryngology, The Chaim Sheba Medical Center, Tel
Hashomer, Israel (Dr Rubinstein).
be
benign tumor, congenital malfor¬ mation, post-traumatic stricture, or
stenosis after chemical burns. Since the first work of Billroth in 1872, and Czerny in 1877, the prob¬ lems resulting from reconstruction of this critical esophageal segment have not all been solved. Transposition of the ascending, de¬ scending, or transverse colon210 showed occasional acceptable results, but restenosis in the anastomotic re¬ gion and fistulas are not infrequent. Reconstruction using a Dacron tube" was, until now, confined to ani¬ mal experimentation, and has not had clinical application. According to Montgomery cited by Sweet,2 after excision of a small seg¬ ment of esophagus, mobilization of the proximal and distal segments by 5 to 7 cm would permit end-to-end anastomosis. Of course, such a mobili¬ zation is more easily performed if the larynx is removed. Marchetta et al12 described a surgi¬ cal technique that employs use of a pharyngoesophageal flap to close the gap after the excision of 4 to 5 cm in length. He used this technique both in animals and humans. Unfortunately, the experimental results were not en¬
couraging. According to Stoner et al,9 an "ideal procedure" should be a one-stage op¬ eration, avoiding temporary pharyngostomy. It should not predispose to stricture or fistula formation, and the tissue used for grafting should be dis¬ tensible and tailored to allow for
a
wider proximal and narrower distal anastomosis. All of these conditions could be ful¬ filled by using a pedicled pharyngeal flap as recommended by Marchetta et
al."
The technique that was developed and used in our department is based on a
pedicled full-thickness pharyn¬
geal flap that is obtained from the posterior wall of the hypopharynx and oropharynx (Pig 1). Its pedicle is situated in the inferior part of the
longitudinal incision, preferably on the side opposite that used for the surgical approach. The flap is rotated downward and, after the closure of the pharyngeal defect, is sutured to
the gap that results from exci¬ sion of the esophageal segment. The width and length of the pha¬ ryngeal flap can be varied according to the size of the esophageal defect that has to be repaired. Three to four weeks after oper¬ ation, the reconstructed esophagus shows some irregularity on the x-ray film in the area where the pedicle was rotated. Later, the wall straightens and the apparent diverticulum dis¬ cover
appears.
After the
catheters,
operation, two Nélaton through each nostril,
one
introduced to maintain the lumen and to allow feeding of the patient. They are removed one to two weeks later. Thereafter, normal liquid diet is possible. A vacuum-sealed drainage appa¬ ratus is used to drain the postoperaare
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Fig 1 .—Full-thickness graft from posterior wall of hypopharynx and oropharynx is prepared. A, Resulting flap is rotated downward. B, It is sutured to cut margin of upper esophageal segment (C). Hypopharyngeal-oropharyngeal defect (D) is sutured and flap is pulled into po¬ sition. E, Esophageal defect. Fig
3.—Free passage
through
upper cervical
Fig 2.—Stenosis of upper cervical esoph¬ agus and large tissue mass in prevertebral space.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
esophagus
after
operation.
tive wound for two weeks and is moved if no fistula is detected.
re¬
REPORT OF A CASE A 10-year-old girl was hospitalized in the Pediatrie Department in November 1974, for massive pulmonary aspiration due to upper esophageal obstruction. From the age of 6 months, she had been able to swal¬ low only small quantities of liquids. Her first hospitalization was at the age of 5 years, when she was admitted with se¬ vere cachexia and bronchopneumonia. Her weight was 7.3 kg (16.2 lb) and her height was 81 cm (2 ft 7 in) (normal for a child of 8 months of age). Roentgenographic examination revealed an esophageal obstruction at the level of the C-4 vertebra. On esophagoscopy, we found a severe stricture at the same level with a filiform passage. A gastrostomy was performed, and by a laterocervical exploration of the esoph¬ agus, a ring stenosis was observed. After digital dilation, a Foley catheter was intro¬ duced and the dilation was repeated daily for a period of two weeks. During the next six months, bimonthly dilations were per¬ formed. After one year, her development was that of a child of 3 years of age, with a weight of 13 kg (28 lb), and she was dis¬ charged from the hospital. For the follow¬ ing two years she was readmitted at 3month intervals for repeated dilations. During 1974, she no longer required peri¬ odic dilation. In November 1974, an emer¬ gency tracheostomy was performed, due to a massive pulmonary aspiration. Roentgenographic examination showed a complete stenosis of the upper cervical esophagus, and a tissue mass in the pre¬ vertebral space at the level of the C4-5 ver-
tebrae (Fig 2). Esophagoscopy confirmed the roentgenographic findings. Gastros¬ tomy was performed for the second time, and after a few days, the neck was ex¬
cedure enables complete rehabilita¬ tion of the patient within a short time.
plored.
of white, hard fibrous tissue,13 1.5 to 2 cm, occupied the space between the cricoid and the vertebrae. No esophageal structure could be detected in this mass. The excision of this fibrous mass left a gap of 2 cm in the esophagus conti¬ nuity. The resulting esophageal defect was repaired with the technique described pre¬ A
References
mass
measuring
viously. COMMENT
The replacement of a circular seg¬ ment in the upper cervical esophagus may take place without complications in a one-stage operation, utilizing a
pedicled full-thickness pharyngeal flap. Generally, the complications af¬ ter restoration of the esophageal tract are cervical fistula, pneu¬
mothorax, bronchopneumonia, paral¬ ysis of the recurrent laryngeal nerve, esophageal diverticula, and scar ste¬ nosis.14 In our experience, a flap of 2 cm in width could easily be rotated from the pharynx. This will diminish its diameter by only 0.6 cm. Due to the good blood supply and the natural elasticity of the graft, an appreciable esophageal defect can be closed. Prior gastrostomy is indicated for
a mal¬ nourished patient. With this procedure of reconstruc¬ tion, the continuity of the peristaltic wave, which begins in the hypophar¬ ynx, is not disturbed (Fig 3). This pro-
1. Ogura JH, Kawasaki M, Neurophysiologic observations mechanism of deglutition. Ann
Tekenouchi ST: the adaptive Otol Rhinol Laron
yngol 73:1062-1081, 1964.
2. Sweet RH: Carcinoma of the superior mediastinal segment of the esophagus: A technique for resection with restoration of continuity of the alimentary canal. Surgery 24:929-938, 1948. 3. Conley J: One stage radical resection of cervical esophagus, larynx, pharynx and lateral neck, with immediate reconstruction. Arch Otolaryngol 58:645-654, 1953. 4. Hong PW, Seel DJ, Dielrick RB: Use of colon in the surgical treatment of benign strictures of the esophagus. Ann Surg 160:203-209, 1964. 5. Farrior RT: Primary reconstruction of cervical esophagus. Arch Otolaryngol 79:258-268, 1964. 6. Bolstad DS: The management of strictures of the esophagus. Ann Otol Rhinol Laryngol 75:1019-1028, 1966. 7. Armstrong DP: Cervical esophageal reconstruction after a laryngectomy and subtotal esophagectomy. Plast Reconstr Surg 48:382-385, 1971. 8. Stephens HB: Colon bypass of the esophagus. Am J Surg 122:217-222, 1971. 9. Stoner JC, Thomas GK, Albo DC: Cervical esophageal replacement. Arch Otolaryngol 95:141-145, 1972. 10. Harrison DFN: The management of upper esophageal stricture. Ann Coll Surg Engl 51:118\x=req-\ 125, 1972. 11. Schuring AG, Ray JW: Experimental use of dacron as an esophageal prosthesis. Ann Otol Rhinol Laryngol 75:202-207, 1966. 12. Marchetta FC, Sako K, Creedon PJ: Rotation esophageal and pharyngeal flaps for reconstruction of the cervical esophagus. Am J Surg 102:854, 1961. 13. Conley J, Stout AP, Healey WV: Clinicopathologic analysis of 84 patients with an original diagnosis of fibrosarcoma of the head and neck. Am J Surg 114:564-569, 1967. 14. Huguier M: Results of esophageal replacement. Surg Gynecol Obstet 130:1054-1058, 1970.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Esophagus
Moshe Rubinstein, MD; Doras Creter, MD; Yaacov Rotem, MD
\s=b\ We describe a surgical technique for reconstruction of the upper cervical esophagus after a segment has been excised. The technique involves the downward rotation of a full thickness pharyngeal flap to close the defect. The flap is obtained from the posterior wall of the hypopharynx and oropharynx. We describe a case in which this technique was used.
(Arch Otolaryngol 101:695-697, 1975) difficulties encountered in reconstruction of the esophagus after excision of a circular segment depend mainly on the location of the lesion. A stricture that is localized in the inferior or middle portion of the esophagus can be managed quite sat¬ isfactorily by standard procedures. Defects of the cervical esophagus
The
are more
difficult to treat, especially
if the lesion to be excised is situated in the upper segment and the larynx is preserved. Delay or interruption of the peristaltic wave in this critical re¬ gion could cause aspiration.1 We discuss reconstruction after re¬ section of a segment from the upper cervical esophagus with a normal air¬ way. The pathologic features that justify such surgical procedures could Accepted
for publication June 26, 1975. From the departments of otolaryngology (Drs Rubinstein and Creter) and pediatrics (Dr Rotem), The Chaim Sheba Medical Center, Tel Hashomer, and Tel Aviv University Medical School, Tel Aviv, Israel. Reprint requests to the Department of Otolaryngology, The Chaim Sheba Medical Center, Tel
Hashomer, Israel (Dr Rubinstein).
be
benign tumor, congenital malfor¬ mation, post-traumatic stricture, or
stenosis after chemical burns. Since the first work of Billroth in 1872, and Czerny in 1877, the prob¬ lems resulting from reconstruction of this critical esophageal segment have not all been solved. Transposition of the ascending, de¬ scending, or transverse colon210 showed occasional acceptable results, but restenosis in the anastomotic re¬ gion and fistulas are not infrequent. Reconstruction using a Dacron tube" was, until now, confined to ani¬ mal experimentation, and has not had clinical application. According to Montgomery cited by Sweet,2 after excision of a small seg¬ ment of esophagus, mobilization of the proximal and distal segments by 5 to 7 cm would permit end-to-end anastomosis. Of course, such a mobili¬ zation is more easily performed if the larynx is removed. Marchetta et al12 described a surgi¬ cal technique that employs use of a pharyngoesophageal flap to close the gap after the excision of 4 to 5 cm in length. He used this technique both in animals and humans. Unfortunately, the experimental results were not en¬
couraging. According to Stoner et al,9 an "ideal procedure" should be a one-stage op¬ eration, avoiding temporary pharyngostomy. It should not predispose to stricture or fistula formation, and the tissue used for grafting should be dis¬ tensible and tailored to allow for
a
wider proximal and narrower distal anastomosis. All of these conditions could be ful¬ filled by using a pedicled pharyngeal flap as recommended by Marchetta et
al."
The technique that was developed and used in our department is based on a
pedicled full-thickness pharyn¬
geal flap that is obtained from the posterior wall of the hypopharynx and oropharynx (Pig 1). Its pedicle is situated in the inferior part of the
longitudinal incision, preferably on the side opposite that used for the surgical approach. The flap is rotated downward and, after the closure of the pharyngeal defect, is sutured to
the gap that results from exci¬ sion of the esophageal segment. The width and length of the pha¬ ryngeal flap can be varied according to the size of the esophageal defect that has to be repaired. Three to four weeks after oper¬ ation, the reconstructed esophagus shows some irregularity on the x-ray film in the area where the pedicle was rotated. Later, the wall straightens and the apparent diverticulum dis¬ cover
appears.
After the
catheters,
operation, two Nélaton through each nostril,
one
introduced to maintain the lumen and to allow feeding of the patient. They are removed one to two weeks later. Thereafter, normal liquid diet is possible. A vacuum-sealed drainage appa¬ ratus is used to drain the postoperaare
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Fig 1 .—Full-thickness graft from posterior wall of hypopharynx and oropharynx is prepared. A, Resulting flap is rotated downward. B, It is sutured to cut margin of upper esophageal segment (C). Hypopharyngeal-oropharyngeal defect (D) is sutured and flap is pulled into po¬ sition. E, Esophageal defect. Fig
3.—Free passage
through
upper cervical
Fig 2.—Stenosis of upper cervical esoph¬ agus and large tissue mass in prevertebral space.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
esophagus
after
operation.
tive wound for two weeks and is moved if no fistula is detected.
re¬
REPORT OF A CASE A 10-year-old girl was hospitalized in the Pediatrie Department in November 1974, for massive pulmonary aspiration due to upper esophageal obstruction. From the age of 6 months, she had been able to swal¬ low only small quantities of liquids. Her first hospitalization was at the age of 5 years, when she was admitted with se¬ vere cachexia and bronchopneumonia. Her weight was 7.3 kg (16.2 lb) and her height was 81 cm (2 ft 7 in) (normal for a child of 8 months of age). Roentgenographic examination revealed an esophageal obstruction at the level of the C-4 vertebra. On esophagoscopy, we found a severe stricture at the same level with a filiform passage. A gastrostomy was performed, and by a laterocervical exploration of the esoph¬ agus, a ring stenosis was observed. After digital dilation, a Foley catheter was intro¬ duced and the dilation was repeated daily for a period of two weeks. During the next six months, bimonthly dilations were per¬ formed. After one year, her development was that of a child of 3 years of age, with a weight of 13 kg (28 lb), and she was dis¬ charged from the hospital. For the follow¬ ing two years she was readmitted at 3month intervals for repeated dilations. During 1974, she no longer required peri¬ odic dilation. In November 1974, an emer¬ gency tracheostomy was performed, due to a massive pulmonary aspiration. Roentgenographic examination showed a complete stenosis of the upper cervical esophagus, and a tissue mass in the pre¬ vertebral space at the level of the C4-5 ver-
tebrae (Fig 2). Esophagoscopy confirmed the roentgenographic findings. Gastros¬ tomy was performed for the second time, and after a few days, the neck was ex¬
cedure enables complete rehabilita¬ tion of the patient within a short time.
plored.
of white, hard fibrous tissue,13 1.5 to 2 cm, occupied the space between the cricoid and the vertebrae. No esophageal structure could be detected in this mass. The excision of this fibrous mass left a gap of 2 cm in the esophagus conti¬ nuity. The resulting esophageal defect was repaired with the technique described pre¬ A
References
mass
measuring
viously. COMMENT
The replacement of a circular seg¬ ment in the upper cervical esophagus may take place without complications in a one-stage operation, utilizing a
pedicled full-thickness pharyngeal flap. Generally, the complications af¬ ter restoration of the esophageal tract are cervical fistula, pneu¬
mothorax, bronchopneumonia, paral¬ ysis of the recurrent laryngeal nerve, esophageal diverticula, and scar ste¬ nosis.14 In our experience, a flap of 2 cm in width could easily be rotated from the pharynx. This will diminish its diameter by only 0.6 cm. Due to the good blood supply and the natural elasticity of the graft, an appreciable esophageal defect can be closed. Prior gastrostomy is indicated for
a mal¬ nourished patient. With this procedure of reconstruc¬ tion, the continuity of the peristaltic wave, which begins in the hypophar¬ ynx, is not disturbed (Fig 3). This pro-
1. Ogura JH, Kawasaki M, Neurophysiologic observations mechanism of deglutition. Ann
Tekenouchi ST: the adaptive Otol Rhinol Laron
yngol 73:1062-1081, 1964.
2. Sweet RH: Carcinoma of the superior mediastinal segment of the esophagus: A technique for resection with restoration of continuity of the alimentary canal. Surgery 24:929-938, 1948. 3. Conley J: One stage radical resection of cervical esophagus, larynx, pharynx and lateral neck, with immediate reconstruction. Arch Otolaryngol 58:645-654, 1953. 4. Hong PW, Seel DJ, Dielrick RB: Use of colon in the surgical treatment of benign strictures of the esophagus. Ann Surg 160:203-209, 1964. 5. Farrior RT: Primary reconstruction of cervical esophagus. Arch Otolaryngol 79:258-268, 1964. 6. Bolstad DS: The management of strictures of the esophagus. Ann Otol Rhinol Laryngol 75:1019-1028, 1966. 7. Armstrong DP: Cervical esophageal reconstruction after a laryngectomy and subtotal esophagectomy. Plast Reconstr Surg 48:382-385, 1971. 8. Stephens HB: Colon bypass of the esophagus. Am J Surg 122:217-222, 1971. 9. Stoner JC, Thomas GK, Albo DC: Cervical esophageal replacement. Arch Otolaryngol 95:141-145, 1972. 10. Harrison DFN: The management of upper esophageal stricture. Ann Coll Surg Engl 51:118\x=req-\ 125, 1972. 11. Schuring AG, Ray JW: Experimental use of dacron as an esophageal prosthesis. Ann Otol Rhinol Laryngol 75:202-207, 1966. 12. Marchetta FC, Sako K, Creedon PJ: Rotation esophageal and pharyngeal flaps for reconstruction of the cervical esophagus. Am J Surg 102:854, 1961. 13. Conley J, Stout AP, Healey WV: Clinicopathologic analysis of 84 patients with an original diagnosis of fibrosarcoma of the head and neck. Am J Surg 114:564-569, 1967. 14. Huguier M: Results of esophageal replacement. Surg Gynecol Obstet 130:1054-1058, 1970.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
