The entire pharynx and cervical esophagus were reconstructed after total laryngectomy and pharyngoesophagectomy for advanced cancer in 14 patients with the use of a pedicled latissimus dorsi myocutaneous island flap. All flaps were transferred successfully in one stage. The reliability of the flap and postoperative state of food passage were studied. Repair was confirmed by roentgenographic examination 6 months after surgery. A slight narrowness was noted at the portion anastomosed with the esophagus, with dilatation of the reconstructed segment. All patients in our study have been able to resume normal oral feeding. The pedicled latissimus dorsi myocutaneous island flap is reliable and useful for the reconstruction of the pharynx and cervical esophagus.

HEAD & NECK SURGERY 7~461-464 1985

ENTIRE PHARYNGOESOPHAGEAL RECONSTRUCTION WITH LATlSSlMUS DORSl MYOCUTANEOUS ISLAND FLAP

KATSURA YAMAMOTO, MD, KOJl YOKOTA, MD, and KIYOTAKE HIGAKI, M D

T h e latissimus dorsi myocutaneous flap has been used for reconstruction of breast,' hes st,^,^ shoul- d e ~ - , ~ and arm.5 Recently, other have reported that this flap is also adaptable and de- pendable for reconstruction of the head and neck.

We have used this flap in entire pharyngo- esophageal reconstruction as a pedicled island flap, with subsequent postoperative evaluation of the patient's ability to pass food through the pharynx and cervical esophagus.

MATERIALS AND METHODS

The latissimus dorsi myocutaneous island flap has been used for several procedures, but for our purpose in reconstruction of the pharynx and cer- vical esophagus, we found several modifications of the technique advantageous.

Proper positioning of the patient in bed aids the operative procedure. With the patient in a supine position, pillows are placed underneath the unilateral shoulder and hip, so the flank area

From the Department of Otolaryngology of the Shinshu University School of Medicine Matsumoto Japan

Address reprint requests to Dr Yamamoto at the Department of Otolaryn- gology Shinshu University School of Medicine 3-1-1 Asahi Matsumoto Naganoken 390 Japan

Accepted for publication February 21 1985

01 48-64031070610461 $04 OO/O 1985 John Wiley & Sons Inc

of the patient is placed in the operative field. In this way, the tumor can be excised and the flap performed simultaneously.

As pointed out by McFee, transverse paral- lel incisions have certain advantages. Total laryngectomy and pharyngoesophagectomy are performed with unilateral radical neck dissec- tion, and a t the time of the procedure the esopha- gus should be sectioned obliquely.

An incision, about 10 cm long, is made along the lateral margin of the latissimus dorsi muscle just below the axilla.

The thoracodorsal neurovascular bundle of the flap is made by ligating the circumflex scapular vessels and other accessory branches to serratus and teres major muscles, and it is dissected freely up to the level of axillary vessels. A pectoral tun- nel is then created from the axilla by finger dis- section between the pectoralis major and minor muscles, and it is opened underneath the clavicle by dissecting the pectoralis major muscle.

The length of the flap is measured from the base of the flap to the recipient site through the pectoral tunnel, and the cutaneous portion of the flap is outlined the same size as the pharyngo- esophageal defect, with its lateral border on the lateral margin of the muscle. In addition, the flap is marked out from the initial incision a t the under part of the axilla to its cutaneous portion. The skin island is cut around, and the incision is

Entire Pharyngoesophageal Reconstruction HEAD & NECK SURGERY JuliAug 1985 461

deepened through the fascia to the muscle. The myocutaneous unit is then dissected superiorly following the direction of the muscle bundle to the level of the neurovascular pedicle.

Because the cutaneous portion of the flap is bulky, i t is sometimes difficult to transport this portion through the pectoral tunnel. To improve this situation, after the cutaneous portion of the flap is wrapped in gauze, another side of the gauze is inserted into the pectoral tunnel (Figure 11 and is drawn out of the tunnel to the neck. By the natural process of this effect, the flap is easily passed through the tunnel into the neck region (Figure 2). The flap enters the neck passing be- neath the bipedicled cervical flap.

The distal end of the flap is implanted in the oropharynx, and a tube is formed with it, and the epithelialized aspect turned inward. The longitu- dinal seam of the tube is placed over the prever- tebral ligament. The proximal end of the tube is anastomosed to the beveled cut end of the esopha- gus.

Finally, the skin of the neck is closed over the reconstructed pharyngoesophagus, and the donor area of the flap is also closed by undermining, approximating, and skin grafting. If the skin of the neck is resected, a deltopectoral flap is used to cover the neck (Figure 3) .

A unilateral radical neck dissection is per- formed in all cases on the same side the flap is performed. The average width of the skin portion

FIGURE 2. Pedicled latissirnus dorsi myocutaneous island flap was passed through pectoral tunnel into neck region.

of the flaps is 10 cm and its length 12 cm. The procedure can be carried out in one stage.

The patient is fed through a nasogastric tube, which is removed about the 14th postoperative day. After the patient has been receiving a soft food diet for 1 week without difficulty, a regular diet is resumed. Dysphagia and regurgitation, which are typical symptoms of esophageal steno- sis, did not occur.

RESULTS

During March 1982 through January 1984, we performed entire pharyngoesophageal recon- structions with the pedicled latissimus dorsi myo- cutaneous island flap in 14 patients with pha- ryngoesophageal cancer who required total laryngectomy and pharyngoesophagectomy. Of the 14 patients, there were 11 men and 3 women, ranging in age from 53 to 80 years.

/ All patients received preoperative irradiation to the primary site and neck, ranging from 3000 (time-dose fractions, 49) to 7000 (time-dose frat-

FIGURE 1. For passing easily pedicled latissimus dorsi myo- cutaneous island flap through pectoral tunnel, skin portion of flap is wrapped up by gauze, and another side of qauze IS . . _ - drawn from tunnel to neck. tions, 115) rad. All patients were reevaluated by

462 Entire Pharyngoesophageal Reconstruction HEAD & NECK SURGERY JuliAug 1985

esophageal carcinoma is the resumption of nor- mal oral feeding. Many reconstructive techniques have been reported in an attempt to cope with this difficult problem.

The medially based deltopectoral skin flap, which Bakamjian' described in 1962 and 1965, is a versatile flap in widespread use for entire pha- ryngoesophageal reconstruction. The technique of Bakamjian has the disadvantage of multistaged repair, thus delaying the patient's initiation of food intake. From time to time we encounter post- operative stenosis at the anastomosis with the esophagus.

The pectoralis major myocutaneous flap uses primaryg,10 reconstruction of the pharynx and cer- vical esophagus. The pectoralis major myocutane- ous flap is a reliable and safe tool and is particu- larly useful for wide reconstruction in heavily irradiated areas. The patient is not delayed in the initiation of deglutition because the procedure is performed in one stage.

The pectoralis major myocutaneous flap may be bulky and, accordingly, when the pharynx and esophagus are reconstructed entirely, the longitu- dinal muscle stump of the tubed flap cannot be sutured.

FIGURE 3. When cervical skin was resected, deltoDectoral flap was used for covering neck. Deltopectoral flap was raised, and pedicled latissimus dorsi myocutaneous island flap was transported into neck. Arrow shows a neurovascu- lar bundle of pedicled latissimus dorsi myocutaneous island flap.

fluorographic examination 6 months postopera- tively.

Two patients developed fistulae caused by hematoma in the early postoperative period, which closed spontaneously. In all cases, the flaps were well supplied with blood, and the donor sites in the flank area healed without complications. We have not noted any weakness of shoulder function as a result of raising the pedicled island flap and radical dissection of the same side of the neck.

Fluorographic examination of the barium swallow was performed 6 months postoperatively in all 14 patients. The reconstructed pharyngo- esophageal segment was expanded as wide as the upper thoracic esophagus. The portion anas- tomosed with the esophagus was narrowed slightly with a ring-like extension (Figure 4).

DISCUSSION

A major problem for the patient who has under- gone a total pharyngolaryngectomy for pharyngo-

FIGURE 4. Fluorographic examination of barium swallow. Arrow shows a narrow anastornosed portion.

Entire Pharyngoesophageal Reconstruction HEAD & NECK SURGERY JuliAug 1985 463

The pedicled latissimus dorsi myocutaneous geal reconstruction on 14 patients without post- island flap has a predictable viability and is reli- operative stenosis a t any anastomotic site. All pa- able for one-stage pharyngoesophageal recon- tients were able to resume normal oral feeding. struction.">l2 Watson et al.I3 reported only a We believe the pedicled latissimus dorsi myocuta- small number of postoperative stenoses of the neous island flap is useful for entire pharyngo- pharyngoesophagus reconstructed entirely by the esophageal reconstruction and is reliable in flap. We carried out the entire pharyngoesopha- heavily irradiated cervical areas.

REFERENCES

1. Tansini I: Nuovo process0 per l'amputazione della mam- maella per cancro. La Riforma Medica 12:3-5, 1896.

2. Desprez JD, Kiehn CL, Eckstein W: Closure of large meningomyelocele defects by composite skin-muscle flaps. Plast Reconstr Surg 47:234-238, 1971.

3. McCraw JB, Penix JD, Baker JW: Repair of major defects of the chest wall and spine with the latissimus dorsi myo- cutaneous flap. Plast Reconstr Surg 62:197-206, 1978.

4. Bostwick J , Nahai F, Wallance JG, Vasconez LO: Sixty latissimus dorsi flaps. Plast Reconstr Surg 63:31-41, 1979.

5. Brones MF, Wheeler ES, Lesavoy MA: Restoration of el- bow flexion and arm contour with the latissimus dorsi myocutaneous flap. Plast Reconstr Surg 69:329-332, 1982.

6. Quillen CG, Shearin JC, Georgiade NG: Use of the latis- simus dorsi myocutaneous island flap for reconstruction in the head and neck area. Plast Reconstr Surg 62:113-117, 1978.

464 Entire Pharyngoesophageal Reconstruction

7. Schuller DE: Latissimus dorsi flap for massive facial de- fects. Arch Otolaryngol 108:414-417, 1982.

8. Bakamjian VY: A two-stage method for pharyngoesopha- geal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36:173-183, 1965.

9. Withers EH, Franklin JD, Madden J J , Lynch JB: Pec- toralis major musculocutaneous flap: a new flap in head and neck reconstruction. Am J Surg 138:537-543, 1979.

10. Bone RC: Myocutaneous flap: strategy for reconstruction. Laryngoscope 91:735-744, 1981.

11. Watson JS, Lendrum J : One stage pharyngeal reconstruc- tion using a compound latissimus dorsi island flap. Br J Plast Surg 34:87-90, 1981.

12. Maruyama Y, Nakajima H, Fujino T One stage recon- struction of a n esophagostoma with a latissimus dorsi myocutaneous flap and pectoralis major myocutaneous flap (case report). Acta Chir Plast 22:80-85, 1980.

13. Watson JS, Lendrum RJ, Stranc MF, Pohl MJ: Pharyngeal reconstruction using the latissimus dorsi myocutaneous flap. Br J Plast Surg 35401-407, 1982.

HEAD 8. NECK SURGERY JuliAug 1985