Auris'NaslIs'Larynx (Tokyo) 18, 383-389 (1991)

SWALLOWING FUNCTION FOLLOWING HYPO­PHARYNGEAL RECONSTRUCTION WITH

THE PECTORALIS MAJOR MUSCULO­CUTANEOUS FLAP

Hiroshi OKAMURA, M.D., Shoko INAKI, M.D., and Toshihiro MORI, M.D.

Department 0/ Otolaryngology, School 0/ Medicine, Ehillle Unil'ersity, Shigenobll-cho, Ehillle, Japan

Swallowing function was studied in three patients following the pecto­ralis major musculocutaneous reconstruction of the hypopharynx and cervical esophagus after extensive resection for hypopharyngeaJ cancer. Fluoroscopy and endoscopy revealed the formation of a sphincter-like ring at the proximal end of the remaining intact esophagus. This ring may act to prevent reflux from the lower esophagus, although its sphinc­teric power is weak. Manometric testing showed that no swallowing pressure was prod uced in the reconstructed gullet; therefore, bolus propulsion at the pharyngeal stage occurs mainly by gravity. Follow-up studies on swallowing indicate a minimum length of the suture line of II cm in order to prevent esophageal stenosis due to anastomotic stric­ture at the distal mucocutaneous junction.

The pectoralis major musculocutaneous flap has been proven reliable for single-stage reconstruction of the pharynx and cervical esophagus following ex­tensive resection for cancer. The serious long-term complication associated with this technique is anastomotic stricture at the distal mucocutaneous junction re­sulting in poor nutrition (SCHULLER, 1983; STELL, 1984; ROBERTSON and ROBINSON, 1984). Long-term follow-up studies on swallowing in these patients are necessary to determine whether changes in surgical technique can prevent this complication (REES, IVEY, SHACK, FRANKLIN, and LYNCH, 1986).

In this report, we examined three patients who had undergone pectoralis major musculocutaneous flap reconstruction after extensive resection for cancer. There were no complaints of swallowing disturbance. Swallowing function was in­vestigated fluoroscopically, endoscopically and by esophageal manometry. Based

Received for publication May 16, 1991

383

384 H. OKAMURA, S. INAKI, and T . MORI

on the results, we propose a minimum length of the suture line between the skin · flap and esophagus to prevent postoperative anastomotic stricture.

MATERIALS AND METHODS

The profiles of the three patients studied are summarized in Table 1. Each patient received preoperative radiotherapy (BOCO). After radical neck dissection and hypopharyngolaryngoesophagectomy, the pharynx and cervical esophagus were reconstructed using the pectoralis major musculocutaneous flap in a single stage. The upper esophageal sphincter (pharyngoesophageal high pressure zone), formed by contraction of the cricopharyngeal muscle, was removed with a tumor in all patients. Our investigation of swallowing functions was performed from I to 3 years after reconstruction. The patients swallowed barium at a concentra­tion of 140 % of barium sulfate and were evaluated by videofluoroscopy. The endoscopic examination was conducted using an electronic imaging esophagoscope (Welch Allyn Video Endoscope system). Findings were recorded on magnetic tape. Esophageal manometric studies were carried out according to a stationally pull-through method at an interval of 1 cm from the cervical esophagus to the velopharynx with a microtip pressure transducer (Miller Co.). The transducer was inserted into th'! esophagus through the naris and swallowing pressure was recorded as the patients swallowed water. As a control, swallowing pressure was also measured in three laryngectomized patients.

Table 1. A profile of patients. --~----------------------.--------.

Case Age Sex Site of tumor TNM Preoperative Date of investigation radiation after operation

1. S.T. 75 Male Pyriform sinus T2NoMo 60 Gy 1 year 2. LT. 67 Male Pryiform sinus T4N 3 Mo 30 Gy 2 years 3 months 3. A.I. 56 Male Pyriform sinus T2N 2Mo 30 Gy 3 years 2 months

RESULTS

I. Fluoroscopic study No anastomotic stricture, diverticulum, or orocutaneous fistula was observed

during fluoroscopic examination in any of the patients. The barium passed smoothly without retention at the mucocutaneous junction, although peristaltic waves failed to occur in the reconstructed gullet. The skin flap was often coated with barium, and it was necessary for the patients to swallow saliva several times to remove it. Fluoroscopy demonstrated a sphincter-like structure near distal to the mucocutaneous junction (Fig. 1) in all patients . The structure closed in the resting state, dilated on contact with the barium, and closed again following its passage. The narrowest portion of the lumen corresponded to the site of a

SWALLOWING FUNCTION IN HYPOPHARYNGEAL RECONSTRUCTION 385

Fig. 1. Fluoroscopic view (case I). Arrow. sphincter-like ring.

sphincter-like structure, and its diameter at maximum dilation on swallowing barium was 14, 16, and 19 mm, respectively.

2. Endoscopic study No anastomotic stricture was revealed at either the proximal or distal end of

the skin flap by endoscopic examinations in any patient. The skin flap collected no debris, was well adapted to adjusting intact esophageal mucosa, and was ac­curately anastomosed to the esophageal mucosa (Fig. 2). The most notable en­doscopic finding was the existence of a sphincter-like ring (Fig. 2) about 1 cm distal to the lower mucocutaneous junction in all patients. This ring was also

Fig. 2. Endoscopic view (case 2). Asterisk, sphincter-like ring; arrows, mucocutaneous junction.

386 H. OKAMURA, S. INAKI, and T. MORI

noted on fluoroscopy (Fig. 1). The ring closed at rest and dilated on contact with the endoscope or during swallowing. This sphincter-like ring is thought to result from contraction of the circular muscle at the proximal end of the remaining esophagus.

3. Manometric study While swallowing of water, normal subjects display three peaks of swallowing

pressure corresponding to the velopharynx, hypopharynx, and cervical esophagus. Laryngectomized patients showed the same three peaks, as shown in Fig. 3.

mmHg 200

150

100

50

0~~--Ll~0------1~5----~2~0----~2~5~cm--

mmHg 100

o

l 1.0 sec

A 1111111111 i I

B 11111 III I!

mm~~ ~111111111Jllill.Ulqlll!II!I. c I i r I I I I ! " II I I I I I I If! f I I I I I f If'

Fig. 3. Swallowing pressure of a laryngectomized patient. Peaks, velopharynx, hypopharynx, and cervical esophagus from the left; the horizontal axis, length from the anterior naris.

Fig. 4. Swallowing pressure (case o 3). A, velopharynx; B, meso­

pharynx; C, reconstructed canal; and D, esophagus. EMG, recorded from the suprahyoid muscles.

SWALLOWING FUNCTION IN HYPOPHARYNGEAL RECONSTRUCTION 387

mmHg 200

150

100

50

0 I , 10 2'0

Fig. 5. Swallowing pressure (case 2). Peaks, velopharynx, mesopharynx, and remaining intact esophagus from the left; the horizontal axis, length from the anterior naris.

However, patients with pharyngeal and cervicoesophageal reconstruction showed only two peaks of pressure corresponding to the velopharynx and meso pharynx (Figs. 4 and 5). No swallowing pressure was observed in the reconstructed gullet, but when the pressure sensor reached the remaining intact esophagus, swallowing pressure reflecting peristaltic waves was recorded. At rest, the intraluminal pres­sure at the site of the sphincter-like ring discovered by endoscopy and fluoroscopy was almost equal to atmospheric pressure and did not show a high pressure zone.

DISCUSSION

In cases of advanced hypopharyngeal cancer, we routinely irradiate preoper­atively, extensively remove tumor with the surrounding tissue, and reconstruct the pharyngeal and cervical esophagus using the pectoralis major musculocutaneous flap as advocated by ARIYAN (1979), in a single stage. The most serious long­term complication of this reconstruction procedure is anastomotic stricture, re­sulting in swallowing disturbance and poor nutrition. To avoid this, many sur­geons (BAEK, LAUSON, and BILLER, 1982; FEE, 1984; LAM, WEI, and LAU, 1987) rely on various devices, particularly of suturing the skin flap to the esophagus. However, the optimal length of the suture line has yet to be determined. Post­operative follow-up studies may provide some reliable indication of the minimum length of the suture line to assure satisfactory swallowing. It is important to study swallowing functions in reconstructed patients in detail in order to achieve better surgical methods. In this study, we selected relatively long-term follow­up patients without dysphagia, who had undergone reconstruction of the pharynx and cervical esophagus, and investigated their swallowing using fluoroscopy, endoscopy, and esophageal manometry.

The notable findings in this study were a sphincter-like ring at the proximal end of the esophagus and the absence of swallowing pressure in the reconstructed gullet. The sphincter-like ring, demonstrated by fluoroscopy and endoscopy, was

388 H. OKAMURA, S. INAKI, and T. MORI

formed about I cm below the distal mucocutaneous junction in all patients. This ring may be formed by a contraction of the circular muscle of the remaining intact esophagus at the proximal end. WITHERS, FRANKLIN, MADDEN, and LYNCH (1981) reported the absence of an upper esophageal sphincter mechanism in patients with hypopharyngeal and cervicoesophageal reconstruction with the pectoralis major musculocutaneous flap. In fact, the intraluminal pressure re­corded at the site of this ring at a resting state in our patients was almost equal to atmospheric pressure. In general, manometric examination showed a high pressure zone at the pharyngoesophageal junction which acts as the upper eso­phageal sphincter. The newly formed ring obviously fulfilled a sphincteric function during swallowing, as demonstrated by fluoroscopy and endoscopy. It may thus act to prevent reflux of a bolus from the lower esophagus, although its sphincteric power is weak.

The absence of swallowing pressure in the flap zone means that the bolus is propagated mainly by gravity. Bolus propulsion at the pharyngeal stage is in­duced by contraction of the remaining intact middle pharyngeal constrictor, as indicated by our manometric findings, although its power was weak. Tests of laryngectomized patients revealed sufficient swallowing pressure in the hypopha­ryngeal cavity, comparable to that of normal persons, and bolus propulsion is induced by increased intraluminal pressure in the hypopharyngeal cavity. In comparison with simple laryngectomy, some device is therefore necessary to suture the skin flap to the remaining intact esophagus in the case of hypopharyngo­laryngoesophagectomy. LAM et al. (1987) recommend a suture line of at least 15 cm, in consideration of the effect of suture line contracture, and uses an in­terdigitating anastomotic line produced by making vertical splits in the skin edge and esophageal stump edge. In dilating esophageal stenosis to improve passage of a solid bolus, the minimum diameter is between 14 and 18 mm (GOLDBERG, MANTERN, and BARKIN, 1986), according to a survey of the literature. In the case of hypopharyngeal and cervicoesophageal reconstruction, a wider diameter is necessary, since the propelling power is induced mainly by gravity. The di­ameter at the mucocutaneous junction in Lam's method should be around 33 mm, based on the assumption that postoperative cicatric contracture occurs around 30 % of its length. In addition to the present studies, our experiences showed that the diameter at the mucocutaneous junction was at least 25 mm in patients who did not complain of swallowing disturbance. Therefore, the shortest length of the suture line should be approximately 11 cm (71' x 2.5 cmj(I-0.3)).

CONCLUSION

Swallowing function was analyzed in three patients following a single-stage reconstruction of the pharynx and cervical esophagus using the pectoralis major musculocutaneous flap after extensive resection for hypopharyngeal cancer. Fluo-

SWALLOWING FUNCTION IN HYPOPHARYNGEAL RECONSTRUCTION 389

roscopic and endoscopic observations revealed the existence of a sphincter-like ring at the proximal end of the remaining intact esophagus, which may serve to prevent reflux from the lower esophagus. Manometric examination showed the absence of swallowing pressure in the reconstructed gullet; hence bolus propulsion occurs mainly by gravity. In order to prevent esophageal stenosis due to anas­tomotic stricture, we recommended that the suture line of the skin flap and esophagus be at least II cm.

REFERENCES

ARIYAN, S.: The pectoralis major myocutaneous flap: A versatile flap for reconstruction in the head and neck. Plast. Recol/str. Slirg. 63: 73-81, 1979.

BAEK, S. M., LAUSON, W., and BILLER, H. F.: An analysis of 133 pectoralis major myocutaneous flap. Plast. Recollstr. Slirg. 69: 460-467, 1982.

FEE, W. E.: Hypopharyngeal reconstruction. Arch. OtolarYlIgol. Head Neck Slirg. 110: 384-385, 1984.

GOLDBERG, R. 1., MANTERN, H.O., and BARKIN, J. S.: Esophageal bougienage with triple metal olive dilators. Gastroilltest. EI/dosc. 32: 226-228, 1986.

LAM, K. H., WEI, W. 1., and LAU, W. F.: Avoiding stenosis in the tubed greater pectoral flap in pharyngeal repair. Arch. OtolarYl/gol. Head Neck Slirg. 113: 428-431,1987.

REES, R. S., IVEY, G. L., SHACK, R. B., FRANKLIN, J. D., and LYNCH, J. B.: Pectoralis major musculocutaneous flaps: Long-term follow-up of hypopharyngeal reconstruction. Plast. Recollstr. Slirg. 77: 586-590, 1986.

ROBERTSON, M. S., and ROBINSON, J. M.: Immediate pharyngoesophageal reconstruction: Use of a quilted skin-grafted pectoralis major muscle flap. Arch. OlolarYl/gol. Head Neck Slirg. 110: 386-387, 1984.

SCHULLER, D. E.: Pectoralis myocutaneous flap in head and neck cancer reconstruction. Arch. OtolarYl/gol. Head Neck Slirg. 109: 185-189, 1983.

STELL, P. M.: Replacement of the pharynx after pharyngoesophagolaryngectomy. AIIII. R. Col!. Slirg. EI/g. 66: 388-390, 1984.

WITHERS, E. M., FRANKLIN, J. D., MADDEN, J. J., and LYNCH, J. B.: Immediate reconstruction of the pharynx and cervical esophagus with the pectoralis major myocutaneous flap follow­ing laryngopharyngectomy. Plast. Recollstr. Surg. 68: 898-904, 1981.

Request reprints to: Dr. H. Okamura, Department of Otolaryngology, School of Medicine, Ehime University, Shigenobu-cho, Onsen-gun, Ehime 791-02, Japan