Surg Today Jpn J Surg (1994) 24:852-853 Suac avTooAv

© Springer-Verlag 1994

Tubed Latissimus Dorsi Musculocutaneous Flaps for Thoracic Esophageal Replacement in Dogs: Possible Clinical Application

ATSUYUKI YAMATAKA AND TAKESHI MIYANO

Department of Pediatric Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113 Japan

Abstract: A circumferential defect of the intrathoracic eso- phagus was successfully replaced with a tubed latissimus dorsi musculocutaneous flap in dogs. This flap obviates the necessity for laparotomy. Therefore, this technique might offer an alternative means of esophageal reconstruction in debilitated patients.

Key Words: latissimus dorsi flap, esophageal reconstruction

Several kinds of tubed musculocutaneous flaps have been used to repair circumferential defects of the cer- vical esophagus, l~2 A partial defect on the thoracic esophageal wall has often been replaced with a non- tubed musculocutaneous flap; 3-5 however, to the best of our knowledge, a tubed musculocutaneous flap has never been used to replace a circumferential defect of the intrathoracic esophagus. The aim of the present study is to examine whether a tubed latissimus dorsi musculocutaneous flap (TLDMF) can be successfully used to replace a circumferential defect of the intra- thoracic esophagus in a dog model.

In 12 dogs (mean weight, 4.8 kg), part of the thor- acic esophagus, two ver tebrae in length, was excised through a right thoracotomy at the level of the fourth intercostal space. A rectangular cutaneous island over- lying the latissimus dorsi muscle, which was outlined with a vertical dimension equal to the defect (two ver tebrae in length), was introduced into the thoracic cavity through the second intercostal space (Fig. 1). The cutaneous layer was then rolled into a tube and interposed into the space of the excised esophagus (Fig. 2). An adequate width was needed for the cutaneous island to be rolled comfortably into a tube.

Reprint requests to: A. Yamataka (Received for publication on July 8, 1993; accepted on Mar. 4, 1994)

The proximal and the distal end esophagus-skin anas- tomsoses were per formed in one layer using 4-0 Maxon sutures in an interrupted manner. Then the muscle layer was wrapped around the anastomosis, and the thorax was closed without a drain.

The first two dogs died of minor leakage, while the fifth and the sixth died of postoperative bleeding and an unknown cause, respectively. However , the T L D M F was successful in 8 out of the 12 cases; 5 of the 8 cases are doing well (mean follow-up time, 2.7 months) while the remaining 3 were sacrificed at 4 months following surgery. A barium meal and endo- scopic examination performed 2 weeks after surgery showed smooth passage (Fig. 3). The necropsy re- vealed the regrowth of hair on the cutaneous layer.

This flap is safe and easy to transfer and tube onto itself; thus, the use of the T L D M F obviates the neces- sity for laparotomy. This technique is therefore con- sidered to be an alternative means of bridging the long gap of the intrathoracic esophagus in debilitated patients.

References

1. Matsunaga W, Ebihara S, Ono I, Saito H, Mazima K, Ooyama W, Harii K (1983) Reconstruction of a the cervical esophagus by means of latissimus dorsi myocutaneous flap (in Japanese with English abstract). Jpn J Plast Reconstr Surg 26:98-103

2. Silver CE, Cusumano R J, Fell SC, Strauch B (1989) Replace- ment of upper esophagus: Results with myocutaneous flap and with gastric transposition. Laryngoscope 99:819-82l

3. Shesol BF, Clarke JS (1980) Intrathoracic application of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg 66: 842 - 845

4. Chen H, Tang Y, Noordhoff MS (1987) Patch esophagoplasty with musculocutaneous flaps as treatment of complications after esophageal reconstruction. Ann Plast Surg 19:448-453

5. Fujita H, Yoshimura Y, Yamana H (1988) A latissimus dorsi muscle flap used for repair of the esophagus after enucleation of a giant leiomyoma - - a case report - - Nippon Geka Gakkai Zasshi (Jpn J Surg Soc) 18:460-464

A. Yamataka and T. Miyano: Thoracic Esophageal Reconstruction 853

Fig. 1. The chest was entered through the fourth intercostal space (arrows). A latissimus dorsi musculo- cutaneous flap (asterisk) designed before thoracotomy was then intro- duced into the thoracic cavity through the second intercostal space (arrowheads)

Fig. 2. The cutaneous layer (aster&k) was rolled into a tube and interposed in the space of the excised esophagus. Then the muscle layer (arrows) was wrapped around the anastomosis

Fig. 3. Barium meal at 2 weeks after surgery showing smooth passage. The arrows indicate the anastomoses be- tween the esophagus and the tubed latissimus dorsi musculo- cutaneous flap (asterisk)