Tracheostomal and cervical esophageal reconstruction with combined deltopectoral flap and microvascular free jejunal transfer after central neck exenteration

Abstract

Background: Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenteration of the neck can be extremely difficult to reconstruct. The objective of this article is to evaluate reconstruction of the central compartment using a combination of free jejunal transfer for pharyngoesophageal reconstruction, together with regional deltopectoral flaps for tracheostomal reconstruction and cutaneous resurfacing. Myocutaneous flaps, such as pectoralis major and latissimus dorsi flaps, have been used previously for external coverage but can be bulky, causing obstruction of the tracheostoma.

Methods: From 1995 to 2002, seven patients underwent reconstruction of the central compartment with seven jejunal and nine deltopectoral flaps. Five patients required resection for tracheostomal recurrence of squamous cell carcinoma, and two patients required resection for massive pharyngocutaneous fistulas. Flap survival, complications, and outcomes were evaluated retrospectively.

Results: The mean age of the patients was 68.7 years and the mean length of follow-up was 1.9 years. Overall free jejunal and deltopectoral flap survival was 100 percent, with no partial loss. All patients maintained an adequate airway with stomal patency.

Conclusions: These complicated defects can be effectively repaired with free jejunal transfers to restore continuity of the alimentary tract and deltopectoral flaps to reconstruct the tracheostoma and surrounding cutaneous defects. The deltopectoral flap provides a large volume of well-vascularized tissue that provides reliable coverage of the newly reconstructed cervical esophagus and exposed major vessels following exenteration of the central compartment. Its thin, pliable nature allows suturing of the tracheal remnants to skin edges without tension and avoids intraluminal prolapse of excess soft tissues, thus maintaining stomal patency.