Acta Otorrinolaringol Esp 2005; 56: 86-88
NOTE CLINICAL-SURGICAL
Surgical repair of an anastomotic stenosis in
pharyngeal reconstructions using antebrachial free
flaps
F. García -Purriños, J. L. Llorente, V. Suárez Fente, R. Cabanillas, C. Suárez
Servicio de ORL. Hospital Central Universitario de Asturias. Oviedo
Abstract: To obtain suitable deglutoria function and less
morbidity after hipopharyngeal surgery,antebrachial free
flaps is a very useful option. A posible complication is
oral fedding impossibility due to neopharyngeal stenosis.
Tumor ecurrence must be excluded. We described two
cases of hipopharyngeal stenosis after antebrachial free
flap re-construccion, proposing surgical eanastomosis
with fibrous ring esection and salivary by-pass stent.
Key words: Antebrachial free-flap. Complications. Salivary bypass.
CLINICAL CASES
Patient 1
A 57-year-old man who had undergone surgery for
an epidermoid carcinoma of the left pyriform sinus
TIN3MO by means of a lateral pharyngectomy with left
radical neck dissection and right functional neck
dissection followed by radiotherapy. In April 1995 a
secondary tumor was detected and treated by means of a
total laryngectomy. During postoperative care a fistula
was detected which closed spontaneously after the
insertion of a nasogastric tube and the application of local
compression. In November 2002 another pharyngeal
tumor was detected. In this case a total pharyngectomy
and pharyngeal reconstruction with antebrachial free
flaps was carried out and parastomal reconstruction was
completed using a deltopectoral flap. The postoperative
period was complicated by a fistula that closed in 30 days
after a Montgomery type by-pass was inserted. After
being discharged in January 2003 the patient started to
Correspondence: José L. Llorente Pendás
C/ JM Caso,14
33006 Oviedo
Fecha de recepción: 8-10-2003
Fecha de aceptación: 2-2-2004
86
show symptoms of digestive stenosis (figure 1) The C.T.
scan shows a concentric area of stenosis on the distal edge
of the antebrachial flap of 1 cm in length, and of good
upper and lower caliber.
In April 2003 an operation was performed. The surgery
consisted of a horizontal suprasternal incision of 3 cm,
identification of the stenosis, opening of the pharyngeal
lumen, resection of the stenosis in its two anterior thirds,
insertion of a salivary by-pass and flat suturing. After 6
months the patient was able to swallow liquids and
purées. In spite of an acceptable pharyngeal passage,
periodic dilations are carried out due to a significant
fibrosis of the neck.
Pharyngeoesophagogram with contrast in which a
stenotic area can be seen at the distal level in a patient
with a neopharynx reconstructed with antebrachial free
flaps.
Patient 2
A 63-year-old male operated on for a nasal
adenocarcinoma in 1993 and treated with postoperative
Figure 1. Pharyngeoesophagogram with contrast in which we can
see a stenotic area at the distal level, in a patient whose neopharynx
has been reconstructed with antebrachial free flap.
SURGICAL REPAIR OF AN ANASTOMOTIC STENOSIS
radiotherapy. In September 1997 the patient was
diagnosed with a retrocricoid epidermoid carcinoma
T3N1M0. A total pharyngolaryngectomy with functional
bilateral dissection and pharyngeal reconstruction using
left antebrachial free flap was performed on the patient.
The immediate postoperative period passed without
complications and the patient was discharged 21 days
after surgery. In October 1997 the patient presented
dysphagia for which a pharyngoesophagogram was
requested which in turn showed a good passageway of
contrast although with a filiform area at the distal suture.
In the esophagoscopy, a cul-de-sac was observed with a
puntiform stenosis at 18 cm from the dental arch, with a
minimal sized orifice which impeded the insertion of the
pediatric endoscope, having the appearance of a normal
flap without evidence of a secondary tumor. Gastric
feeding was carried out and on November 24 a
reanastomosis was performed with the insertion of a
nasogastric tube and a salivary by-pass. On December 6
an esophagoscopy was performed in which a permeable
anastomosis was confirmed (figure 2) and with a good
passageway for which oral tolerance was started. On
January 2 the gastrostomy was closed. The patient
remains asymptomatic and with the ability to swallow to
date.
Figure 2. Postsurgical pharyngeoesophagogram with contrast of patient 2,in
which we can see a good passageway of the contrast.
DISCUSSION
The reconstruction of the hypopharynx is one of the
most difficult reconstructive procedures of the head and
neck area; for this reason the complete function must be
restored in a septic environment where small
complications can mean significant functional failures.
When the tumor resection is large, one must turn to free
flap reconstruction in order to achieve the best functional
results1. The free flaps most commonly used are the
radical antebrachial , jejunum or lateral muscle free flaps
and the less commonly used are the wide dorsal muscle
or rectal abdominal free flaps2. The choice of one kind of
flap over another depends on the individual
characteristics of the patient and on the experience of the
surgeon. In our opinion, the free flap of choice for
hypopharyngeal reconstruction at the present time, is the
antebrachial free flap. We favor this type of flap for its
versatility in the suturing of the pharynx (above all in the
upper area ) and the suturing of the pedicle (for its size
and independence) and because it does not necessitate the
opening of the abdomen. Two cases of stenosis of the
mouth anastomy are presented out of 30 hypopharynx
reconstructions using antebrachial free flaps performed
between 1994 and 2002.
The possibility of dysphagia after pharyngeolaryngeal surgery is high. When a postoperative
dysphagia is produced we must rule out the existence of
stenosis or a secondary tumor. One way of diagnosing
and identifying the stenosis is by using a
pharyngoesophagogram3 with contrast although a C.T.
scan is indispensable, above all in the detection of
secondary tumors.
More than 90% of patients have some degree of
dysphagia after having had a
total or semi-total pharyngo-laryngectomy3. Other studies
conclude that as regards hypopharyngeal reconstruction
with free flaps, 12% of patients need a nasogastric tube
while 78% are able to tolerate a normal or plain diet5.
The rate of stenosis after reconstruction with
antebrachial free flaps ranges between authors from 3% to
36%7. The place in which it is usually produced is the
distal anastomosis in which there are already 2
superimposed sutures (antebrachial flap-esophagus and
skin-trachea). This is also the area in which fistulas most
frequently form (with the subsequent retraction of the
suture in scar formation in the second attempt). Antistenosis techniques such as avoiding the superimposition
of sutures or using a mucosal incision to avoid circular
retraction that could cause scarring can be carried out in
order to avoid this complication.
Numerous techniques have been suggested in order
to re-establish the permeability of the digestive tract:
metal stents8 (which in our experience should not be used
except with terminal patients); salivary by-pass; the use of
dilation tubes which can be used in initial or primary
87
F. GARCÍA-PURRIÑOS ET AL.
cases or in non-serious cases; yet above all, reintervention
to remove the hypertrophic material which provokes the
stenosis, and adequate re-anastomosis.
The ultimate objective of surgery is the eradication of
scar material (pharyngeal and cervical) and to reanastomose in order to achieve the basic closure of the
suture. The temporary by-pass helps to maintain the
caliber of the neopharynx and above all to direct the
saliva towards the stomach, minimizing the risk of fistulas
and favoring primary closure.
We present two patients with postoperative stenosis
in the joining of the free flaps with the oesophagus which
were resolved by a re-anastomosis and a temporary bypass. We believe that this technique should be considered
as one of the first options in cases of localized
postoperative stenosis for its low aggressiveness and ease.
The aforementioned technique should be seen as the first
option in the case of localized postoperative stenosis
before the use of other reconstructive techniques that are
more complicated or less resolutive and troublesome
(dilation, stents) In cases of stenosis other techniques
should be considered.
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