An Alternative Application of Anterolateral Thigh Musculocutaneous Free Flap for Eliminating Persistent Esophageal Leakage-A Case Report

以大腿前外側肌皮游離皮瓣根除持續性食道滲漏－病例報告

黃曉芃(Hsiao-Peng Huang) ； 黃才旺(Tsai-wang Huang) ； 陳錫根(Shyi-Gen Chen) ； 陳天牧(Tim-Mo Chen) ； 王志信(Chih-Hsin Wang)

《臺灣整形外科醫學會雜誌》 24卷4期 (2015/12) Pp. 338-346

摘要

背景：食道癌行食道切除併頸部食道—胃吻合術後病患之吻合處滲漏發生率為10至15%，其與食道狹窄均為棘手的併發症；持續性的吻合處滲漏可能形成?管，進而造成慢性且巨大、多層組織之缺損。目的及目標：我們利用簡單、快速、可靠之大腿前外側肌皮游離皮瓣成功地重建複雜性之食道併多層組織缺陷。材料及方法：一名54歲男性患有食道下三分之一之鱗狀細胞癌，接受術前同步化療電療後行改良型McKeown食道切除暨頸部食道—胃吻合術，術後發生吻合處滲漏併有頸部一慢性、巨大及食道至皮膚之多層缺損。由於周圍組織接受過放射治療之傷害，局部皮瓣在此病患不適用，清創後以我們選擇以大腿前外側肌皮游離皮瓣重建。結 果：皮瓣手術成功，經過術後六個月的追蹤，病患恢復正常飲食，無吞嚥困難；食道攝影顯示無狹窄；且達到良好之外觀。結論：根據此病例之治療經驗，部分食道缺損，且併有食道、多層組織缺陷及放射性傷害之複雜傷口，大腿前外側肌皮游離皮瓣重建是一個簡單、快速、可靠，提供良好功能重建及美觀的好方法。

並列摘要

Background: Persistent anastomotic leakage or cervical esophagogastric anastomosis strictures are troublesome complications of gastric pull-up procedures. The persisting leakage often results in a chronic, large wound that can develop into a complex defect in the esophagus and skin. Numerous methods of treating persisting esophageal leakage have been reported. However, most of these involved complicated designs, lack of volume for a large defect, or lengthy procedures, thereby enhancing surgical and anesthetic risks. Aim and objectives: We report a successful reconstruction of a complex non-circumferential esophageal defect with a simple, reliable, versatile technique by using a free anterolateral thigh (ALT) musculocutaneous flap. Materials and Methods: A 54-year-old man who had squamous cell carcinoma of the lower third of the esophagus (T3N2M0, stage IIIB) was treated with neoadjuvant concurrent chemoradiation therapy, and subsequently, a modified McKeown esophagectomy with cervical esophagogastrostomy via the posterior mediastinum approach. Pathological results indicated that the malignant tumor was completely eliminated. The patient later presented to us with persistent post-surgical leakage and a large defect (3 cm long and 1.5 cm wide while the skin defect was 8 cm long and 6 cm wide) encompassing the anterior neck skin. A free anterolateral thigh musculocutaneous flap was harvested to repair the defect. Results: After 6 months of follow-up, the flap survived completely. The patient’s swallowing function was restored. An esophagogram showed a smooth passage of contrast without leakage or stenosis. After 20 months of follow-up, the endoscopic findings revealed native mucosa on the reconstructed defect. A good cosmetic result was achieved in terms of flap appearance. Conclusion: Secondary reconstruction of cervical esophageal and anterior neck defects after resection of esophageal carcinoma usually requires complicated designs and lengthy procedures. In this case, a partial esophageal defect with an anterior neck composite large defect, a free musculocutaneous ALT flap with its muscle component sealing off the esophageal defect can provide a vascularized surface for spontaneous mucosa healing. It is a simple, reliable, versatile, and effective procedure associated with lower donor-site morbidity. An excellent functional and aesthetic outcome can be achieved with this technique.

並列關鍵字

esophageal defect ； esophageal leakage ； anterolateral thigh musculocutaneous flap