|2009 Annual Meeting Abstracts
Pharyngoesophageal Reconstruction with the Anterolateral Thigh (ALT) Flap: Seven Years Later
Peirong Yu, M.D., M.S., Roman Skoracki, MD, Matthew Hanasono, MD, Donald Baumann, MD.
University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.
PURPOSE: Pharyngoesophageal defects were traditionally reconstructed with the jejunal flap. We started using the ALT flap for such reconstructions in 2002 and reported our initial experience in 2004. The purpose of this study was to update our experience over a seven-year period.
METHODS: A retrospective review identified 91 male and 22 female patients with a mean age of 63±11 years. Pathology included primary squamous cell carcinoma (SCC) (27%), recurrent SCC (42%), pharyngocutaneous fistula (17%), benign stricture (8%), and thyroid cancers (6%). Prior to reconstruction, 48% of patients had undergone both surgeries and radiotherapy, 19% had received radiotherapy only and 4% had undergone surgery only. Major medical comorbidities included hypertension (44%), cardiac (24%), pulmonary (20%), diabetes mellitus (10%), cerebral vascular accidents (6%), peripheral vascular disease (5%), and psychological disorders (5%). There were 67 circumferential and 47 near-circumferential defects.
RESULTS: Mean ICU stay was 1.9±2.2 days, ventilator support was 1.1±0.7 days, and length of hospital stay was 9.0±4.7 days. Postoperative complications occurred in 37% of patients. Two patients experienced total flap loss (one reconstructed with another ALT flap and the other was not reconstructed) and one patient had a small partial flap necrosis. Pharyngocutaneous fistulas occurred in 9% of patients 4 to 43 (28±15) days after surgery. Spontaneous closure occurred in 5 patients within 4 weeks. Two patients with large fistulas (early proximal dehiscence) were repaired with pectoralis major flaps. Two fistulas did not heal due to early tumor recurrence and one did not heal because of tracheoesophageal fistula. Esophageal strictures occurred in 7% of patients 3 to 24 (8±7) months after surgery, all responded to endoscopic balloon dilatation. Other complications included wound infection (6%), hematoma (6%), seroma (4%), delayed wound healing (5%), ischemic bowel (2%), and major cardiopulmonary complications (10%) with a 30-day mortality of 1.8%. Excluding 14 patients with early recurrence, death, flap loss, and loss of follow-up, 86 patients tolerated a regular or soft diet, 5 patients tolerated pureed diet, 7 patients were partially and 2 were totally tube feeding dependent. Tracheoesophageal puncture (TEP) was performed for speech rehabilitation in 49 patients. Among the 11 patients with primary TEP (performed at the time of reconstruction), 5 were successful and achieved fluent TE speech. Secondary TEP were performed in 32 patients 2 to 15 (6±3) months after reconstruction and 26 (81%) were successful. Fluent TE speech was achieved in 24 patients and the other two had a wet and labored speech. All six patients with a preexisting TEP achieved fluent speech after reconstruction. Rates of fistula, stricture, and functional outcomes were not different between patients with circumferential and near-circumferential defects.
CONCLUSION: This large series have demonstrated that the ALT flap is an excellent choice for pharyngoesophageal reconstruction with acceptable fistula and stricture rates and superior functional outcomes. Primary TEP should be discouraged due to low success rate.