Secondary reconstruction with a transverse colon covered with a pectoralis major muscle flap and split thickness skin grafts for an esophageal defect and wide skin defects of the anterior chest wall

Secondary reconstruction of a failed esophageal reconstruction is quite difficult [6-9]. For secondary reconstruction of the esophagus, several organs are used, including the jejunal interposition, free jejunum, and skin roll prepared from a myocutaneous flap as well as the colon interposition [7]. Among these, colon tissue can be used for the long segment replacement. In our case, the right colon segment (the terminal ileum to the ascending colon), which was supplied by the middle colic artery, was used as the primary reconstruction organ. Therefore, the transverse colon, which was supplied by the left colic artery, was used antegradely as the secondary reconstruction organ.

The necessity of additional microvascular anastomosis is controversial. Mine et al. reported that it is unnecessary to routinely use microvascular surgery during colon reconstruction, because no graft necrosis has been observed; thus, 96.5% of their patients underwent colon reconstruction without microvessel anastomosis [4]. In contrast, Saeki et al. demonstrated that colon interposition with microvascular surgery, especially superdrainage, was associated with satisfactory postoperative outcomes, including no serious anastomotic problems [2]. In our case, additional microvascular anastomosis was not performed in the first esophageal reconstruction. However, in the second reconstruction, microvascular anastomosis was performed in the artery and vein to achieve a more reliable postoperative outcome. Therefore, microvascular anastomosis should be considered after colonic interposition, because it is possible to prevent colon necrosis during insufficient blood circulation.

The pectoralis major muscle flap is widely used for various purposes, especially in head and neck reconstruction surgery. The use of the pectoralis major muscle flap involves a well-established technique, and because it is well vascularized, it can be easily mobilized. Heitmiller et al. reported the use of the pectoralis major myocutaneous flap in the management of cervical esophageal anastomotic complications [10]. Additionally, Morita et al. reported that in patients with esophageal cancer, the simple method of using the pectoralis major muscle flap to cover the anastomotic repair site prevents the development of recurrent leakage after reconstruction via the subcutaneous route [9]. Similarly, we applied a pectoralis major muscle flap to reinforce the anastomotic site.

Split thickness skin grafts can be meshed by cutting slits into the sheet of a graft and expanding it. Meshed grafts are quite useful when there is a paucity of available donor skin, the recipient bed is bumpy or convoluted, or the recipient bed is suboptimal as with exudate. Split thickness skin grafts readily take to the recipient site, and the donor site re-epithelializes quickly [11]. Split thickness skin grafts have also been used to cover the abdominal viscera in patients with a wide abdominal wall defect during planned hernia repair [12]. In our case, split thickness skin grafts were used to cover the reconstructed organ (the transverse colon) with a wide skin defect of the anterior chest wall. In addition, a wide range of skin defects can be repaired using split thickness skin grafts without excessive tension of the reconstructed organ.

Okazaki et al. also reported that because primary wound closure is often difficult in the secondary reconstruction of the esophagus, the pectoralis major musculocutaneous flap is reliable for covering the reconstructed esophagus. In those cases, they reported that a pectoralis major musculocutaneous flap was used to cover the reconstructed esophagus, and the flap donor site of the anterior chest wall was repaired with a split thickness skin graft [7]. In our method, the anastomotic site was fully covered with the pectoralis major muscle flap, and the esophageal conduit was covered with a split thickness skin graft. Since this causes less deformation to the anterior chest wall and the bilateral breast, this method should be considered in female patients because of the cosmetic advantage.