The increasing use of the stomach as a conduit has led to increasing reports of peptic ulcer in the conduit. The risk of ulcer development in a gastric conduit is higher than that in the normal stomach . The incidence of gastric conduit ulcer is reported to be 6.1–19.4% [2, 3]. The denervated gastric conduit recovers intraluminal acidity with time . More than 80% of patients with a gastric conduit develop a peptic ulcer within 5 years. The time for the development of these ulcers varies widely, ranging from 1 month to as long as 150 months. The causes of gastric conduit ulcers remain controversial. Several mechanisms for the formation of gastric conduit ulcers have been hypothesized, including hypersecretion of gastric juice, Helicobacter pylori infection, delayed gastric emptying as a result of vagal denervation, bile juice regurgitation, insufficient blood supply due to gastric conduit creation, radiation, and the use of non-steroidal anti-inflammatory drugs (NSAIDs), aspirin, or steroids. Vagotomy, including the afferent sympathetic nerve fibers of 7th to 9th thoracic spinal cord, which transmits pain originating from the stomach, may be one of the reasons for the absence of symptoms. Consequently, the gastric conduit ulcer may penetrate any adjacent organ. Cutaneous fistulation after esophageal reconstruction is uncommon and has been reported to occur due to various mechanisms, such as leakage and radiation therapy . It occurs regardless of whether the reconstruction route is antesternal or retrosternal. In our case, the use of aspirin without a PPI may have caused the peptic ulcer of the gastric conduit. PPI treatment reduces the risk of peptic ulcer associated with the continuous use of low-dose aspirin . Long-term PPI treatment may reduce the rate of complications, and patient education after esophagectomy is necessary to prevent the development of gastric conduit ulcer. The surrounding organs perforated by refractory anastomotic leakage or gastric conduit ulcer vary and include the lung, trachea-bronchus, aorta, pericardium, chest wall, thoracic cavity, mediastinum, and skin [7,8,9,10,11]. As there is no standard management of fistula, the location, size, and extent of the fistula determine the appropriate treatment method. Several methods for managing anastomotic leakage and fistula have been suggested, including conservative treatment and more aggressive treatments, such as stent insertion, endoclip, and repair with a free jejunal graft and vascularized pedicle flaps .
The application of fibrin glue to a gastrocutaneous fistula after gastrostomy tube removal has been reported; however, this was contraindicated in cases involving a fistulous orifice of > 1 cm or infection of the fistulous tract . Endoclips are conventional and effective but are too small to treat larger defects and are inadequate for closing scarred and hardened fibrotic tissue. In contrast, the application of an over-the-scope clip (OTSC) is a relatively less invasive method that is newly designed for the management of bleeding, perforation, and fistula. As the OTSC has a greater compressive force, it can be applied to larger defects and more hardened tissues . The successful application of an OTSC in the treatment of esophagocutaneous fistula due to Boerhaave’s syndrome was reported . However, it is difficult to maneuver the OTSC well in the narrow gastrointestinal tract lumen with a tangential view. This is especially problematic in the case reconstructed via the antesternal route, as the tortuous reconstructed tract makes it more difficult to maneuver. Thus, in the present case, we decided not to apply an OTSC. The present case was indeed a worthy target of the abovementioned endoscopic treatments; however, it was more important to achieve the complete removal of the lesion because repetitive fistula formation at the same site due to gastric conduit ulcer was recognized in the present case. Although we planned to use free jejunal grafts in cases involving relatively large fistulas or in which the inflammatory range was too wide, the present case was successfully treated by partial resection alone.
Muscle flaps, including the pectoralis major, sternocleidomastoid muscle, deltopectoral muscle, latissimus dorsi muscle, and diaphragm can also be used in the treatment of refractory gastric conduit defects. The choice of which muscle to use for the repair depends on the location of the fistula. Pectoralis major muscle flaps have a rich blood supply and are useful in the neck and precordial region. As blocking of sialic leakage is very important for the engraftment of plombage tissue, a closed fistula should be covered with a muscle flap with a rich blood supply.
Morita reported that a pectoralis major muscle flap was useful for repairing anastomotic leakage with refractory cutaneous fistula after reconstruction via the antesternal route for esophageal cancer . Trimming and repair of the leakage site were initially performed and the anastomotic site was then covered with a muscle flap. A muscle flap repair was indicated under similar conditions to our case of cutaneo-gastric conduit fistula. The reported advantages of pectoralis major muscle flaps include the readily available source of vascularized tissue and the fact that it can be easily harvested for use in the head and neck . In addition, a split-thickness skin graft should be considered in cases involving wide skin defects. Sadanaga reported that an esophageal defect and a wide skin defect of the anterior chest wall were successfully treated with a split-thickness skin graft and a pectoralis major muscle flap .