RESUMEN
Abstract Introduction A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. Objective This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. Methods Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. Results All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months. Conclusion The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.
Resumo Introdução Uma fístula anastomótica cervical refratária, que permanece sem cicatrização por mais de 2 meses sob cuidados conservadores, afeta gravemente a qualidade de vida do paciente e potencialmente causa estenose anastomótica após a cicatrização da fístula. É amplamente aceito que as fístulas anastomóticas cervicais refratárias devem ser submetidas a tratamentos mais agressivos. No entanto, quando e qual intervenção cirúrgica deve ser considerada ainda é incerto. Objetivo Avaliar o papel do retalho miocutâneo do peitoral maior no manejo de fístula anastomótica cervical refratárias com base em nossa experiência de 6 casos e uma revisão da literatura. Métodos Foram incluídos no estudo seis pacientes diagnosticados com fístula anastomótica cervical refratária após esofagectomia tratados com transferência de retalho miocutâneo do peitoral maior. Os dados clínicos, detalhes cirúrgicos e resultado do tratamento foram analisados retrospectivamente. Resultados Todos os pacientes sobreviveram às cirurgias. Um paciente com defeito anastomótico circunferencial, resultante da exploração cirúrgica, desenvolveu uma fístula leve no sítio neoanastomótico no 5° dia de pós-operatório, que foi resolvida após 7 dias de tratamento conservador. Esse paciente desenvolveu uma estenose anastomótica parcialmente aliviada por uma dilatação endoscópica anastomótica. Todos os outros 5 pacientes tiveram recuperações sem intercorrências após as cirurgias, restabeleceram a ingestão oral 10 ou 15 dias após a operação e toleraram dietas normais sem sequelas subsequentes no seguimento. Um paciente desenvolveu recorrência local e pulmonar e morreu 15 meses após a cirurgia, enquanto os outros 5 pacientes sobreviveram com bom controle tumoral durante o seguimento de 25 a 53 meses. Conclusão O resultado satisfatório do tratamento em nosso estudo demonstra que a reconstrução com o retalho miocutâneo do peitoral maior é uma modalidade de manejo confiável para as fístula anastomótica cervical refratárias após a esofagectomia, particularmente nos pacientes que apresentaram falha após o tratamento conservador das feridas cirúrgicas e com fechamento repetido delas.
RESUMEN
INTRODUCTION: A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. OBJECTIVE: This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. METHODS: Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. RESULTS: All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months. CONCLUSION: The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.