(207) Free Tissue Reconstruction of the Cervical Esophagus with Concurrent Sternotomy

Introduction: Reconstruction of the cervical esophagus is highly complex. While local pedicled muscle flaps may sufficiently address small esophageal defects, large defects in previously radiated tissue or those with substernal extension may require microvascular free tissue transfer. Clinical outcomes and post-operative complications, particularly in the latter group of patients, remain poorly characterized.

Methods: Case series

Results: Four cases of cervical esophageal reconstruction with concurrent sternotomy performed between 2013 and 2021 were identified. All patients were male with mean age at the time of surgery was 67 years. Microvascular free tissue transfer was performed in 3 patients for ablative laryngopharyngectomy and esophagectomy, and one patient underwent free flap reconstruction for tracheo-esophageal fistula and pharyngeal stenosis repair after previously treated hypopharyngeal squamous cell carcinoma. Three of the four patients had prior head and neck radiation therapy. Reconstruction was performed using the anterolateral thigh free flap in 3 cases and radial forearm free flap in 1 case. Median inset ischemia time was 172.5 minutes and a salivary bypass tube was used in all reconstructions. There were no partial or complete free flap failures, and there were no fistulas or anastomotic leaks observed post-operatively. Two patients developed sternal osteomyelitis requiring parenteral antibiotic therapy and surgical debridement, one of whom had associated mediastinitis from local extension of infection. All patients had resolution of gastrostomy dependence and were able to take oral nutrition. One patient developed clinically significant esophageal stenoses requiring serial dilations.

Conclusions: In this case series, microvascular free tissue reconstruction of cervical esophageal defects with concurrent sternotomy was not associated with anastomotic leaks, flap failure, or long-term gastrostomy dependence. However, patients may require close monitoring for possible infectious complications, such as sternal osteomyelitis.