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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 153-156

A myomucosal reconstruction solution to stricture postradiation cervical esophagus


1 Department of Head and Neck Oncology and Reconstructive Surgery, VPS Lakeshore Hospital, Kochi, Kerala, India
2 Department of Plastic and Reconstructive Surgery, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Submission25-Aug-2020
Date of Decision09-Oct-2020
Date of Acceptance29-Oct-2020
Date of Web Publication8-Dec-2020

Correspondence Address:
Shawn T Joseph
Departments of Head and Neck Oncology and Reconstructive Surgery, VPS Lakeshore Hospital, NH.47 Bypass, Maradu, Nettoor P.O. Kochi - 682 040, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_41_20

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  Abstract 


A late side effect of radiation for head and neck cancer that has a significant effect on quality of life is esophageal stricture. Many newer techniques of radiation have evolved, but esophageal stricture still remains a complication, especially in a concurrent chemoradiation setting. The treatment options in such conditions can be either invasive or noninvasive. We present a reconstructive option in the form of islanded facial artery myomucosal (iFAMM) flap which carries less donor site morbidity and also provides a mucosal lining. A patient with carcinoma hypopharynx reported with dysphagia following concurrent chemoradiation. The patient was evaluated clinically (video-laryngoscopy, esophago-gastro-duodenoscopy, and video-fluoroscopy) and radiologically and diagnosed as stricture cervical esophagus. The patient had undergone repeated noninvasive techniques of dilatation and failed. Stricture release and patch pharyngoplasty were done with iFAMM flap. Till the last follow-up of 1 year, the patient showed satisfactory deglutition with normal voice. iFAMM is a viable and esthetically appealing option for reconstruction of partial postradiation hypopharynx and cervical esophagus stricture of up to 6 cm in length that are not amenable to dilatation procedures.

Keywords: Esophageal stricture, island flaps, radiation effects, surgical flaps, upper aero-digestive tract neoplasms


How to cite this article:
Mohan MT, Naveen B S, Joseph ST, Tharayil J. A myomucosal reconstruction solution to stricture postradiation cervical esophagus. J Head Neck Physicians Surg 2020;8:153-6

How to cite this URL:
Mohan MT, Naveen B S, Joseph ST, Tharayil J. A myomucosal reconstruction solution to stricture postradiation cervical esophagus. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Jan 17];8:153-6. Available from: https://www.jhnps.org/text.asp?2020/8/2/153/302630




  Introduction Top


A late side effect of head-and-neck cancer that has a significant effect on quality of life is esophageal stricture. A study has shown that the incidence of stricture is 3.3% after external beam radiation.[1] Many newer techniques of radiation have evolved, but esophageal stricture still remains a complication, especially in a concurrent chemoradiation setting. There is an increased risk of stricture in patients who take enteral feed during treatment and those receiving >45 Gy dose to cervical esophagus.[2] The fragile and radiosensitive nature of the proximal esophagus may be why stricture occurs when radiation is given even in other areas other than head and neck, for example, breast carcinoma, lung carcinoma, and esophageal carcinoma.[3],[4]

The treatment options in such conditions can be either invasive or noninvasive. Noninvasive techniques include bougienage and rigid scope balloon dilatation. These techniques, although safe, usually require several repetitions to achieve desired result.[5],[6],[7] The invasive techniques involve visceral transpositions or use of flaps in tubed or in onlay form. Several flaps have been used in this effect, which include cutaneous, myocutaneous, and fasciocutaneous free flaps. We present a reconstructive option in the form of islanded facial artery myomucosal (iFAMM) flap which carries less donor site morbidity and also provides a mucosal lining.


  Materials and Methods Top


The patient is a 56-year-old male with carcinoma hypopharynx cT3N2c diagnosed in December 2017. At our center, he was seen by head-and-neck oncologist, medical oncologist, and radiation oncologist. Metastatic workup showed no signs of metastasis. Based on multidisciplinary tumor board discussion, the patient was explained pros and cons of surgery versus definitive chemoradiotherapy, and they opted for definitive chemoradiotherapy. He completed two cycles of neoadjuvant chemotherapy with cisplatin and 5-flurouracil followed by radical chemoradiation of 66 Gy in 30 fractions to gross disease (both primary and gross node with 1 cm margin) and 60 Gy in 30 fractions to entire laryngopharynx/retrostyloid, retropharyngeal, Ib, II, III, and IV nodal levels with five cycles of concurrent chemotherapy with weekly cisplatin 40 mg/m2 which was completed in March 2018. Due to severe dysphagia and increasing tiredness, he was referred for percutaneous endoscopic gastrostomy in February 2018. Video-laryngoscopy showed normal laryngeal function with pooling in the hypopharynx. In July 2018, he was referred to a gastroenterologist for dilatation procedure. Serial dilatations failed to give desired result, and following inability to pass endoscope for dilatation, the patient was referred to head-and-neck oncology in February 2019 for transcervical widening of esophageal passage.

Video-laryngoscopy was done to confirm normal functioning of the larynx. Video-fluoroscopy was done to adjudge level and intensity of obstruction [Figure 1]. The patient had a cervical esophageal stricture of length 5.5 cm.
Figure 1: Video-laryngoscopy image showing stricture cervical esophagus with thin barium meal trail

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The stricture was classified as RTOG/EORTC Late Esophagitis Morbidity Grading Criteria[8] Grade 3, as shown in [Table 1]. Postoperative improvement was adjudged using functional oral intake scale (FOIS) as shown in [Table 2] and video-fluoroscopy.
Table 1: RTOG/EORTC Late Esophagitis Morbidity Grading Criteria

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Table 2: Functional oral intake scale

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Procedure

After explaining procedure and obtaining written consent, under general anesthesia, tracheostomy was done and airway shifted. A horizontal incision was placed at mid-level of the thyroid cartilage and subplatysmal flaps raised. Anterior triangle was exposed and vascular compartment separated. Care was taken to not injure the superior laryngeal nerve or the facial vessels. Pharynx was entered by releasing suprahyoid muscles, and the stricture was released from cricopharynx downward. As the stricture was partial, it did not require complete transection of segment. Length of stricture released was approximately 6 cm.

Reconstruction was done by raising iFAMM flap from the same side and delivering it into the neck [Figure 2]. The length of the pedicle and mucosal lining allowed the flap to be easily placed. Before suturing, two size 16 nasogastric tubes were passed through nose into esophagus to act as a stent. The flap was sutured by parachuting with 3-0 absorbable polyglactin 910 round body sutures. Leak test with methylene blue was done. Negative suction drain was placed and defect closed in layers.
Figure 2: Islanded facial artery myomucosal flap delivered under marginal mandibular nerve showing reach of flap

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  Results Top


Postoperatively, the patient could be decannulated after 10 days and initiated on liquid feeds. He underwent regular swallowing therapy, and gradual improvement in the amount of feed was noted. Video-fluoroscopy was done [Figure 3], which showed no leak or aspiration. At 1 month, he is taking semisolid feed comfortably which was an improvement from FOIS level 1 to level 5. He has maintained level 5 for a year.
Figure 3: Video-laryngoscopy image showing stricture cervical esophagus with thick barium meal trail

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  Discussion Top


Injury to esophagus is a dose-limiting factor in radiation.[9],[10] Due to fractionated doses of 60 Gy or more, microscopically submucosal fibrosis, capillary telangiectasia, thick-walled arterial vessels, mucus glandular atrophy, atypical fibroblasts, and grossly ulcers, strictures, or fistulas are noted. There also appears to be an effect on muscle motor activity controlling swallowing through the upper segment of the esophagus.[11] There is a higher incidence of esophagitis with concurrent chemotherapy and radiation therapy with conventional fractionation versus radiation therapy alone with conventional fractionation.[12],[13]

Earliest reconstruction was done using neck skin flaps (Czerny in 1877 and Mikulizc in 1866). The staged neohypopharynx using anterior neck skin was devised by Wookey in the 1940s. Visceral transposition surgeries evolved after the 1960s, including gastric pull-up (Ong and Lee), revascularized autografts of hollow organs (Huguier et al.), and colon transposition (Keling and Vuillet).

More recently, tissue transposition has evolved with plenty of options. Pectoralis major myocutaneous (PMMC) flap comes with the advantages of a robust flap but with the disadvantage of bulkiness and cutaneous lining.[14] Deltopectoral flap comes with a similar advantage but requires a second-stage procedure and also the disadvantage of cutaneous lining.[15] Free flaps have been used to good effect but carry the disadvantage of poor native vessel quality and thus a risk of failure or anastomotic blowout.[16] Other disadvantages may be the inability to monitor the flap effectively and the cutaneous lining. Visceral transposition carries the risk of a free flap, anastomotic site stricture, and a gastrosurgical procedure.[17]

Of recent interest in head-and-neck reconstruction is the use of iFAMM flap. It has been well used in the reconstruction of oral and pharyngeal defects.[18],[19] In the above-presented case, we find that the flap could be easily harvested with less donor site morbidity. The mucosal lining gives a fairly good like to like representation and pliability to stretch across the defect. The blood supply is good and the buccinator muscle bulk gives ample support while not creating a bulge in the neck. The take up is fairly rapid; as a delay is expected in postradiation patients. Decannulation could be attained and laryngeal functions preserved so as to give an aspiration free swallow. Main disadvantages we noted were the development of House Brackmann II–III marginal mandibular nerve weakness initially, which usually recovers with exercises. Careful dissection is required to free the vessels in the neck due to extensive fibrosis in the irradiated site. The flap can only be used as an onlay and not in tubed form in complete resection cases. Maximum obtainable flap dimensions are less compared to other flaps due to obvious anatomical restrictions.


  Conclusion Top


iFAMM is a viable and esthetically appealing option for reconstruction of partial postradiation hypopharynx and cervical esophagus stricture of up to 6 cm in length that is not amenable to dilatation procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Lee NY, O’Meara W, Chan K, Della-Bianca C, Mechalakos JG, Zhung J, et al. Concurrent chemotherapy and intensity-modulated radiotherapy for locoregionally advanced laryngeal and hypopharyngeal cancers. Int J Radiat Oncol Biol Phys 2007;69:459-68.  Back to cited text no. 1
    
2.
Ahlberg A, Al-Abany M, Alevronta E, Friesland S, Hellborg H, Mavroidis P, et al. Esophageal stricture after radiotherapy in patients with head and neck cancer: Experience of a single institution over 2 treatment periods. Head Neck 2010;32:452-61.  Back to cited text no. 2
    
3.
Laurell G, Kraepelien T, Mavroidis P, Lind BK, Fernberg JO, Beckman M, et al. Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer 2003;97:1693-700.  Back to cited text no. 3
    
4.
Jham BC, da Silva Freire AR. Oral complications of radiotherapy in the head and neck. Braz J Otorhinolaryngol 2006;72:704-8.  Back to cited text no. 4
    
5.
Piotet E, Escher A, Monnier P. Esophageal and pharyngeal strictures: Report on 1,862 endoscopic dilatations using the Savary-Gilliard technique. Eur Arch Otorhinolaryngol 2008;265:357-64.  Back to cited text no. 5
    
6.
Ahlawat SK, Al-Kawas FH. Endoscopic management of upper esophageal strictures after treatment of head and neck malignancy. Gastrointest Endosc 2008;68:19-24.  Back to cited text no. 6
    
7.
Steele NP, Tokayer A, Smith RV. Retrograde endoscopic balloon dilation of chemotherapy- and radiation-induced esophageal stenosis under direct visualization. Am J Otolaryngol 2007;28:98-102.  Back to cited text no. 7
    
8.
Silvain C, Barrioz T, Besson I, Babin P, Fontanel JP, Daban A, et al. Treatment and long-term outcome of chronic radiation esophagitis after radiation therapy for head and neck tumors. A report of 13 cases. Dig Dis Sci 1993;38:927-31.  Back to cited text no. 8
    
9.
Mavroidis P, Lind BK, Theodorou K, Laurell G, Fernberg JO, Lefkopoulos D, et al. Statistical methods for clinical verification of dose-response parameters related to esophageal stricture and AVM obliteration from radiotherapy. Phys Med Biol 2004;49:3797-816.  Back to cited text no. 9
    
10.
Hirota S, Tsujino K, Endo M, Kotani Y, Satouchi M, Kado T, et al. Dosimetric predictors of radiation esophagitis in patients treated for non-small-cell lung cancer with carboplatin/paclitaxel/radiotherapy. Int J Radiat Oncol Biol Phys 2001;51:291-5.  Back to cited text no. 10
    
11.
Weisenberg E. Radiation Esophagitis. Available from: http://www.pathologyoutlines.com/topic/esophagusirradiation.html. [Last accessed 2019 May 06].  Back to cited text no. 11
    
12.
Choy H, Akerley W, Safran H, Graziano S, Chung C, Williams T, et al. Multiinstitutional phase II trial of paclitaxel, carboplatin, and concurrent radiation therapy for locally advanced non–small cell lung cancer. J Clin Oncol 1998;16:3316-22.  Back to cited text no. 12
    
13.
Laurell G, Kraepelien T, Mavroidis P, Lind BK, Fernberg JO, Beckman M, et al. Stricture of the proximal esophagus in head and neck carcinoma patients after radiotherapy. Cancer 2003;97:1693-700.  Back to cited text no. 13
    
14.
Ananthakrishnan N, Nachiappan M, Subba Rao KS. Island pectoralis major myocutaneous flap for pharyngo-oesophageal strictures prior to oesphagocoloplasty. J R Coll Surg Edinb 2001;46:202-4.  Back to cited text no. 14
    
15.
Guha G, Gupta S, Chakraborty S. Pharyngo oesophageal strictures and its reconstruction by delto pectoral flaps. Indian J Otolaryngol Head Neck Surg 2005;57:229-34.  Back to cited text no. 15
    
16.
Harii K, Ebihara S, Ono I, Saito H, Terui S, Takato T. Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985;75:463-76.  Back to cited text no. 16
    
17.
Reece GP, Bengtson BP, Schusterman MA. Reconstruction of the pharynx and cervical esophagus using free jejunal transfer. Clin Plast Surg 1994;21:125-36.  Back to cited text no. 17
    
18.
Joseph ST, Naveen BS, Mohan TM. Islanded facial artery musculomucosal flap for tongue reconstruction. Int J Oral Maxillofac Surg 2017;46:453-5.  Back to cited text no. 18
    
19.
Joseph ST, Naveen BS, Mohan T M, Tharayil TJ. Tracheal advancement with myomucosal island flap for partial laryngopharyngectomy defect reconstruction. Head Neck 2018;40:E40-4.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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