30 Years Follow Up of Tubed Latissimus Dorsi Island Flap Free Jejunal Graft Cervical and Thoracic Esophagus

Introduction: This unusual surgery was performed at 15 months of age for correction of an impassable esophageal stricture following ingestion of strong lye at 9 months. Contrast dye study and esophagoscopy failed to delineate the stricture. Attempted Forced dilatation had resulted in esophageal tear and chemical mediastinitis. A feeding gastrostomy was performed to improve his general condition. A fine thread was negotiated retrograde through the gastrostomy and thereafter the retrograde contrast study delineated the extent of the stricture involving the oro-pharynx, cervical and upper thoracic esophagus.

Methodology and Material: Reversed tubed islanded latissimus dorsi flap for one stage esophageal reconstruction. The flap was harvested on the left side including the muscle and the skin paddle of 12.0 × 6.0 cm Thoracotomy performed in the fourth inter-costal space through the donor area of the latissimus flap. A part of the 2nd rib was resected in the mid axillary line to allow the passage of the neo esophagus from an extra thoracic to the intra thoracic placement. Thoracotomy performed in the fourth inter-costal space through the donor area of the latissimus flap. The diseased esophagus in the posterior mediastinum was found to be severely scarred, hence was left in situ. The distal part of the normal looking esophagus was identified, isolated and looped for distal end to side anastomosis. A tunnel was created superiorly by blunt and blind finger dissection. Adequate size stoma was made on the lateral aspect of the normal distal esophagus. The proximal end the flap (distal part of the neo esophagus) was anastomosed end to side (skin with mucosal lining and the muscular layer with the adjoining adventitia. Thoracotomy was closed with inter costal drain. The flap donor area on skin grafted. The neo esophagus was negotiated upside down in the posterior mediastinum and rail roaded in the cervical region through previously created tunnel. The patient was turned supine at this stage. Considering the complexity of the structures in the neck and the cervical region, tracheotomy was performed to allow a suitable dissection in the cervical esophagus and the oro-pharynx. Through a “V” incision in the posterior pharyngeal wall + rail roading, space was created for the neo esophagus. The anterior wall of the oro-pharynx as well the neo esophagus was left un-sutured due to proximity to the epiglottis as well the paucity of space.

Results: Patient is able to eat and swallow normally and has no donor site problems. Serial esophagoscopy did confirm proportionate growth of the neo-esophagus. Last esophagoscopy at the age of 32 years shows complete transition of the skin in to mucosa (though histopathology: stratified squamous epithelium).

Conclusions: Considering the extent of the stricture, limitations of conventional methods of esophageal reconstruction i.e., gastric pull up, gastric tube or colonic interposition graft and the author’s experience with various applications of the latissimus dorsi flap, it is a long term result and which has set in a new approach to the Intra-thoracic application of an extra thoracic muscle.