Long-Term Outcomes of Simultaneous Skin and Bowel Flaps for Esophageal Reconstruction

Esophageal reconstruction can be performed with skin or bowel flaps. The choice of flap remains controversial, as the long-term outcomes of skin flaps cannot always be assessed in patients with limited life expectancies due to advanced malignancy, unlike the pediatric and benign cases which have had esophageal reconstruction using bowel flaps. We report the long-term clinical and histopathological outcomes in a series of 45 cases repaired with combined skin and bowel flaps. Four patients developed symptomatic strictures after corrosive esophageal injuries were repaired with a combination of a tubed free radial forearm fasciocutaneous flap and a pedicled bowel flap. On average, 24 years had passed since uneventful initial esophageal reconstructions. Barium esophagograms were obtained in all cases and pathological examination was performed upon all surgical specimens. The cutaneous portions of the reconstructed esophagus exhibited a variety of findings on barium examination. Each of the 4 cases developed an esophagocutaneous fistula after revision; an average of 4 surgeries was required to close these fistulae. The inner surfaces of the portion of esophagus repaired with skin flaps showed extensive ulceration, polypoid lesions, and fibrosis. Pathology specimens from skin flaps showed extensive acute and chronic inflammation, microabscesses, fibrosis, and acanthosis, with depletion and degeneration of the pilosebaceous units. By contrast, adjacent parts of the esophagus repaired with bowel were widely patent with normal appearing mucosa. Our findings indicate that a bowel flap is durable with good tolerance to gastrointestinal content over long periods, whereas skin flaps often developed morphological changes and could not maintain long-term esophageal function without eventual stricture and dysphagia. We therefore recommend use of bowel flaps for esophageal reconstruction in patients with long life expectancy.