Pharyngoesophageal reconstruction with a tubed free radial forearm flap

Various attempts at reconstruction of pharyngoesophageal defects after ablative surgery have been made to restore the function of the pharyngoesophagus. A tubed free radial forearm flap was used to reconstruct the pharyngoesophagus in 23 patients after resection of neoplasms from May 1989 to October 1995. Nineteen were males and four were females, the average patient age was 62.2 years. The follow-up ranged from 10 to 64 months (mean: 18 months). Oral intake within 3 weeks was possible in 18 patients (78 percent). The immediate postoperative complications were hematoma (n = 1), bleeding (n = 2), infection (n = 3), fistula (n = 4), and venous thrombosis (n = 1). A late complication was stricture of the lower anastomosing site (n = 3). The tubed free radial forearm flap has advantages over free jejunal transfer, including the larger caliber of the vascular pedicle, longer possible ischemic time, no laparotomy with less morbidity of the donor site, and better toleration of radiotherapy. Troublesome disadvantages include stricture and fistula formation at the suture sites. The authors modified the conventional free radial forearm flap to reduce complications. A small monitoring flap supplied by the septocutaneous branch of the radial artery was elevated to check the survival of the flap. During tubing, the vertical suture line was overlapped with a deepithelialized skin flap, and double layer sutures were done to prevent fistula. Two small triangular flaps were designed and inserted at the distal anastomotic site to prevent circular contracture. The outer-layer sutures were anchored to the surrounding rigid structure to withstand shrinkage and circular contraction. With this modification, the incidence of stricture and fistula formation was reduced to 13.0 percent and 17.4 percent, respectively, and these complications could be treated conservatively.