Latissimus Dorsi Muscle Onlay Flap Post-esophagectomy Leakage with Mediastinitis and Failed Stenting
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CASE REPORT
Latissimus Dorsi Muscle Onlay Flap Post-esophagectomy Leakage with Mediastinitis and Failed Stenting Kaushal Yadav 1
&
Sharan Chaudhary 2
Received: 4 March 2019 / Accepted: 27 January 2020 # Indian Association of Surgical Oncology 2020
Keywords Ivor lewis esophagectomy . Esophagogastric anastomosis leakage . Latissimus dorsi muscle flap . Mediastinitis
Introduction Despite the recent advances in techniques and principles of surgery, esophagectomy is still considered a high-risk procedure. Reported morbidities after esophagectomy are around 6% and it is associated with mortality in approximately 3% of cases [1–3]. Most dreaded of complications after esophagectomy is intrathoracic anastomosis leakage as it is associated with longer ICU stay and is the main reason for postoperative mortality [4]. It is associated with mortality in around 12% of cases [5, 6]. Management strategy for anastomosis leakage should be planned according to the general condition of the patient and degree of leakage [7]. The latest review for the management of esophageal perforations showed a mortality rate of 12% with and without reinforcement and considered surgical repair as the most successful. The mortality rate increases with the time delay between perforation and treatment, 4% for less than 24 h and 14% for a delay of more than 24 h [5, 8]. Intrathoracic anastomosis leakage with mediastinitis and sepsis is a difficult situation to manage. The primary repair has a high rate of failure. Drainage alone has been recommended in critically ill patients but has a mortality rate of 37% [5]. Endoscopic esophageal stents have also been recommended for second-degree anastomosis leakage with a success rate of up to 70% [7]. Esophagogastric disconnection and diversion is recommended for intrathoracic leakage in critically ill patients with severe mediastinal inflammation and is associated with a mortality rate of 24% [8]. In these situations, vascularized muscle onlay flap over debrided leakage site of * Kaushal Yadav [email protected] 1
Surgical Oncology, Paras Hospital, Gurgaon, India
2
Surgical Oncology, Max Hospital, Gurgaon, India
the esophagus can be considered as a safer alternative. A large and well-vascularized muscle flap provides a good substitute without risk of narrowing and avoids diversion. Though vascularized muscle flaps are commonly used in head and neck cancer surgeries, there is the paucity of studies describing latissimus dorsi muscle flap for Ivor Lewis esophagogastric anastomosis leakage repair for malignancy. Our reported case and described technique are an attempt to highlighting the importance of muscle flap for this difficult situation.
Case Presentation A 29-year-old male was diagnosed as a case of adenocarcinoma gastroesophageal junction (GE Jn) cT2N1M0. Postneoadjuvant chemotherapy, he underwent Ivor Lewis esophagectomy with two-field lymph node dissection. Musclesparing right thoracotomy approach was utilized. On postoperative day (POD) 3, he had persistent tachycardia and an episode of fe
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