The "bowtie" reconstruction flap: A unique solution to cervical esophageal discontinuity repair

Describe a novel technique for repair of cervical esophageal discontinuity.

A 66-year-old female underwent hiatal hernia repair with a Nissen fundoplication. This was complicated by ischemic necrosis of the proximal stomach requiring urgent return to the operative suite for partial gastrectomy, esophageal diversion and subsequent esophagectomy repaired with a colonic interposition graft by Thoracic Surgery. This was further complicated by a cervical esophageal colonic anastomotic leak maturing to a cervical esophageal fistula and necessitating jejunostomy tube placement and consultation to Head and Neck Surgery.

Case report.

In a team approach with Otolaryngology and Thoracic Surgery, she underwent a unique, multilevel repair with a salivary bypass stent bridging the gap between the proximal esophagus and distal colonic conduit. Bilateral local advancement flaps were elevated using the skin lateral to the fistula on each side with a random blood supply pedicled medially. Each flap was rotated medially over the stent and imbricated at midline. Next, a left myogenous pectoralis flap was raised and rotated over the site of imbrication. Lastly, a split thickness skin graft from the thigh was harvested and sutured over the pectoralis flap. Three months postoperatively, the salivary bypass stent was removed and by five months, the fistula was completely closed. With cervical esophageal dilations bimonthly, the patient has graduated to an oral diet without need of her jejunostomy tube for nearly four months.

This case report describes a novel and efficacious solution to cervical esophageal discontinuity.