Author Affiliations: Departments of Otolaryngology, Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington (Dr Bayles) Mayo Clinic, Scottsdale, Arizona (Dr Hayden).
To present the use of an infrequently used tool, gastro-omental free flaps, available to head and neck surgeons in the modern reconstruction era.
In this case series, 25 gastro-omental free flaps were performed. The technical aspects of harvest are reviewed, and the advantages and disadvantages of this flap are described, as well as illustrative cases displaying this flap's utility when other donor sites cannot be harvested.
Flap survival was 96%, with 1 flap being successfully salvaged after the development of a venous thrombosis and 1 flap failing as a result of a kink in the arterial pedicle. Exteriorization of the omentum as an external marker heralded vascular compromise in both cases. Complications included 2 delayed gastric outlet obstructions, 1 salivary leak, 1 delayed abscess and fistula formation 7 months following reconstruction, and 1 case of mild superficial bleeding from the transplanted gastric mucosa.
The gastro-omental flap has proven to be a reliable and valuable tool in head and neck reconstruction, particularly in complex oropharyngeal wounds with large soft tissue components.
With the advent of free tissue transfer, one's ability to limit the functional impact of radical resection of oral, oropharyngeal, and pharyngoesophageal structures has improved. No flap possesses all of the characteristics of native tissues with respect to sensation, pliability, thickness, muscular activity, or secretory capacity. The flap of choice for any given patient must reflect a compromise between tissue defect and available donor sites.
The first report of successful transfer of a free graft of gastric antrum with revascularization to replace the cervical esophagus was described by Hiebert and Cummings1 in 1961. Papachristou and Fortner2 later presented the experimental use of pedicled gastric flaps to the neck in 1977. This was followed by a report by Baudet3 on using free transfer of greater omentum and stomach in reconstructing the pharyngeal wall. Papachristou and Fortner2 additionally described the experimental use of free gastric flaps to repair pharyngoesophageal defects in 1979. Head and neck reconstruction with the gastro-omental free flap was subsequently popularized by Panje et al4 in their report of 7 gastro-omental flaps for immediate reconstruction of oral cavity and pharyngeal defects and subsequent reports for complex wound reconstruction including those associated with osteoradionecrosis and skull base defects with cerebrospinal fluid leakage.5- 7
The gastro-omental free flap is a valuable addition to the modern reconstructive surgeons' armamentarium. Advantages of this flap are many. The gastro-omental flap allows for transfer of a smooth, thin, pliable mucosal flap that can be varied in size. In the present report, we describe our use of the gastro-omental flap in 25 patients with head and neck defects over a 19-year period (1987-2006) and discuss the particular applications of this flap that we have found advantageous. Illustrative cases are presented demonstrating the superiority of this flap in certain situations when skin-based flaps were not available to the reconstructive team.
All patients were counseled on reconstructive alternatives. Written informed consent was obtained from all patients to proceed with gastro-omental free flap reconstruction. Harvest of the gastro-omental flap is straightforward. The stomach is approached through a standard laparotomy or may be performed endoscopically. The stomach is mobilized from the gastrocolic ligament. The flap is based on the right gastroepiploic artery and vein. The left gastroepiploic artery and vein are sectioned. A gastrointestinal anastomosis stapling device is then used to make the first division along the proximal greater curvature of the stomach (Figure 1). The gastrointestinal anastomosis stapler is then redirected to make a second division based on the size of the gastric patch desired. Care is made to avoid dividing the greater curvature too close to the pyloric outlet because postoperative edema in this region may result in delayed gastric outlet obstruction. Patches are usually 6 × 10 cm, but larger amounts of the greater curvature of the stomach can be harvested. The right gastroepiploic artery and vein are then dissected back to their origin from the gastroduodenal artery and vein by serially ligating the corporeal vessels along the distal aspect of the greater curvature. A pedicle length of up to 30 cm may be achieved, allowing remote microvascular anastomosis from the defect site (Figure 2). A gastrojejunostomy tube is inserted at the time of harvest to allow for early postoperative jejunal feeding and simultaneous gastric decompression, limiting the period of postoperative ileus.
The stomach is approached through a laparotomy. The left gastroepiploic artery and vein are sectioned, and the gastrointestinal anastomosis stapler is directed along the proximal greater curvature.
Harvested gastro-omental flap. The ruler length is 15 cm. Note the extensive pedicle length to the flap.
If the omentum is not desired, dividing and controlling the omental vessels can be performed to remove the omentum. When the gastrointestinal anastomosis staples are removed, a smooth mucosal patch is available for reconstruction, or it may be left tubed by only opening the proximal and distal ends of the flap for total pharyngeal reconstruction (Figure 3).8 The flap is inset into the defect before revascularization, since mucosal edge bleeding and mucous production can be a nuisance in an uncompleted wound closure. A segment of omentum may also be exteriorized as an external marker to monitor the flap (Figure 4).
The gastro-omental flap may be used for total pharyngeal reconstruction. A, The gastric mucosa is left tubed to provide a conduit for cervical esophageal reconstruction. B, The omentum was used for coverage of great vessels and to provide for neck resurfacing due to overlying skin sacrifice. C, The stoma was fashioned after mediastinal resection of manubrium and clavicular heads by a deltopectoral flap.
Flap perfusion may be observed visually. A, Omentum is exteriorized through the neck incision as an external marker of flap viability. B, Cyanosis of the omental monitor allows for the identification of flap ischemia. This flap developed a venous thrombosis that was successfully salvaged as a result of rapid identification of pedicle compromise by visible change in the monitor segment of omentum.
From 1987 to 2006, 25 gastro-omental free flaps were harvested for reconstruction of composite oropharyngeal head and neck defects resulting from tumor ablation. A 26th flap had to be abandoned secondary to a previously undiagnosed asymptomatic peptic ulcer, which was identified at the time of harvest. Patient ages ranged from 53 to 70 years. Complications were few. The flap success rate was 96%, with 1 flap developing venous thrombosis on the second postoperative day. This was rapidly identified by change in the omental monitoring segment (Figure 4B), and the flap was salvaged by reoperation, with removal of the thrombosis and revision of the venous anastomosis. An additional flap was lost secondary to kinking of the artery, which could not be salvaged secondary to the no-reflow phenomenon. Two patients developed delayed gastric outlet obstruction, which subsequently resolved spontaneously with gastric decompression and bowel rest. One patient developed a delayed neck abscess and fistula formation 7 months after her reconstruction, which required additional flap closure of the wound. One additional patient developed mild bleeding from the transferred gastric segment, which subsequently stopped with proton pump inhibition. One patient who underwent total pharyngoesophageal reconstruction with a tubed flap developed a small salivary leak on postoperative day 5, which was reexplored and primarily closed with a single suture without further fistula formation.
Rehabilitation times were in keeping with other reconstructive methods. Time to decannulation was not found to be prolonged as a result of mucous production, with all patients being decannulated within 3 weeks. The mean hospital stay was 14 days. The mean time to enteral jejunal alimentation was 2 days.
The following cases are described to illustrate patient selection criteria and the variety of defects that may be reconstructed with this flap.
A 51-year-old man with a social history of intravenous drug abuse was evaluated for a T4N2M0 squamous cell carcinoma of the tonsil. Examination of both upper extremities revealed diffuse track marks with no ballotable veins, including the cephalic and basilic. A composite resection of the oropharynx was performed, with a modified radical neck dissection. A gastro-omental free flap was used to reconstruct the hemisoft palate, tonsillar fossa, lateral pharyngeal wall, and base of tongue, given the lack of availability of the radial forearm flap. The patient's tracheostomy was decannulated within a week. He developed delayed gastric outlet obstruction, which was compounded by noncompliance with his nothing-by-mouth status and activation of chronic alcoholic gastritis, which subsequently responded to increased antacid coverage and gastric decompression. With resolution of his gastric outlet obstruction, he resumed a total oral diet and maintained his weight throughout his radiation therapy (Figure 5).
Gastro-omental flap inset into oropharyngeal defect (A) and 1-year postoperative result (B). Note the ongoing mucous production despite radiation therapy.
A 64-year-old women with a T2N0M0 oral tongue squamous cell carcinoma had a history of a malunioned Colles fracture of her nondominant wrist, resulting in significant deformity. Our reluctance to use a radial forearm flap from her dominant arm resulted in us selecting a gastro-omental flap to reconstruct her hemiglossectomy defect. She was decannulated and resumed a full oral diet within 2 weeks of her operation (Figure 6).
Gastric mucosa is used to reconstruct the hemiglossectomy defect (A) and 1-year postoperative result (B).
The gastro-omental free flap is a valuable addition to modern head and neck reconstruction. Advantages of this flap are many. The gastro-omental flap allows for the transfer of a smooth, thin, pliable mucosal flap that can be varied in size. This flap also has the potential to be tubed for complete circumferential defect reconstruction. The omentum can be combined with the gastric mucosa to provide for complex soft tissue augmentation and carotid artery protection and can be exteriorized for visible monitoring of flap viability. In our series, we are able to demonstrate the value of the monitor segment of omentum, since both flaps that developed vascular compromise were heralded by cyanotic change in the omental monitor. This led to the successful salvage of 1 flap that had developed a venous thrombosis. Loss of the second flap is instructive to readers. While the additional pedicle length of the gastro-omental flap provides one of its greatest assets, care must be taken to reduce the redundancy of the pedicle when performing the anastomosis. The surgeon should pay particular attention to the pedicle geometry as the omentum is directed out of the neck because the weight of the omentum may change the pedicle geometry, and this may go unnoticed as the pedicle becomes covered by the omentum. Additional tacking sutures may be placed to stabilize the omentum to the native tissues to resist this gravitational force on the pedicle before directing the omentum out of the neck.
The thin, pliable nature of the gastric mucosa can be 3-dimensionally conformed to recreate complex defects of the oral cavity and oropharynx, while restoring mucous production to the postradiated xerostomic patient. This flap provides a valuable alternative, particularly in the obese patient in whom skin-based free flaps, such as the radial forearm flap or lateral arm flap, may possess excess bulk and limit the 3-dimensional mobility of the tissue. This flap has many additional advantages in comparison with other mucosal enteric flaps, such as the jejunum. The size of the gastric patch can be widely varied, depending on the size of mucosal defect requirement. This is in contrast to the jejunal mucosal patch, which has a fixed diameter when splitting along the antimesenteric border and can only be varied in length. The gastro-omental flap's pedicle is large in caliber and long, with achievable lengths of up to 30 cm, allowing remote microvascular anastomosis from the defect. The gastroepiploic vein can, however, be thin, requiring skilled handling with the anastomosis. The pedicle also allows for a great deal of independent mobility with respect to the mucosal component, in comparison with the jejunal flap's pedicle, which has a relatively fixed orientation with respect to its enteric component due to the mesenteric arcades that cannot be sectioned. The omentum can be carried by the flap but can be sectioned depending on the independent needs of the defect, whereas the jejunal mesenteric fat is an obligate component of the composite tissue because of housing the mesenteric vasculature. The mucosal rugae of the gastric patch ultimately smooth out after transfer, unlike the jejunum, which retains its mucosal folding pattern over time. The circular folds of the jejunum can be problematic when used as a mucosal patch because they tend to trap food debris, which can be difficult for the patient to clear.
The disadvantages are relatively minor and revolve around the need to violate the abdomen, which is not required for cutaneous-based flaps. However, this provides an opportunity to place an enteral feeding tube for rapid reinstitution of postoperative feedings. We prefer to place a gastrojejunostomy tube to stent the pylorus and allow for early reinstitution of distal jejunostomy feeding while simultaneously decompressing the stomach. We have found that this seems to limit the period of postoperative ileus. Ultimately, the jejunal port may be pulled back into the stomach to bolus feed the patient after gastric outputs are reduced to acceptable levels. In our series, we encountered 2 patients who developed delayed gastric outlet obstruction. Both patients were in the early experience of flap harvest, and the gastric outlet obstruction resulted from encroachment of the pyloric outlet leading to a period of postoperative edema in the region. Both cases resolved spontaneously with gastric decompression.
In their initial experience, Panje et al4 reported delayed decannulation due to the excessive mucous production from the gastric mucosa. It has not been our experience that the mucous production is problematic in airway management. In fact, the increased mucous production is frequently commented on by our patients as a source of added oral comfort, particularly in the postradiated xerostomic patient. Gastro omental free flap reconstruction is an attractive method in patients in whom radiotherapy or chemoradiotherapy has failed because not only can their xerostomia be palliated but the omentum also provides for an added barrier to wound breakdown in patients with impaired healing capabilities. Only 1 patient developed a wound breakdown requiring further flap reconstruction as a result of a delayed abscess formation 7 months after surgery. At the time of reexploration to drain the infection, we noted that the folded serosal edges of the gastric patch, which had been contoured to create a soft palate and lateral pharyngeal wall, had not healed together, creating a compartmentalized space. We hypothesized that this created a dead space where fluid collected and ultimately became infected. This phenomenon is in keeping with the role of the enteric serosa of providing a sliding, nonadherent surface for the bowel in the peritoneum. Since this case, we have made it our practice to apply sterile talc to the serosal surfaces if they are to be folded on one another. This induces an inflammatory response and allows these surfaces to heal together, thus avoiding a dead space.
Our experience has also shown that this flap may be used safely in patients who are to receive postoperative radiotherapy. The transplanted gastric mucosa additionally tolerates radiation well, and the gastric mucosa maintains its secretory capacity to a greater degree than the native oral mucosa.9
In conclusion, the gastro-omental free flap reconstruction has many distinct advantages when applied to select head and neck reconstructive situations. The flap is highly reliable, and this is a particularly attractive method in patients whose body habitus precludes use of standard skin-based flaps. The addition of the omentum carries an added barrier to wound breakdown, which is particularly useful in the postchemoradiated patient and affords the opportunity to restore mucous production in the severely xerostomic patient.
Correspondence: Stephen W. Bayles, MD, Virginia Mason Medical Center, Mail Stop X10-ON, 1100 Ninth Ave, PO Box 900, Seattle, WA 98101 (email@example.com).
Accepted for Publication: January 10, 2008.
Author Contributions:Study concept and design: Bayles and Hayden. Acquisition of data: Bayles and Hayden. Analysis and interpretation of data: Bayles. Drafting of the manuscript: Bayles and Hayden. Critical revision of the manuscript for important intellectual content: Bayles. Administrative, technical, and material support: Bayles and Hayden. Study supervision: Hayden.
Financial Disclosure: None reported.
Previous Presentation: A partial earlier series was presented at the International Conference on Head and Neck Cancers; July 29–August 2, 2000; San Francisco, California.
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