CARCINOMA IN A RECONSTRUCTED (ESOPHAGUS. By PERCY H. JAYES, M.B., F.R.C.S. From The Queen Victoria Hospital, East Grinstead

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1 CARCINOMA IN A RECONSTRUCTED (ESOPHAGUS By PERCY H. JAYES, M.B., F.R.C.S. From The Queen Victoria Hospital, East Grinstead THE purpose of this short paper is twofold: first, to report a condition which is extremely rare, possibly unique, namely the development of a carcinoma in a prethoracic skin tube; secondly, to describe how the oesophagus was repaired for the second time in the same patient, after the growth, had been removed. In 1949 Ragnell, reviewing the literature on oesophageal reconstruction, stated that up to that time about IOO successful cases of prethoracic repair had been published by thirty different surgeons. Although the number of cases is comparatively large, most of the reports concentrate on operative technique and very few patients have been followed up for more than five years. A careful search of the literature has failed to reveal any previous record of a carcinoma occurring in a prethoracic skin tube. A B FI~. i A, The condition on admission to hospital, showing the original oesophagodermato-jejuno-gastrostomy with the growth breaking through to form a fistula in the region of the manubrium sterni. B, Close-up view of the fistula. CASE REPORT Twenty-three years ago a woman aged 3o, with stenosis of the oesophagus due. to ingestion of hydrochloric acid, was successfully treated by H. H. Sampson of Birmingham, using a technique which he later published (Sampson, 1933). He performed an 212

2 CARCINOMA IN A RECONSTRUCTED (ESOPHAGUS 2I 3 A B FIG. 2 Photomicrographs of the tumour. Squamous-celled carcinoma (Br6der Grade 2). A~ Low power. B~ High power.

3 214 BRITISH JOURNAL OF PLASTIC SURGERY oesophago-dermato-jejuno-gastrostomy and the patient lived a normal life, with practically no difficulty in swallowing, for twenty-one years. However, in October I954, following a minor blow on the chest, a fistula developed in the upper part of the skin tube and the patient was referred to my clinic at St Bartholomew's Hospital. Examination revealed a fistula 2 cm. in diameter over the manubrium sterni through which much leakage of food and fluids occurred (Fig. I). The edges of the fistula were very unhealthy and nodular and a biopsy showed a squamous-celled carcinoma (Br6der Grade 2) (Fig. 2). Treatment.--As a preliminary measure a gastrostomy was performed (Mr E. G. Muir) to improve nutrition and diminish sepsis at the site of the fistula. FIG. 3.FIG' 4 Fig. 3.--The excised portion of eesophagus and skin tube opened longitudinally to display the growth. Fig. 4.--The condition after excision of the tumour. Note the open end of the eesophagus in left side of the neck and the divided skin tube in mid-chest. Ten days later the skin tube was opened longitudinally in the region of the fistula and the growth displayed. The tumour was arising in the line of anastomosis between the cervical oesophagus and the skin tube. It was papilliferous in type and involved the entire circumference of the skin tube for a distance of about 8 cm. below the anastomosis. The oesophagus was divided above and below the growth, leaving a good margin of healthy tissue and the involved portion was removed, together with a wide margin of surrounding tissue and overlying skin (Fig. 3). The upper end of the original oesophagus was brought to the surface in the left side of the neck and the divided end of the skin tube was left open at the level of the fourth intercostal space (Fig. 4). The defect on the chest wall was closed by local rotation flaps and rapid healing occurred. The patient returned home after a few weeks in hospital and continued with gastrostomy feeds. There was some leakage of saliva from the oesophageal opening in the neck and occasional regurgitation of gastric contents from the lower end of the skin tube, but the general condition of the patient continued to improve. Repair of the (Esophagus.--The repair of a long segment of the oesophagus for the second time in the same patient involved special problems on account of previous scars and shortage of skin on the front of the chest. Nevertheless, it was possible to obtain complete reconstruction in one stage by using carefully designed local flaps (Fig. 5).

4 CARCINOMA IN A RECONSTRUCTED CESOPHAGUS 2I 5 FIG. 5 FIG. 6 FIG, 7 FIG, Fig. 5.--The markings show the strip of skin which was to be tubed to restore the continuity of the oesophagus and the two flaps from the left side of the neck and chest designed to cover the tube. Fig. 6.--The new skin tube partially formed. Fig. 7,--The tube almost completed and the covering flaps raised. Fig. 8.--The repair completed, The secondary defects or~ the chest wall have been covered with split-skin grafts. Fig. 9.--The condition two years after removal of the growth. FIG. 9

5 216 BRITISH JOURNAL OF PLASTIC SURGERY The operation was performed nine months after excision of the growtti. The missing portion of the oesophagus was reconstituted by tubing a strip of skin between the two ends left open at the previous operation, thus restoring continuity of the oesophagus. The new tube was then completely covered by local rotation flaps, the secondary defects being grafted (Figs. 6, 7, and 8). The suture lines healed well and the patient began taking food by mouth three weeks after operation. Two and a half months later the gastrostomy was closed (Mr E. G. Muir). A FIG. Io X-rays of a barium swallow. B A, Before operation, showing the constriction and fistula due to the turnout. B, After the repair, showing an oesophagus of uniform and good calibre. Result.--Two years have elapsed since the growth was removed and the patient is in excellent health. Her weight is steady and she takes a normal diet without difficulty or delay (Fig. 9). A barium swallow shows that the reconstructed oesophagus is of a good uniform calibre (Fig. IO, B). There are no clinical or radiological signs of local or distant metastases. DISCUSSION The reader will naturally ask whether the growth originated in the cervical oesophagus or in the prethoracic skin tube. Careful examination of the specimen has failed to provide a definite answer to this question. At the time of operation

6 CARCINOMA IN A RECONSTRUCTED (ESOPHAGUS 21" 7 the tumour involved a smau segment of the oesophagus above the anastomosis but its main spread was down the skin tube. The only safe deduction that can be made is that the growth originated in the anastomotic area. The growth had spread extensively within the tube, but there was very little involvement of the surrounding tissues and the line of excision was well clear of the tumour. For these reasons the prognosis is considered to be reasonably favourable. I shoum like to express my thanks to Mr E. G. Muir for his help in the treatment of this patient. I am also greatly indebted to Dr W. Campbell for the radiological investigations, to Dr Barbara Evans and Professor G. Cunningham for the histology and to Mr G. Clemetson for the photographs. REFERENCES RAGNELL, A. (1949). Acta chir. scand., 98, 369. SAMI'SON, H. H. (I933). Brit. J. Surg., 20, 447.