Prophylactic Pectoralis Major Muscle Flap in Esophageal Reconstruction: A Preventive Approach to Anastomotic Leakage.

Leakage from gastrointestinal flap anastomoses remains a significant challenge in reconstructive esophageal surgery, occurring in 10%-25% of cases, leading to prolonged hospital stays and high mortality rates. We explored a novel preventive approach, where the flap anastomosis is wrapped with a pectoralis major muscle (PMM) flap. We describe 3 patients (men aged 70-78 y) with esophageal cancer who underwent esophageal reconstruction with a jejunal flap followed by prophylactic PMM flap coverage. In case 1, the jejunal flap was supercharged and underwent esophagojejunal anastomosis. The esophagojejunal anastomosis was covered with the PMM flap. In case 2, pharyngojejunal and jejunogastric anastomoses were performed, and the latter was wrapped with a PMM flap. In case 3, the patient initially underwent a retrosternal gastric pull-up, which failed due to complications. During salvage surgery, a free jejunal flap was used, and the pharyngojejunal and jejunogastric anastomoses were both prophylactically covered with a PMM flap. Anastomotic leakage was not observed on postoperative endoscopy. PMM flap coverage may reduce anastomotic leakage by providing well-vascularized muscle tissue that promotes wound healing and by protecting the anastomosis from gravitational traction forces and mechanical stress. Although preliminary, our results suggest that prophylactic use of PMM flaps may prevent complications after esophageal reconstruction, particularly in patients requiring high-risk esophageal reconstruction.